The Future of Quality Improvement for Cirrhosis

Abstract

Cirrhosis has a significant and growing impact on public health and patient-reported outcomes (PROs). The increasing burden of cirrhosis has led to an emphasis on the quality of care with the goal of improving overall outcomes in this high-risk population. Existing evidence has shown the significant gaps in quality across process measures (eg, hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address the gaps in quality care. This multistep process forms the quality continuum, and it depends on clearly defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein we review the current state of quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in PRO evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.

Figure 1:

A Cross-section of Cirrhosis Practice Measures FFP = fresh frozen plasma, HCC = hepatocellular carcinoma, HE = hepatic encephalopathy, LSM = liver stiffness measurement, plt = platelets, SBP = spontaneous bacterial peritonitis

Figure 2:. The Future of Quality Improvement

Improving quality improvement will involve enhancing our approach to: a. Prevention: early diagnosis and linkage-to-care for cirrhosis, pre-emptive beta-blockers to prevent bleeding and possibly ascites, integrated care for alcohol-use disorder (AUD) by either training the workforce in pharmacotherapy and behavioral interventions or streamlining referrals, and expanding access to nutrition services and integrating remote monitoring for decompensations. b. Measurement: creating real-time metric dashboards, tracking patient reported outcomes (PROs) as we have for AUD, and benchmarking center performance for clinical outcomes. c. Evaluation: the effectiveness of interventions must be tested utilizing robust methods for program evaluation such as stepped-wedge (pictured) and cluster-randomized designs. d. Linkage-to-care: quality efforts should focus on delivery of care proven to improve outcomes such as AUD therapy, lifestyle change, and transplant evaluation