Rony Ghaoui

Measurement of the quality of care of patients admitted with decompensated cirrhosis

Process‐based quality measures are increasingly used to evaluate hospital performance. However, practices vary, and patients with cirrhosis are a challenge to manage, given their risks of mortality, morbidity, and resources utilization. In 2010, process‐based quality measures were developed to improve the care of these patients. We examined adherence with these quality measures for a cohort of patients admitted with decompensated cirrhosis in 2009.

Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis

BACKGROUND AND AIMS Patients with decompensated cirrhosis (DC) have significant morbidity and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met <50% of the time. We established a gastroenterology mandatory consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC. METHODS This was a prospective cohort study with historic control examining all admissions in a year for DC at an academic medical center. All admissions were seen by a gastroenterologist encouraged to implement QIs (MC). Scores were calculated for each group per admission as the proportion of QIs met versus QIs for which the patient was eligible. QI scores were examined as a function of group assignment multivariable fractional logit regression. We evaluated the impact of the intervention on compliance with QIs, length of stay (LOS), 30-day readmission, and inpatient death. RESULTS Three hundred three patients were observed in 695 hospitalizations (149 patients in 379 admissions [UC]; 154 patients in 316 admissions [MC]). The QI score was significantly higher in the MC group than the UC group (77.0% vs 46.0%, P < 0.001), reflecting better management of ascites and documentation of transplant evaluation. The management of variceal bleeding improved also but did not reach statistical significance. CONCLUSION The MC intervention was associated with greater adherence to recommended care but was not powered to detect difference in LOS, readmission, or mortality rates.

Russell body gastritis

Introduction Russell body gastritis, first described in 1998 [1], is a reactive gastric mucosal infiltration of plasma cells filled with cytoplasmic Russell bodies. Russell bodies are immunoglobulins present within dilated rough endoplasmic reticulum cisternae that have accumulated secondary to abnormal secretion [2]. We present a case of Russell body gastritis occurring in a 75-year-old man with a history of alcohol use, renal failure, dyslipidemia, and prior rhabdomyolysis. He was noncompliant with reflux medications and reported Image 1. Regenerative gastric mucosa showing numerous plasma cells filled with bright eosinophilic Russell bodies (H&E stain; original magnification 3200).

Use of paracentesis in hospitalized patients with decompensated cirrhosis and ascites: Opportunities for quality improvement

To the Editor: Ascites is the most common complication of cirrhosis leading to hospital admission.1 Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these do not present with abdominal pain, fever, nausea, or vomiting.2 Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long-term antibiotic prophylaxis for survivors of an SBP episode.3 Despite evidence that in-hospital mortality is reduced in those patients who receive paracentesis in a timely manner,4, 5 only 40–60% of eligible patients receive paracentesis.4, 6, 7 We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage

Goals: To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH). Background: Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (⩽12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices. Study: We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ⩽5 d), length of stay, and 30-day readmission. Results: Guideline adherence was variable: endoscopy ⩽12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P⩽0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks. Conclusions: Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.

Open access colonoscopy: Critical appraisal of indications, quality metrics and outcomes.

INTRODUCTION In an era of cost containment and measurement of value, screening for colon cancer represents a clear target for better accountability. Bundling payment is a real possibility and will likely have to rely on open-access colonoscopy (OAC). OAC is a method to allow patients to undergo endoscopy without prior evaluation by a gastroenterologist. We conducted a cross-sectional study to evaluate the indications and outcomes among patients scheduled for OAC or traditional colonoscopy at a tertiary medical center. We hypothesized that outcomes in OAC patients would be similar to those from traditional referral modes. METHOD Using a standardized data abstraction form, we documented indications for colonoscopy, clinical outcomes (complications, emergency room visits, phone calls), and compliance with quality indicators (QI) in a random sample of 1000 patients who underwent an outpatient colonoscopy at an academic medical center in 2013. We compared baseline characteristics and outcomes between two cohorts: OAC vs. patients who were scheduled after previous evaluation by a gastroenterologist or physician assistant or non-open access colonoscopy (NOAC). RESULTS Patients in the OAC group were more likely to be male, non-Hispanic, to be privately insured, and to have screening (vs. diagnostic) indication. However they were significantly less likely than those in the NOAC group to have a procedure performed once scheduled, (45.5% vs. 66.9%, p<0.001), due to no-show (24/178 or 13.5% vs. 60/822 or 7.3%), cancellation (56/178 or 31.5 vs. 156/822 or 19.0%), and non-compliance (9/178 or 5.1% vs. 20/822 or 2.4%). There were no clinically meaningful differences between groups with respect to outcomes such as polyp detection (35.6% OE vs. 39.5% NOE, p=0.54), postoperative call to GI practice (5.5% vs. 2.5%, p=0.41), or QI metrics such as documentation of prep quality (99.8% vs. 98.8%, p=0.24). CONCLUSION Patients undergoing OAC are more likely to have a screening colonoscopy but with overall similar clinical outcomes and compliance with QI to patients scheduled as NOAC. OAC remains handicapped by high cancellation and no-show rates.