Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit

Abstract

Background and aims: Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB.

Approach and results: We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality.

Conclusions: Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.

Graphical abstract

FIGURE 1

Proportion of patients adhering to the acute variceal bleeding quality indicators. The adherence to beta-blocker and full adherence to all quality indicators remained suboptimal in real-world settings. *NSBB group defined as the prescription of NSBB before discharge. Full adherence was defined as adherence to all 5 quality indicators. Abbreviation: NSBB, nonselective beta-blocker.

FIGURE 2

Clinical outcomes among acute variceal bleeding patients according to (A) unmatched cohort and (B) propensity-matched cohort. Full adherence was associated with a lower risk of infection, early rebleeding, and mortality in both the matched and unmatched cohort. #Full adherence: define as adherence to all quality indicators. Abbreviation: ACLF, acute-on-chronic liver failure.

FIGURE 3

Clinical outcomes in patients with full adherence to quality indicators of acute variceal bleeding (n=305), stratified CTP class. Despite full adherence, patients with CTP-class C remained at a higher risk of early rebleeding (23.8% vs. 3.9%, p=0.003), and death (6-week mortality: 38.1% vs. 6.0%, p<0.001; 1-year mortality: 47.6% vs. 19.4%, p=0.005) compared to patients in CTP-class A or B. Abbreviations: ACLF, acute-on-chronic liver failure; CTP, Child-Turcotte-Pugh.

FIGURE 4

(A) Observed 6-week mortality across various MELD scores between full and suboptimal adherence groups. Calibrated MELD score underestimated the risk of 6-week mortality in the overall cohort (B), particularly at the higher MELD scores. The 6-mortality was higher than the predicted risk in suboptimal adherence group (C) with a lower MELD score; the predicted risk of mortality was lower in suboptimal adherence group with a higher MELD score. In full adherence group (D), the 6-week mortality was consistently overestimated, indicating a lower observed mortality risk with full adherence of acute variceal bleeding quality indicator.