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Study Suggests VA Care May Be Sub-Optimal for Veterans with Cirrhosis-Related Ascites

Cirrhosis is a prevalent and expensive condition, affecting about 5.5 million patients at a cost of more than $1.5 billion annually in the U.S. Patients with cirrhosis are susceptible to several complications of advanced liver disease. Ascites is the most common of these complications, and once patients develop ascites, the probability of survival at five years is only 50%. Evidence-based guidelines define the criteria and standards of care in patients with cirrhosis and ascites. However, the extent to which care for patients with ascites meets these standards is largely unknown. This observational study sought to determine the quality of ascites care in 774 Veterans with cirrhosis and ascites who received treatment in three VAMCs between 2000 and 2007. Quality of care was measured by eight panel-derived quality indicators (QIs), which are part of a broader set of QIs that measure care for patients with cirrhosis. Investigators also reviewed Veterans' medical charts to assess the role of patient refusal, outside care, or other justifiable exceptions to care processes as explanations for non-adherence to the quality indicators.


  • The quality of healthcare, measured according to whether Veterans received recommended services, was sub-optimal for cirrhosis-related ascites. For five of eight QIs of ascites care, Veterans in this study received the recommended care less than two-thirds of the time, even after accounting for possible justified exceptions.
  • Quality scores varied across individual QIs, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis to 90% for testing paracentesis fluid for cell count and differential.
  • In general, care targeted at treatment was more likely to meet standards than preventive care.
  • Veterans with no comorbidity, who saw a gastroenterologist, or who were seen in a VAMC with an academic affiliation received higher quality of care.


  • Due to the study design, causal inferences between QIs and some of the predictors — or between QIs and outcomes — could not be made.
  • Certain aspects of care also could not be ascertained, e.g., patient education and counseling.
  • Quality scores in ascites care may have significantly improved since 2007.
  • Data were limited to three VAMCs and thus cannot be generalized to other Veterans seeking care in other facilities.

Drs. Kanwal, Kramer, and El-Serag are part of HSR&D's Houston Center for Quality of Care and Utilization Studies; Dr. Asch is co-Director of VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI).

PubMed Logo Kanwal F, Kramer J, Buchanan P, Asch S, Assioun Y, Bacon B, Li J, and El-Serag H. The Quality of Care Provided to Patients with Cirrhosis and Ascites in the Veterans Administration. Gastroenterology March 27, 2012;Epub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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