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Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA

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Abstract

Background and Aim

The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis.

Methods

This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined.

Results

A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0–8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12–176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01–1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73–2.46), whereas cardiovascular (OR 0.81, CI 0.69–0.95), mental health (OR 0.79, CI 0.68–0.91), and respiratory (OR 0.85, CI 0.72–0.99) comorbidities were associated with reduced likelihood of EV screening.

Conclusion

EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.

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Acknowledgments

The authors would like to thank Dr. David Goldberg for his expertise and suggestions regarding the VA CCR. This study was supported in part by the Canadian Association for the Study of the Liver (CASL)/Merck Clinical Hepatology Fellowship (JAF). This publication was also supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number KL2 TR000143. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

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Authors and Affiliations

  1. Departments of Medicine and Public Health Sciences, Queen’s University, 166 Brock Street, S4-012, Kingston, ON, K7L 5M2, Canada

    Jennifer A. Flemming

  2. Department of Medicine, University of California San Francisco, San Francisco, CA, USA

    Varun Saxena, Hui Shen, Norah A. Terrault & Catherine Rongey

  3. Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA

    Hui Shen & Catherine Rongey

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  1. Jennifer A. Flemming
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  2. Varun Saxena
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Correspondence to Jennifer A. Flemming.

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Flemming, J.A., Saxena, V., Shen, H. et al. Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA. Dig Dis Sci 61, 62–69 (2016). https://doi.org/10.1007/s10620-015-3865-8

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  • DOI: https://doi.org/10.1007/s10620-015-3865-8

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