Screening in Cirrhosis: Why Isnʼt It Getting Done? A Performance Assessment of an Academic Institution

Abstract

Purpose: Standards of care in cirrhosis include immunization to hepatitis A and B, endoscopic screening for varices, and the routine monitoring for hepatocellular carcinoma (HCC). Vaccination is recommended in chronic liver disease much earlier before the onset of cirrhosis. For variceal screening, the AASLD endorses upper endoscopy (EGD) to be performed upon diagnosis of cirrhosis; however, less than 50% of gastroenterologists are compliant. Finally, a biannual program to monitor for HCC has shown adherence rates as low as 12%. We sought to assess our clinic performance in addressing these issues, and to identify the factors that lead to non-compliance. Methods: The Stony Brook University Hepatology Clinic was used to identify all patients with a new diagnosis of cirrhosis over a three-year period. Each chart was reviewed for documentation in regards to hepatitis vaccination, variceal screening, and HCC surveillance, and recorded in a database. Performance was evaluated by calculating percent compliance in addressing and performing the necessary tests. Factors were identified to determine the most common reasons why patients did not adhere to screening. A total of 120 charts were reviewed. Results: Vaccination to hepatitis A and B was addressed at the first clinic visit in 81% and 84% of patients, respectively. The most common reason for non-compliance, however, was the lack of discussion by the physician (31%). Another factor was loss to follow-up; 35% of patients had missed at least one appointment during their clinic course, and this was significantly associated with whether HAV and HBV vaccinations were addressed. 40% of patients did not receive an EGD within a year of diagnosis; again, mainly due to the lack of discussion (31%). Proper HCC surveillance was performed in 98% of patients. Variables such as age at first visit, ethnicity, and gender did not have any statistically significant association with lack of vaccination, EGD, or HCC monitoring. Conclusion: As a clinic within a tertiary care center, we are representative of health care centers throughout the United States. Our study demonstrates that compliance with screening recommendations has much need for improvement. Here, we analyzed our own performance in addressing these standards, as well as identifying the factors that lead to no-compliance. Although vaccinations, EGD, and HCC surveillance are addressed in nearly every patient, this does not always happen during the patient's initial clinic visit. Furthermore, as approximately 1/3 of patients will miss an appointment, the window of opportunity to address these issues can be lost. To improve adherence rates, we have instituted a flowsheet to be included in new charts in an effort to enhance care and translate to better clinical outcomes.