T1006 Poor Adherence to Guidelines for Prevention of Recurrent Variceal Bleeding Among Veterans

Abstract

Background: Variceal hemorrhage is the most lethal complication of cirrhosis, with 20% mortality rate within the first 6 weeks. When untreated, the risk of rebleeding is as high as 60% within 2 years. Guidelines have been proposed by the AASLD to prevent recurrence of variceal hemorrhage. We hypothesize that adherence to these guidelines is suboptimal at this Veterans Affairs Hospital. Aims: (1) To determine the proportion of patients who adhered to current AASLD guidelines for secondary prophylaxis of variceal bleeding, (2) to identify barriers to adherence and (3) to compare outcomes between patients who were compliant and those non-compliant with the guidelines. Methods: All cirrhotic patients presenting to the NF/SGVHS with an index episode of esophageal variceal bleeding between 1/1/2000 and 12/31/ 2008 were identified. Individual charts were reviewed. Primary endpoints were rebleeding or death. Statistical analyzes were performed as appropriate. Results: 67 male patients were included, mean age 59 years old (range 35-81), and followed for a mean of 18.7 months (range 0-85). Beta-blockers were initiated prior to discharge in 55 patients (82%). After index EVL, GI recommended repeat EGD in 46/67 (69%), EGD was ordered prior to discharge in 37/67 (55%), and performed within the guideline recommended 7-14 days in only 4/67 (6%). 18/67 (27%) had EVL within 30 days. Reasons for nonadherence were: MD did not order EGD in 16/32 (50%), patient cancelled in 13/32 (41%) and clinic cancelled in 3/32 (9%). Regardless of the interval between EGDs, 26 patients achieved eradication of varices, and only 9 (13.4%) had follow-up EGD for confirmation of eradication. In all, 26 patients (38.8%) suffered a rebleeding episode, and 51 (76%) were deceased by the end of the study period. Rebleeding rate was 25% of those re-scoped within 2 weeks, 35.7% of those re-scoped within 15-30 days, and 40% of the remaining patients (p=NS). There was also no difference in rebleeding rate according to eradication status. However, mortality was higher among patients who did not achieve eradication (55% vs. 21%, p= 0.0011). Conclusion: Only a negligible proportion of patients undergo appropriate secondary prophylaxis for esophageal variceal bleeding and this poor adherence is associated with increased mortality. Further efforts should be directed toward strategies to provide guideline concordant care should be targeted towards educating providers and identifying patient centered barriers to adherence. One strategy we are exploring is the creation of an order set for EGD scheduling prior to discharge.