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The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers


Cirrhosis is morbid and increasingly prevalent - yet the U.S. healthcare system lacks enough physicians and specialists to adequately manage patients with cirrhosis. While advanced practice providers (APPs) can expand access to cirrhosis-related care, their impact on quality of care remains unknown. We sought to determine the effect on care-quality and outcomes for patients managed by APP using a retrospective analysis of a nationally representative American commercial claims database (Optum) which included 389,257 unique adults with cirrhosis. We evaluated a complication of process measures - rates of hepatocellular carcinoma (HCC) screening, endoscopic varices screening, and use of rifaximin after hospitalization for hepatic encephalopathy (HE) - and outcomes (30-day readmissions and survival). Compared to patients without APP-care, patients with APP-care had higher rates of HCC screening (adjusted odds ratio (OR) 1.23 95%CI[1.19,1.27]), varices screening (OR 1.20 [1.13,1.27]), use of rifaximin after a discharge for HE (OR 2.09[1.80,2.43]), and reduced risk of 30-day readmission (OR 0.68[0.66,0.70]). Gastroenterology/hepatology consultation was also associated with improved quality metric performance compared to primary care, however shared visits between gastroenterologist/hepatologists and APP were associated with the best performance and lower 30-day readmissions compared to subspecialty consultation without APP (OR 0.91 [0.87, 0.95]. Multivariate analysis adjusting for comorbidities, liver disease severity and other factors including gastroenterology/hepatology consultation showed that patients seen by APPs were more likely to receive consistent HCC and varices screening over time, less likely to experience 30-day readmissions, and had lower mortality (adjusted hazard ratio 0.57 95%CI[0.55,0.60]). CONCLUSION: APPs, particularly when working with gastroenterologists/hepatologists, are associated with improved quality of care and outcomes for patients with cirrhosis. 


Tapper EB1,2, Hao S3, Lin M3, Mafi JN4,5, McCurdy H2, Parikh ND1,2, Lok AS1,2. Hepatology. 2019 May 7. doi: 10.1002/hep.30695. [Epub ahead of print]

Author Information

1.  Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

2.  Veterans Affairs, Ann Arbor, MI.

3.  University of Michigan, Ann Arbor, MI.

4.  Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA.

5.  RAND Health, RAND Corporation.

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