title: The quality of care provided to patients with varices in the department of Veterans Affairs.
abstract: OBJECTIVE
  Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care.
  
  
  METHODS
  We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators.
  
  
  RESULTS
  Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care.
  
  
  CONCLUSIONS
  Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.
authors.affiliation: Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, USA.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Buchanan
authors.affiliation: Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Kramer
authors.affiliation: 1] Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
authors.affiliation: Department of Medicine and Health Services Research, Palo Alto VA Healthcare System, Palo Alto, California, USA.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.affiliation: Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA.
authors.forename: Youssef
authors.initials: Y
authors.lastname: Assioun
authors.affiliation: Department of Medicine, Saint Louis University, Saint Louis, Missouri, USA.
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Bacon
authors.affiliation: 1] Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
mesh_terms: D003697:Delphi Technique; D004932:Esophageal and Gastric Varices / Q000209:etiology* / Q000628:therapy*; D005260:Female; D005762:Gastroenterology / Q000592:standards*; D019983:Guideline Adherence; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012189:Retrospective Studies; D014481:United States; D014728:Veterans