title: Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA.
abstract: OBJECTIVE
  The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis.
  
  
  METHODS
  This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined.
  
  
  RESULTS
  A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0-8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12-176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01-1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73-2.46), whereas cardiovascular (OR 0.81, CI 0.69-0.95), mental health (OR 0.79, CI 0.68-0.91), and respiratory (OR 0.85, CI 0.72-0.99) comorbidities were associated with reduced likelihood of EV screening.
  
  
  CONCLUSIONS
  EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.
authors.affiliation: Departments of Medicine and Public Health Sciences, Queen's University, 166 Brock Street, S4-012, Kingston, ON, K7L 5M2, Canada. flemmij@hdh.kari.net.
authors.forename: Jennifer A
authors.identifier: http://orcid.org/0000-0002-9911-0925
authors.initials: JA
authors.lastname: Flemming
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Varun
authors.initials: V
authors.lastname: Saxena
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA, USA.|Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA.
authors.forename: Hui
authors.initials: H
authors.lastname: Shen
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Norah A
authors.initials: NA
authors.lastname: Terrault
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, CA, USA.|Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Rongey
mesh_terms: D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D018450:Disease Progression; D016099:Endoscopy, Gastrointestinal / Q000592:standards; D004932:Esophageal and Gastric Varices / Q000175:diagnosis* / Q000401:mortality / Q000821:virology; D005260:Female; D019983:Guideline Adherence; D006268:Health Facilities / Q000592:standards; D006526:Hepatitis C / Q000175:diagnosis / Q000401:mortality; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000401:mortality / Q000821:virology; D016015:Logistic Models; D008297:Male; D008403:Mass Screening / Q000379:methods* / Q000592:standards; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011237:Predictive Value of Tests; D012017:Referral and Consultation / Q000592:standards; D012307:Risk Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D058014:Veterans Health
keywords: Cirrhosis; Endoscopy; Hepatitis C; Variceal screening