Where: Baystate Medical Center, a 650-bed tertiary care center in Springfield, Mass.
The issue: Improving inpatient treatment of decompensated cirrhosis.
At Baystate Medical Center, 4 different groups of gastroenterologists see patients who are admitted with decompensated cirrhosis. After new guidelines on cirrhosis care came out in 2010, Rony M. Ghaoui, MD, and his colleagues decided to look at how closely all of the GI subspecialists were following them.
“We reviewed all our admissions to Baystate over a year, and we saw that we were compliant [with the guidelines] less than 50% of the time. There were many discussions internally on how we could fix this,” said Dr. Ghaoui, who is director of endoscopy and an assistant professor of medicine at Baystate. One thing that might help, they concluded, was to make sure that every decompensated cirrhosis inpatient was seen at least once by a gastroenterologist.
How it works
From June 2011 to June 2012, every time a patient was admitted with decompensated cirrhosis, the admitting physician was required to call for a GI consult. Dr. Ghaoui ensured compliance. “I had to, for a year, check all the [close to 200] admissions every day to the hospital and try to figure out who has decompensated cirrhosis and who doesn't, and then from there, contact the admitting team, making sure that they call the consultant for GI, and then making sure there was no pushback,” he said.
Pushback from the admitting team didn't turn out to be much of an issue. “I thought if it was a straightforward admission, maybe the hospitalist would not feel the need for a consultation,” said Dr. Ghaoui. “People were generally more receptive than I thought they would be.”
Thanks to the cooperation of the clinicians, all of the 154 cirrhosis patients in the intervention cohort were seen by a gastroenterologist, compared with fewer than half of the pre-intervention 149-patient comparison group.
The patients in the consult program were more likely to receive care that met quality indicators, 77% of the time versus 46%, according to results published by the Journal of Hospital Medicine on Dec. 30, 2014. The difference in quality was largely driven by dramatic improvements in use of diagnostic paracentesis for ascites (82.2% vs. 39.9%) and evaluation for liver transplantation (73.6% vs. 29.4%).
The main challenge of the intervention is that it's not practical as a permanent solution, according to Dr. Ghaoui. “You cannot force a hospitalist to call a GI consult,” he said. “Some of it is how people were trained, some of it is personal preference… All of that is mixed in what makes people call for a consult.” Subspecialists also vary in what they do when consulted; the study found that the GI doctors who were employed by the hospital were more likely to meet quality measures in their treatment of the intervention patients than outside groups.
Performance measurement may also be a factor affecting how hospitalists approach consults, he noted. “Do you measure [a hospitalist] by how little consultancy he calls for, or how often patients get readmitted, or length of stay?” Dr. Ghaoui said. In the study, the mandatory consults didn't significantly change length of stay or readmissions within 30 days for better or worse.
Another challenge is that the study didn't specifically look at cost-effectiveness, and future research could show that a subspecialist might be more effective staying in the background on easily handled cases. “I do not believe that those patients need to be systematically seen by a gastroenterologist unless we bring added value by doing paracentesis or coordinating the care for transplant,” Dr. Ghaoui said.
Dr. Ghaoui's next project in this area is to geographically localize patients with decompensated cirrhosis after they're identified in the emergency department. “We can flag them like a [heart failure] exacerbation and try to have them end up in a special part of the hospital: a unit where the nurses are more comfortable, more exposed to this type of admissions, where the hospitalists get more engaged in taking care of them,” he said.
Words of wisdom
Whatever solution a hospital chooses, it's important to work on optimizing cirrhosis care now to prepare for the predicted increases in this complication of hepatitis C and nonalcoholic fatty liver disease, Dr. Ghaoui advised. “Hepatology has changed a lot in the past 10 years,” he said. “I think many of the smaller hospitals deal with this differently or do not want to deal with this at all and transfer them to transplant centers. I think you're going to deal with these patients more and more.”