How should we assess quality of cirrhosis care?

Insurance companies and government agencies attempt to assess healthcare quality to develop quality-based reimbursement models. It is a challenge to define and measure quality of care, however, especially for complex, chronic diseases such as cirrhosis. Two studies in the August issue of Clinical Gastroenterology and Hepatology (CGH) identify tools for determining quality of care for patients with cirrhosis.

Fasiha Kanwal et al. identified quality indicators for treatment of patients with cirrhosis. A panel of 11 experts established a list of 41 quality indicators for 6 areas of care—ascites, variceal bleeding, hepatic encephalopathy, hepatocellular cancer, liver transplantation, and general cirrhosis care. In a related CGH podcast co-author Bruce Bacon describes the final 8 most important quality indicators selected by the panel. The authors conclude that this list begins to fill the void of quality assessment in cirrhosis; physicians might also use this list to identify processes in cirrhosis care that can be modified to improve patient outcomes. However, before this list is used in assessment processes, we must determine how adherence to this list of quality indicators actually affects outcomes. A better system to measure and track quality indicators also needs to be developed.

Hepatitis C-specific quality indicators have been implemented as part of the Medicare’s Physician Quality Reporting Initiative, a voluntary program that connects reimbursement incentive to compliance with performance using quality indicators. Kanwal et al. believe that with the increasing burden of cirrhosis, Medicare might extend the quality reporting initiatives to include the cirrhosis metrics, and that insurers will follow. The authors suggest that their list of quality indicators might be used as part of the assessment efforts in these healthcare systems.

Jayavani Moodley et al. investigated whether following quality recommendations actually improves patient outcomes. The 2007 American Association for the Study of Liver Disease and American College of Gastroenterology practice guidelines recommend screening and intervention to prevent esophageal varices in patients with cirrhosis. Moodley et al. studied whether there was an association between compliance with these guidelines and rate of esophageal variceal hemorrhage. In following 179 patients for almost 2 years, they associated physician compliance with a statistically significant reduction in first esophageal variceal hemorrhage. However, this study was performed at a tertiary care center that had a very high level of compliance, so the findings should be confirmed in community gastroenterology practices. The authors are planning investigate the patient, environment, and physician factors that contribute to noncompliance of guidelines.

Study population and screening endoscopy. *Reasons for exclusion: previous diagnosis of EV, EVH or already treated with beta blockers. CCF, Cleveland Clinic Foundation.

In an accompanying editorial, Nezam Afdahl adds that with the increasing emphasis on quality assessment and quality-based reimbursement models, we need to find the best tools for assessing healthcare quality and for implementing guidelines. Moodley et al. adds that there needs to be increased awareness among healthcare providers about existing practice guidelines.

Kanwal F, Kramer J, Asch SM, et al. An explicit quality indicator set for measurement of quality of care in patients with cirrhosis. Clin Gastroenterol Hepatol 2010;8:709–717.

Moodley J, Lopez R, and Carey W. Compliance with practice guidelines and risk of a first esophageal variceal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol 2010;8:703–708.

What do you think? Use the “Leave a Comment” link below to post your thoughts.

Read the accompanying Editorial:
Lai M and Afdhal NH. Health care quality measurement in the care of patients with cirrhosis. Clin Gastroenterol Hepatol 2010;8:649–650.

Read the following related Comment from the Editor:
Volk ML, Piette JD, Singal AS, et al. Chronic disease management for patients with cirrhosis. Gastroenterology 2010;139: 14–16.

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