Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit.

INTRODUCTION: Acute variceal bleeding (AVB) is a major complication in cirrhosis patients. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB.

METHODS: We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all five QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-weeks mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.

RESULTS: A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6-week (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) (p<0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, non-adherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence with the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality.

CONCLUSION: Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.