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Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination

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Abstract

Background

Two-thirds of patients with cirrhosis do not receive guideline-concordant liver care. Cirrhosis patients are less likely to receive recommended care when followed exclusively by primary care providers (PCPs), as opposed to specialty co-management. Little is known about how to optimize cirrhosis care delivered by PCPs.

Aims

We conducted a qualitative analysis to explore PCPs’ attitudes and self-reported roles in caring for patients with cirrhosis.

Methods

We recruited PCPs from seven Veterans Affairs facilities in the Pacific Northwest via in-service trainings and direct email from March to October 2012 (n = 24). Trained staff administered structured telephone interviews covering: (1) general attitudes; (2) roles and practices; and (3) barriers and facilitators to cirrhosis management. Two trained, independent coders reviewed each interview transcript and thematically coded responses.

Results

Three overarching themes emerged in PCPs’ perceptions of cirrhosis patients: the often overwhelming complexity of comorbid medical, psychiatric, and substance issues; the importance of patient self-management; and challenges surrounding specialty care involvement and co-management of cirrhosis. While PCPs felt they brought important skills to bear, such as empathy and care coordination, they strongly preferred to defer major cirrhosis management decisions to specialists. The most commonly reported barriers to care included patient behaviors, access issues, and conflicts with specialists.

Conclusions

PCPs perceive Veterans with cirrhosis as having significant medical and psychosocial challenges. PCPs tend not to see their role as directing cirrhosis-related management decisions. Educational efforts directed at PCPs must foster PCP empowerment and improve comfort with managing cirrhosis.

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Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Portions of this work were presented at The Liver Meeting (November 5, 2013), the annual meeting of the American Association for the Study of Liver Disease. This material is the result of work supported by resources from the VA Puget Sound Health Care System (Seattle, Washington). Funding was provided by the VA National Hepatitis C Resource Centers program, through the Office of HIV, Hepatitis C, and Public Health Pathogens.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Primary Care Service, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA

    Lauren A. Beste & Ginger A. Evans

  2. Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA

    Lauren A. Beste & Bonnie K. Harp

  3. Division of General Internal Medicine, University of Washington, Seattle, WA, USA

    Lauren A. Beste & Ginger A. Evans

  4. Mental Health Service, VA Puget Sound Health Care System, Seattle, WA, USA

    Rebecca K. Blais

  5. Department of Psychology, Utah State University, Logan, UT, USA

    Rebecca K. Blais

  6. Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA

    Susan L. Zickmund

  7. Departments of Medicine and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA

    Susan L. Zickmund

Authors
  1. Lauren A. Beste
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  2. Bonnie K. Harp
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  3. Rebecca K. Blais
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  4. Ginger A. Evans
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  5. Susan L. Zickmund
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Corresponding author

Correspondence to Lauren A. Beste.

Appendix: Interview Questions

Appendix: Interview Questions

We are interested in your story about treating patients with cirrhosis:

  1. (1)

    How often do you encounter patients with cirrhosis or end-stage liver disease?

  2. (2)

    What comes to mind when you think about cirrhosis patients?

We are interested in your role as a primary care provider:

  1. (3)

    What do you think are the role(s) of primary care providers in managing patients with cirrhosis?

  2. (4)

    Have you ever diagnosed cirrhosis before? If so, how did you make the diagnosis?

  3. (5)

    How comfortable do you feel with making treatment decisions related to cirrhosis?

  4. (6)

    Do you think cirrhosis is easy or difficult to diagnose compared to other conditions?

Follow-up: What makes you say this?

  1. (7)

    What do you think is the role of the patient in self-management of cirrhosis?

We are interested in problems that arise in caring for cirrhosis patients:

  1. (8)

    What factors do you think tend to delay the diagnosis of cirrhosis?

  2. (9)

    What is the biggest challenge you face in caring for cirrhosis patients?

  3. (10)

    What do you think are barriers to managing cirrhosis patients after hospital discharge?

We are interested in learning where you get information about cirrhosis:

  1. (11)

    Where do you get most of your information about cirrhosis? Is there a source you tend to rely on the most?

  2. (12)

    Do you feel you can reach out for assistance if you have questions about a patient with cirrhosis?

  3. (13)

    Is there anything you would like to add that would help us to understand your experience of diagnosing cirrhosis?

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Beste, L.A., Harp, B.K., Blais, R.K. et al. Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination. Dig Dis Sci 60, 2628–2635 (2015). https://doi.org/10.1007/s10620-015-3592-1

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  • DOI: https://doi.org/10.1007/s10620-015-3592-1

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