Tracking Cirrhosis Care During the COVID-19 Pandemic
January 29, 2023
Understanding how the COVID-19 pandemic has affected the delivery of preventative medicine is essential to restoring and improving care as the United States progresses through the pandemic. Shari Rogal, MD, MPH, and Adeyinka Adejumo, MD, PhD, MS, have been utilizing novel methodology to evaluate the impact of the COVID-19 pandemic on the implementation of high-value care among veterans with cirrhosis.
A healthy diet has long been lauded as an essential part of a healthy lifestyle conducive to disease prevention. While the nutrients and healthy fats digested in the stomach and small intestine are essential, the nondigestible fiber from plant foods that passes through the colon is crucial for good health as well.
Dietary Switch Studies
The United States Veterans Health Administration (VHA) provides care for over 9 million veterans at 146 VA Medical Centers (VAMCs) and 1,113 clinics nationwide. To maintain and improve their system, the VHA collects massive amounts of data reflecting which patients are seeking care, which patients are getting care, and the quality of care provided by each hospital in the system.
Dr. Rogal, a staff transplant hepatologist and gastroenterologist in the VA Pittsburgh Healthcare System and associate professor of Medicine, Surgery, and Clinical and Translational Science in the Division of Gastroenterology, Hepatology and Nutrition, evaluates the programs offered by the VHA and was awarded a grant from the VHA to assess COVID-related disruptions to the care of patients with liver disease.1,2 Dr. Rogal hypothesized that utilization of preventative services would decline during the COVID pandemic even for critically ill patients, such as those with cirrhosis. Testing this hypothesis was possible due to VA databases that contain complex longitudinal data from the large population treated at VHA facilities, along with the expertise of Dr. Adejumo, a clinical and T32 research fellow in the Division, who proposed and applied an advanced computational analysis to the large data set under Dr. Rogal’s mentorship.
Approximately 80,000 veterans with cirrhosis receive care nationally at VAMCs. To examine the impact of the COVID-19 pandemic on the care of patients with advanced liver disease, all U.S. veterans with cirrhosis who were enrolled in VHA health care in October 2018 were identified using ICD-10-CM codes. This cohort was then followed for 12 quarters, through September 2021. Outcomes measured for each quarter included whether hepatocellular carcinoma (HCC) screening was performed and whether endoscopic variceal surveillance was conducted or treatment initiated with nonselective beta-blockers to prevent bleeding based on clinical findings suggestive of varices. Imaging to screen for HCC every six months and endoscopic surveillance of esophageal varices or initiation of beta-blocker treatment are considered the standard of care when monitoring patients with cirrhosis, and a VHA improvement initiative aimed to increase guideline-concordant utilization of these tests prior to the COVID pandemic.1,3,4 Additionally, all-cause hospitalizations and mortality were assessed by quarter.
Dr. Adejumo applied joinpoint regression analysis to identify inflection points in the data reflecting increased or decreased health care use.5,6 This analysis used data to select important timepoints rather than the investigators selecting timepoints based on a priori perceptions. Using joinpoint regression, Dr. Adejumo found that screening for HCC dropped precipitously in early 2020. Guidelineconcordant screening for HCC began to recover in late 2020, although as of September 2021, it had not returned to 2019 levels. Screening or treatment for suspected esophageal varices also dropped precipitously at the beginning of the pandemic and was still decreasing at nearly the same rate when the study period ended in September 2021. Dr. Adejumo and Dr. Rogal are currently continuing the analyses through 2022.
When the cohort was stratified by gender, race, proximity to a VAMC, or socioeconomic factors, there were no differences in the observed trends in the subgroups assessed. Dr. Rogal had hypothesized that people with limited access or other barriers to care would be disproportionately affected by the COVID pandemic, resulting in decreases in preventative screenings necessitated by their severe liver disease. Reassuringly, the study indicated that many disparities in health care that were exacerbated by the COVID pandemic were not exacerbated in patients with cirrhosis treated by the VA Healthcare System. However, the decreases observed in preventative care across all veterans with cirrhosis are concerning and are being actively addressed by the VHA leadership.
Dr. Adejumo presented this work in May 2022 at Digestive Diseases Week, a large, multisociety meeting for physicians, researchers, and industry partners in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery, where it was well-received.
The study provides information that will help guide policies for the VHA at a national level and suggests potential areas for improvement to other health care systems as well. The VHA is offering support for VAMCs with barriers to care. Understanding trends in the utilization of preventative medical care is necessary to ensure a full recovery of services as the country progresses through the COVID pandemic.
References/Recommended Reading
1. Yakovchenko V, Morgan TR, Miech EJ, Neely B, Lamorte C, Gibson S, et al. Core implementation strategies for improving cirrhosis care in the Veterans Health Administration. Hepatology. 2022;76:404-417.
2. Yakovchenko V, Morgan TR, Chinman MJ, Powell BJ, Gonzalez R, Park A, et al. Mapping the road to elimination: A 5-year evaluation of implementation strategies associated with hepatitis C treatment in the Veterans Health Administration. BMC Health Serv Res.2021;21:1348.
3. Frenette CT, Isaacson AJ, Bargellini I, Saab S, Singal AG. A practical guideline for hepatocellular carcinoma screening in patients at risk. Mayo Clin Proc Innov Qual Outcomes. 2019;3:302-310.
4. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Practice Guidelines Committee of the American Association for the Study of Liver Diseases, Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922-938.
5. Kim HJ, Chen HS, Byrne J, Wheeler B, Feuer EJ. Twenty years since Joinpoint 1.0: Two major enhancements, their justification, and impact. Stat Med. 2022;41:3102-3130.
6. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2000;19:335-351.
