Published online Apr 27, 2018. doi: 10.4240/wjgs.v10.i4.40
Peer-review started: February 7, 2018
First decision: February 28, 2018
Revised: March 9, 2018
Accepted: April 11, 2018
Article in press: April 11, 2018
Published online: April 27, 2018
Processing time: 78 Days and 11.1 Hours
Esophageal variceal hemorrhage is a significant complication of cirrhosis and is associated with a high mortality rate. Current guidelines recommend a combination of non-selective beta adrenergic receptor blockers with endoscopic variceal ligation as the most effective way of reducing variceal rebleeding. It is increasingly recognized that cirrhotic patients often do not receive evidence-based treatments for disease related complications.
Whereas prior studies have focused on gaps in cirrhosis-related quality care attributable to decisions made by healthcare professionals, this study focused specifically on patient factors which may impact adherence to endoscopic variceal surveillance. By identifying a patient population at risk of poor adherence, we hope to spur future studies which will assess interventions to promote adherence to improve disease-related outcomes.
We sought to identify potential factors, in a real world setting, which may prevent patients from completing variceal obliteration and adhering to surveillance endoscopy following their first esophageal variceal hemorrhage.
We performed a retrospective review of the records of patients with cirrhosis admitted to the medical intensive care unit between 2000 and 2014 for first time esophageal variceal hemorrhage treated with endoscopic variceal ligation who were subsequently discharged and scheduled for surveillance endoscopy at our medical center. Demographic and clinical data were obtained through the medical records. Differences between groups were determined by Fisher’s exact test for categorical variables, by Mann-Whitney U test for continuous non-parametric variables, and by Student’s t test for continuous parametric variables. Kaplan-Meier curves for both survival and time to rehospitalization were compared using the log-rank test.
Of 99 patients included in the study, 33% completed variceal obliteration and 12% adhered to annual surveillance. Completion of variceal obliteration was associated with fewer rehospitalizations for variceal rebleeding (27% vs 56%, P = 0.0099) and when rehospitalizations occurred, they occurred later in those who had completed obliteration (median 259 d vs 207 d, P = 0.0083). Incomplete adherence to endoscopic surveillance was associated with more rehospitalizations for variceal rebleeding compared to those fully adherent to annual endoscopic surveillance (51% vs 17%, P = 0.0328). Those adherent to annual surveillance were more likely to be insured privately or through Medicare (a national government-sponsored health plan that provides universal coverage for age 65 or greater) compared to those who did not attend post-hospital discharge endoscopy (100% vs 63%, P = 0.0119).
We found that the minority of survivors of esophageal variceal bleeding completed variceal obliteration and fewer adhered to annual surveillance. Those completing variceal obliteration had fewer and later rehospitalizations for variceal rebleeding. Incomplete adherence to endoscopic surveillance was associated with more frequent rehospitalizations for variceal rebleeding. Collectively, these observations reinforce the importance of variceal obliteration and annual endoscopic surveillance for prevention of variceal rebleeding. Incomplete adherence to endoscopic surveillance was associated with lack of health care insurance or health care insurance through Medicaid (a government-sponsored health plan that defrays medical expenses in selected low income individuals). This population has been shown in prior studies to have greater financial barriers to healthcare, poor health literacy, and limited transportation, all of which may be contributing to the decreased endoscopic adherence observed in our study.
This study provides a link between health care coverage vulnerability, a marker of lower socioeconomic status, and reduced adherence to endoscopic surveillance following esophageal variceal bleeding. Future research should attempt to improve adherence in this population using interventions which have been shown to be successful in other fields, such as scheduling procedures on the same day as a preexisting appointment, using text message appointment reminders, or even using financial incentives.