title: Guideline adherence and outcomes in esophageal variceal hemorrhage: comparison of tertiary care and non-tertiary care settings.
abstract: BACKGROUND
  Implementation of consensus guidelines for esophageal variceal hemorrhage yields improved outcomes. We evaluated guideline adherence and outcomes after variceal hemorrhage at a university hospital (UH) and a staff-model health maintenance organization (HMO).
  
  
  METHODS
  Factors associated with short-term bleeding, infection, and death were retrospectively identified in UH (n=160) and HMO (n=123) patients with esophageal variceal hemorrhage from January 2000 to December 2006. A second analysis of factors associated with long-term rebleeding was conducted in patients who survived ≥14 days without rebleeding.
  
  
  RESULTS
  UH patients were younger, with more severe liver disease and overall illness (P<0.01). UH patients more often received vasoactive agents and prophylactic antibiotics (P<0.01), however the rate of endoscopic therapy did not differ. Infections at 14-days were similar (18.2% vs. 13.0%, P=0.25), but UH patients had greater in-hospital rebleeding (16.4% vs. 5.7%, P<0.01) and mortality (15.2% vs. 4.1%, P<0.01). Poor liver function and overall illness predicted infection, rebleeding, and death (adjusted odds ratio 2.75 to 13.39). Long-term rebleeding occurred in 36.1% of UH patients and 25.9% of HMO patients. Secondary prophylaxis reduced late rebleeding (hazard ratio 0.37 to 0.41). Poor liver function did not predict late rebleeding. Adherence to secondary prophylaxis was greater at the HMO (P<0.05), but late rebleeding did not differ (36% vs. 26%, P=0.13).
  
  
  CONCLUSIONS
  Irrespective of practice setting, poor liver function and critical illness predicted short-term bleeding, infection, and death after esophageal variceal hemorrhage, and secondary prophylaxis prevented long-term rebleeding. Differing guideline adherence did not influence outcomes between tertiary care and non-tertiary care centers.
authors.affiliation: Division of Gastroenterology & Hepatology, Department of Medicine, Oregon Health & Science University , Kaiser Permanente Northwest, Portland, OR 97239, USA.
authors.forename: Barry
authors.initials: B
authors.lastname: Schlansky
authors.forename: Brent
authors.initials: B
authors.lastname: Lee
authors.forename: Laurel
authors.initials: L
authors.lastname: Hartwell
authors.forename: Jennifer
authors.initials: J
authors.lastname: Urquhart
authors.forename: Brian
authors.initials: B
authors.lastname: Willis
authors.forename: Atif
authors.initials: A
authors.lastname: Zaman
mesh_terms: D000328:Adult; D000368:Aged; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000517:prevention & control / Q000601:surgery / Q000628:therapy*; D019983:Guideline Adherence; D006279:Health Maintenance Organizations / Q000706:statistics & numerical data*; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D055502:Secondary Prevention; D015996:Survival Rate; D016896:Treatment Outcome