title: The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.
abstract: OBJECTIVE
  Ascites are the most common complication of cirrhosis. Evidence-based guidelines define the criteria and standards of care for patients with cirrhosis and ascites. However, little is known about the extent to which patients with ascites meet these standards.
  
  
  METHODS
  We evaluated the quality of ascites care, measured by 8 explicit Delphi panel-derived quality indicators, in 774 patients with cirrhosis and ascites, seen at 3 Veterans Affairs Medical Centers between 2000 and 2007. We also conducted a structured implicit review of patients' medical charts to determine whether patient refusal, outside care, or other justifiable exceptions to care processes account for nonadherence to the quality indicators.
  
  
  RESULTS
  Quality scores (maximum 100%) varied among individual indicators, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis, to 90% for assays for cell number and type in the paracentesis fluid. In general, care targeted at treatment was more likely to meet standards than preventive care. Only 33.2% (95% confidence interval [CI]: 29.9%-32.9%) of patients received all recommended care. Patients with no comorbidity (Deyo index 0 vs >3; odds ratio = 2.21; 95% CI: 1.43-3.43), who saw a gastroenterologist (odds ratio = 1.33; 95% CI, 1.01-1.74), or were seen in a facility with academic affiliation (odds ratio = 1.73; 95% CI: 1.29-2.35) received higher-quality care. Justifiable exceptions to indicated care, documented in charts, were common for patients with paracentesis after diagnosis with ascites, patients that received antibiotics for gastrointestinal bleeding, and patients that required diuretics. However, most patients did not have an explanation documented for nonadherence to recommended care.
  
  
  CONCLUSIONS
  Health care quality, measured by whether patients received recommended services, was suboptimal for patients with cirrhosis-related ascites. Care that included gastroenterologists was associated with high quality. However, for some of the quality indicators, too many denominator exceptions existed to allow for accurate automated measurement.
authors.affiliation: Department of Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA. fasiha.kanwal@va.gov
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Kramer
authors.forename: Paula
authors.initials: P
authors.lastname: Buchanan
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Youssef
authors.initials: Y
authors.lastname: Assioun
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Bacon
authors.forename: Juan
authors.initials: J
authors.lastname: Li
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
mesh_terms: D001201:Ascites / Q000209:etiology / Q000628:therapy*; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000628:therapy*; D008297:Male; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care