Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Liver Disease

Similar to patients with luminal gastrointestinal disease, definitions of quality measures are necessary for patients with advanced liver disease and cirrhosis.[70] Kanwal et al[71] have developed a set of evidence-based quality indicators for physicians and institutions to use as a tool in the care of patients with cirrhosis. Surveillance for hepatocellular carcinoma (HCC) and management of varices are 2 important examples of quality indicators for outpatient clinical practices that manage patients with advanced liver disease and cirrhosis.

Hepatocellular Carcinoma

The annual incidence of HCC ranges from 3% to 8% among patients with advanced liver disease,[72,73] and for this reason systems are needed to ensure proper surveillance and management. Patients are often diagnosed with HCC at a late stage of tumor progression, so their tumors are large and have undergone vascular invasion and metastasis, precluding surgical resection or transplantation; subsequently, mortality is high. Surveillance with biannual ultrasound examinations appears to be cost-effective for patients with cirrhosis; they have an expected annual incidence of HCC that exceeds 1.5%/year among patients with hepatitis C and 0.2%/year among those with hepatitis B.[74] Surveillance with abdominal ultrasound is recommended by both AASLD and European Association for the Study of the Liver.

Levels of alpha fetoprotein are often used with imaging analyses to identify patients with HCC, but this approach increases costs and has a high false-positive rate, so it is not recommended as a surveillance tool by AASLD.[75,76] These guidelines suggest surveillance for all patients with cirrhosis and for patients with hepatitis B in these categories: Asian man >40 years, Asian woman >50 years, HBV-associated cirrhosis, African and North American blacks, and family history of HCC. Whites with low HBV activity have a low risk for developing HCC, so surveillance generally is not recommended, in contrast to white patients with high viral load and active hepatitis.[75] A large randomized controlled trial that included 18,816 patients found that mortality from HCC was significantly lower after 5 years in the screened group (who received biannual ultrasound and alpha fetoprotein tests) compared with the control group (83 vs 132 per 100,000; mortality rate ratio of 0.63).[77]

Despite data to support the benefits of surveillance for high-risk populations, the prevalence of adequate screening is unknown but appears to be low. In a population-based retrospective cohort study of patients diagnosed with HCC by Davila et al,[72,78] only 17% of patients in the Medicare database >65 years old received regular examinations for HCC, and 38% were examined inconsistently. Patients at highest risk for inadequate surveillance were those living in urban areas, with lower incomes, and receiving care at nonacademic centers.[72,78] The large retrospective cohort study of Veterans Administration hepatitis C virus patients demonstrated that 88% of patients with cirrhosis did not receive guideline-based HCC surveillance. At 1 year, only 42% received guideline-based surveillance, and rates subsequently fell during the next 2–3 years of follow-up.[79]

QI initiatives to improve HCC outcomes need to provide a system-based approach to improve surveillance in high-risk cohorts to increase survival through earlier detection of tumors. A QI initiative for surveillance of HCC could include the following: (1) a retrospective review of HCC screening in appropriate individuals; (2) intervention, which could include sending reminders to specific patients or physicians, especially for patients at highest risk of missing examinations, or standardized, closed-loop communication with referring primary care physicians; and (3) prospective review of improvements in surveillance after set interventions; these should be assessed and alterations made as needed.

Gastroesophageal Varices

Varices develop in approximately 50% of patients with cirrhosis and are an important factor to consider in determining QI for outpatients with liver disease (second to cost and mortality from variceal bleeding). It is important to evaluate these patients by endoscopy and provide β-blocker therapies as prophylactics. The incidence of varices development is 8% per year, and development is correlated with the severity of liver disease.[80,81] Patients with compensated cirrhosis without varices should be evaluated for varices development by endoscopy at 2- to 3-year intervals, patients with small varices should be evaluated every 1–2 years, and patients with decompensated cirrhosis should be evaluated every year (grade C*).[82,83] The risk of variceal bleeding and liver-related mortality is significantly reduced with β-blocker therapies,[84] and therapy was shown to be cost-effective in primary prophylaxis of variceal bleeding.[85,86]

Surveillance and treatment of varices have been found to be lower than would be suggested on the basis of guidelines.[87] QI initiatives should address inadequate screening and prophylaxis. One could consider the following: (1) reviewing the numbers of routine examinations patients receive for varices and comparing these with recommendations from guidelines; (2) identifying barriers to appropriate screening; (3) creating and testing computer-based templates to document patients' heart rates at each visit to ensure proper doses of β-blockers; and (4) creating a screening sheet for patients with advanced liver disease to improve follow-up and communication with referring physicians.