title: Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies.
abstract: OBJECTIVE
  Gastroenterologists should strive to improve the outcomes associated with acute variceal hemorrhage (AVH) by optimizing care delivery and clinician preparedness through training. Unfortunately, data regarding contemporary outcomes and management of AVH are limited.
  
  
  METHODS
  We performed a systematic review of cohort studies examining outcomes and management of AVH from January 1990 to September 2016. We pooled data on mortality and utilization of medical therapy, endoscopic interventions, balloon tamponade (BT), and salvage procedures (portal decompressive surgery or transjugular portosystemic shunt).
  
  
  RESULTS
  The pooled 6-week mortality rate after AVH was 17.7% (95% confidence interval [CI], 14.4%-21.7%). Sclerotherapy was used in 18.7% of cases (95% CI, 9.2%-34.3%), and no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). The overall rate of BT use was 10.8% (95% CI, 8.2%-14.1%). Salvage procedures were used in 5.7% (95% CI, 3.7%-8.6%), falling to 1.7% (95% CI, 0.7%-3.8%) among patients treated after 2000. Although pooled rates of timely endoscopy and vasoactive medication use were high (85.8% and 83.0%, respectively), only half of patients received prophylactic antibiotics (52.8%; 95% CI, 40.0%-66.2%). In studies that enrolled patients exclusively after 2000, 13.8% of patients (95% CI, 7.0%-25.4%) received sclerotherapy, salvage transjugular portosystemic shunt fell to 1.7% (95% CI, 0.7%-3.8%), BT use fell slightly to 8.7% (95% CI, 6.4%-11.6%), and vasoactive medication and prophylactic antibiotic use rose to 91.4% (95% CI, 86.0%-94.9%) and 62.7% (95% CI, 48.9%-74.9%), respectively.
  
  
  CONCLUSIONS
  AVH is associated with high mortality rates and suboptimal implementation of evidence-based therapies including prophylactic antibiotics and endoscopic interventions, suggesting a need for quality improvement. In addition, the frequent need for BT and sclerotherapy suggests that specific attention to these procedures in gastroenterology training curricula may be warranted.
authors.affiliation: Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan. Electronic address: etapper@umich.edu.
authors.forename: Elliot B
authors.initials: EB
authors.lastname: Tapper
authors.affiliation: Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington.
authors.forename: Lauren
authors.initials: L
authors.lastname: Beste
authors.affiliation: Liver Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Michael
authors.initials: M
authors.lastname: Curry
authors.affiliation: Liver Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Alan
authors.initials: A
authors.lastname: Bonder
authors.affiliation: Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan.
authors.forename: Akbar
authors.initials: A
authors.lastname: Waljee
authors.affiliation: Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan.
authors.forename: Sameer
authors.initials: S
authors.lastname: Saini
mesh_terms: D013505:Digestive System Surgical Procedures / Q000379:methods*; D019468:Disease Management; D004724:Endoscopy / Q000379:methods; D006471:Gastrointestinal Hemorrhage / Q000401:mortality* / Q000601:surgery*; D006801:Humans; D016019:Survival Analysis; D016896:Treatment Outcome; D014648:Varicose Veins / Q000150:complications*
keywords: Cirrhosis; Gastroenterology; Liver Disease; Portal Hypertension