In the Journals

Advanced practice providers make difference in cirrhosis care quality

Patients with cirrhosis had improved quality of care and outcomes when treated by advanced practice providers compared with those without such care.

In the study published in Hepatology, Elliot B. Tapper, MD, from the University of Michigan, and colleagues retrospectively analyzed a “complication of process measures” including rates of hepatocellular carcinoma, hepatic encephalopathy, readmissions, and survival.

“A major barrier to optimal care for cirrhosis is limited access to subspecialty care,” Tapper and colleagues wrote. “Most patients with cirrhosis are not comanaged by a gastroenterology or hepatology trained specialist. Previous studies have demonstrated that advanced practice providers (APPs) provide care that is equivalent in quality to medical doctors (MDs) in both primary care and specialty care when their practice is focused on one condition.”

Of the 389,257 patients analyzed, 57% never had a visit with an APP. Compared with that 57%, patients evaluated by an APP with or without gastroenterology or hepatology consultation had improved HCC screening (OR = 1.23; 95% CI, 1.19-1.27), varices screening (OR = 1.2; 95% CI, 1.13-1.27), and use of rifaximin after discharge for hepatic encephalopathy (OR = 2.09; 95% CI, 1.8-2.43).

However, APP management alone was inferior to management by gastroenterologists or hepatologists without assistance by APP in all measures except 30-day readmissions (OR = 0.61; 95% CI, 0.58-0.63).

Older age, additional medical comorbidities, and advanced cirrhosis had higher hazard ratios for mortality. In an analysis that accounted for these competing risks, APP involvement correlated with a reduced risk for death (HR = 0.57; 95% CI, 0.55-06) and liver transplantation (HR = 0.33; 95% CI, 0.21-0.5).

APP involvement also correlated with increased overall costs compared with those who did not see an APP (HR = 1.79; 95% CI, 1.77-1.8). The main procedures that drove costs included radiology tests, endoscopy procedures, and liver resection. Tapper and colleagues noted that cost analyses are needed to confirm these associations as well as whether these increased charges could be cost-effective.

“The key opportunity suggested by our data is to encourage care delivery that leverages broader availability of APPs to implement care plan co-developed with gastroenterologists/hepatologists,” the researchers concluded. – by Talitha Bennett

Disclosure: Tapper reports he has received research grants from Valeant. Please see the full study for all other authors’ relevant financial disclosures.

Patients with cirrhosis had improved quality of care and outcomes when treated by advanced practice providers compared with those without such care.

In the study published in Hepatology, Elliot B. Tapper, MD, from the University of Michigan, and colleagues retrospectively analyzed a “complication of process measures” including rates of hepatocellular carcinoma, hepatic encephalopathy, readmissions, and survival.

“A major barrier to optimal care for cirrhosis is limited access to subspecialty care,” Tapper and colleagues wrote. “Most patients with cirrhosis are not comanaged by a gastroenterology or hepatology trained specialist. Previous studies have demonstrated that advanced practice providers (APPs) provide care that is equivalent in quality to medical doctors (MDs) in both primary care and specialty care when their practice is focused on one condition.”

Of the 389,257 patients analyzed, 57% never had a visit with an APP. Compared with that 57%, patients evaluated by an APP with or without gastroenterology or hepatology consultation had improved HCC screening (OR = 1.23; 95% CI, 1.19-1.27), varices screening (OR = 1.2; 95% CI, 1.13-1.27), and use of rifaximin after discharge for hepatic encephalopathy (OR = 2.09; 95% CI, 1.8-2.43).

However, APP management alone was inferior to management by gastroenterologists or hepatologists without assistance by APP in all measures except 30-day readmissions (OR = 0.61; 95% CI, 0.58-0.63).

Older age, additional medical comorbidities, and advanced cirrhosis had higher hazard ratios for mortality. In an analysis that accounted for these competing risks, APP involvement correlated with a reduced risk for death (HR = 0.57; 95% CI, 0.55-06) and liver transplantation (HR = 0.33; 95% CI, 0.21-0.5).

APP involvement also correlated with increased overall costs compared with those who did not see an APP (HR = 1.79; 95% CI, 1.77-1.8). The main procedures that drove costs included radiology tests, endoscopy procedures, and liver resection. Tapper and colleagues noted that cost analyses are needed to confirm these associations as well as whether these increased charges could be cost-effective.

“The key opportunity suggested by our data is to encourage care delivery that leverages broader availability of APPs to implement care plan co-developed with gastroenterologists/hepatologists,” the researchers concluded. – by Talitha Bennett

Disclosure: Tapper reports he has received research grants from Valeant. Please see the full study for all other authors’ relevant financial disclosures.