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Organizational and Implementation Factors Associated with Cirrhosis Care in the Veterans Health Administration

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Abstract

Background

The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis.

Aims

This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care.

Methods

Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models.

Results

Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool (“dashboard”). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs.

Conclusions

Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.

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Abbreviations

CDW:

Corporate Data Warehouse

CFIR:

Consolidated Framework for Implementation Research

EVST:

Esophageal variceal surveillance or treatment

FAB:

Field Advisory Board

NGHP:

National Gastroenterology and Hepatology Program

VA:

Department of Veterans Affairs

VAMC:

VA medical centers

VHA:

Veterans Health Administration

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Funding

Funding for this quality improvement project was provided by the Department of Veterans Affairs National Gastroenterology and Hepatology Program Office. Funding for Dr. Rogal’s time was provided in part by grant K23DA048182 from the National Institute on Drug Abuse. The views expressed here are those of the authors and do not represent those of the Department of Veterans Affairs, the National Institutes of Health, or the United States Government.

Author information

Authors and Affiliations

  1. Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA

    Heather McCurdy

  2. Digestive Diseases Section, Cincinnati VA Medical Center, Cincinnati, OH, USA

    Anna Nobbe

  3. VA Central Texas Healthcare System, Temple, TX, USA

    Dawn Scott

  4. VA San Diego Healthcare System, San Diego, CA, USA

    Heather Patton

  5. University of California San Diego, La Jolla, CA, USA

    Heather Patton

  6. VA Long Beach Healthcare System, Long Beach, CA, USA

    Timothy R. Morgan & Jennifer Anwar

  7. Department of Medicine, University of California, Irvine, CA, USA

    Timothy R. Morgan

  8. National Gastroenterology and Hepatology Program, Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA

    Timothy R. Morgan, Jennifer Anwar & Jason A. Dominitz

  9. Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA

    Jasmohan S. Bajaj

  10. Division of Gastroenterology, Hepatology and Nutrition, Central Virginia VA Health Care System, Richmond, VA, USA

    Jasmohan S. Bajaj

  11. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Vera Yakovchenko, Monica Merante, Sandra Gibson, Carolyn Lamorte & Shari S. Rogal

  12. Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Sandra Gibson & Shari S. Rogal

  13. Section of Gastroenterology, Department of Medicine, VA Boston Healthcare System, Boston, MA, USA

    Gyorgy Baffy

  14. Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Gyorgy Baffy

  15. VA Puget Sound Health Care System, Seattle, WA, USA

    George N. Ioannou & Jason A. Dominitz

  16. University of Washington, Seattle, WA, USA

    George N. Ioannou & Jason A. Dominitz

  17. VA Connecticut Healthcare System, West Haven, CT, USA

    Tamar H. Taddei

  18. Yale University, New Haven, CT, USA

    Tamar H. Taddei

  19. VISN 12 PBM, VA Great Lakes Health Care System, Westchester, IL, USA

    Karine Rozenberg-Ben-Dror

  20. Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Shari S. Rogal

  21. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Building 30 Room 2A113, University Drive (151C), Pittsburgh, PA, 15240, USA

    Shari S. Rogal

Authors
  1. Heather McCurdy
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  2. Anna Nobbe
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  3. Dawn Scott
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  4. Heather Patton
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  5. Timothy R. Morgan
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  6. Jasmohan S. Bajaj
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  7. Vera Yakovchenko
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  8. Monica Merante
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  9. Sandra Gibson
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  10. Carolyn Lamorte
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  11. Gyorgy Baffy
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  12. George N. Ioannou
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  13. Tamar H. Taddei
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  14. Karine Rozenberg-Ben-Dror
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  15. Jennifer Anwar
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  16. Jason A. Dominitz
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  17. Shari S. Rogal
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Corresponding author

Correspondence to Shari S. Rogal.

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Conflict of interest

Dr. Baffy consults for iota Biosciences. The remaining authors have no conflict to report.

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McCurdy, H., Nobbe, A., Scott, D. et al. Organizational and Implementation Factors Associated with Cirrhosis Care in the Veterans Health Administration. Dig Dis Sci (2024). https://doi.org/10.1007/s10620-024-08409-6

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  • DOI: https://doi.org/10.1007/s10620-024-08409-6

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