title: Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease.
abstract: BACKGROUND
  Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention.
  
  
  METHODS
  We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC.
  
  
  RESULTS
  We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38).
  
  
  CONCLUSIONS
  Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
authors.affiliation: 1 Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California , Los Angeles, California.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Walling
authors.forename: Hannah
authors.initials: H
authors.lastname: Schreibeis-Baum
authors.forename: Neville
authors.initials: N
authors.lastname: Pimstone
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Linda
authors.initials: L
authors.lastname: Robinson
authors.forename: Sheri
authors.initials: S
authors.lastname: Korlekar
authors.forename: Karl
authors.initials: K
authors.lastname: Lorenz
authors.forename: Tracy
authors.initials: T
authors.lastname: Nwajuaku
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rosenfeld
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000601:surgery / Q000628:therapy; D003142:Communication; D015897:Comorbidity; D058625:End Stage Liver Disease / Q000453:epidemiology / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000601:surgery / Q000628:therapy; D008113:Liver Neoplasms / Q000601:surgery / Q000628:therapy; D016031:Liver Transplantation / Q000592:standards*; D010166:Palliative Care / Q000592:standards*; D018579:Patient Selection; D058996:Quality Improvement / Q000592:standards; D011788:Quality of Life; D012720:Severity of Illness Index; D019966:Substance-Related Disorders / Q000453:epidemiology; D013727:Terminal Care / Q000592:standards*; D058014:Veterans Health / Q000592:standards* / Q000706:statistics & numerical data