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.
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.