Lim Nicholas, Lidofsky Steven D
Division of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington, Vermont, United States of America; University of Vermont Medical Center, Burlington, Vermont, United States of America.
PLoS One. 2015 Apr 2;10(4):e0123490. doi: 10.1371/journal.pone.0123490. eCollection 2015.
Decompensated cirrhosis is a common precipitant for hospitalization, and there is limited information concerning factors that influence the delivery of quality care in cirrhotic inpatients. We sought to determine the relation between physician specialty and inpatient quality care for decompensated cirrhosis.
We reviewed 247 hospital admissions for decompensated cirrhosis, managed by hospitalists or intensivists, between 2009 and 2013. The primary outcome was quality care delivery, defined as adherence to all evidence-based specialty society practice guidelines pertaining to each specific complication of cirrhosis. Secondary outcomes included new complications, length-of-stay, and in-hospital death.
Overall, 147 admissions (59.5%) received quality care. Quality care was given more commonly by intensivists, compared with hospitalists (71.7% vs. 53.1%, P = .006), and specifically for gastrointestinal bleeding (72% vs. 45.8%, P = .03) and hepatic encephalopathy (100% vs. 63%, P = .005). Involvement of gastroenterology consultation was also more common in admissions in which quality care was administered (68.7% vs. 54.0%, P = .023). Timely diagnostic paracentesis was associated with reduced new complications in admissions for refractory ascites (9.5% vs. 46.6%, P = .02), and reduced length-of-stay in admissions for spontaneous bacterial peritonitis (5 days vs. 13 days, P = .02).
Adherence to quality indicators for decompensated cirrhosis is suboptimal among hospitalized patients. Although quality care adherence appears to be higher among cirrhotic patients managed by intensivists than by hospitalists, opportunities for improvement exist in both groups. Rational and cost-effective strategies should be sought to achieve this end.
失代偿期肝硬化是住院治疗的常见诱因，关于影响肝硬化住院患者优质护理提供的因素，相关信息有限。我们试图确定医生专业与失代偿期肝硬化住院患者优质护理之间的关系。
我们回顾了2009年至2013年间由住院医师或重症监护医师管理的247例失代偿期肝硬化住院病例。主要结局是优质护理的提供，定义为遵循所有基于证据的专业学会针对肝硬化每种特定并发症的实践指南。次要结局包括新发并发症、住院时间和院内死亡。
总体而言，147例住院病例（59.5%）接受了优质护理。与住院医师相比，重症监护医师更常提供优质护理（71.7%对53.1%，P = 0.006），特别是在治疗胃肠道出血（72%对45.8%，P = 0.03）和肝性脑病方面（100%对63%，P = 0.005）。在接受优质护理的住院病例中，胃肠病学会诊的参与也更常见（68.7%对54.0%，P = 0.023）。对于难治性腹水住院病例，及时进行诊断性腹腔穿刺与新发并发症减少相关（9.5%对46.6%，P = 0.02），对于自发性细菌性腹膜炎住院病例，与住院时间缩短相关（5天对13天，P = 0.02）。
住院患者中失代偿期肝硬化优质指标的遵循情况欠佳。尽管由重症监护医师管理的肝硬化患者中优质护理的遵循率似乎高于住院医师管理的患者，但两组都存在改进的空间。应寻求合理且具有成本效益的策略来实现这一目标。
