The Future of Quality Improvement for Cirrhosis

Abstract

Cirrhosis has a significant and growing impact on public health and patient reported outcomes. The increasing burden of cirrhosis has led to an emphasis on quality of care with the goal of improving overall outcomes in this high risk population. Existing evidence has shown the significant gaps in quality across process measures (e.g. hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address gaps in quality care. This multistep process forms the quality continuum and it depends on clearly-defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein, we review the current state quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in patient reported outcome evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.

Introduction

Improving the quality of care, making it safe, patient-centered, and efficient, has taken on increasing importance over the last two decades.(1) The formalized pursuit of quality in cirrhosis care began with a landmark publication by Kanwal et al in 2010.(2) The authors rendered the evidence-base for cirrhosis care into measurable actions and target populations. These process measures have since been studied around the world to detail gaps in practice, the impact of best-practices, and the effect of quality improvement (QI) interventions.(3) In addition to process measures, there is now a better understanding of the structural components necessary for effective QI. The synergy between measures and infrastructure allows for the iterative plan-do-study-act paradigm for continual improvement of quality.

QI in cirrhosis care is now evolving, shaped by three main forces. First, alongside process measures, the centrality of clinical and patient reported outcomes (PROs) in adjudicating the quality of care is increasingly recognized,(4) focusing QI efforts on factors that extend or enrich the lives of patients. Second, there is a pressing need to demonstrate the impact of our interventions on patients and the return on investing in QI using robust methodologies.(5–7) Third, the cost of care has spiraled, expanding the focus of QI from measuring and implementing reactive care (to the complications of cirrhosis) to preventative care to forestall potential complications.

Herein, we will review the past and present of QI in cirrhosis as well as the future of measurement, implementation, and the novel emphasis on patient-centered quality and prevention.

A QI philosophy

QI is a continual, multistep process that aims to improve population-based outcomes. Cyclical iterations of the ‘plan-do-study-act’ continuum provide an organizational blueprint for QI. Most centers are familiar with the process of quality measurement or have undertaken QI interventions. Sustainable and effective QI, however, must be nurtured by a supportive environment and propelled by culture of introspection and continuous improvement that is informed by a shared mission. Key organizational investments include infrastructure (electronic health record-based tools as well as quality offices to conduct the work) and financial resources, funding the planning and measurement efforts and incentivizing QI interventions. Infrastructure such as the clinical information systems – e.g. electronic health record systems and computerized provider order entry – are essential for both data extraction as well as the delivery of real-time decision support to guide adherence to QI interventions.(8) A focus on outcomes is essential, both to evaluate the effectiveness and show the value of interventions. Beyond the transactional care indicated by process measures, true QI flourishes in a feedback loop when the value of our measures are reinforced by their impact on meaningful outcomes. The basic applications of this QI philosophy for the needs of contemporary patients with cirrhosis are many-fold. This includes: 1) selection, quantification, and refinement of process measures consequential to the care of persons with cirrhosis, 2) deployment of interventions to improve gaps in process measure completion, 3) measurement of relevant and reproducible clinical and patient-reported outcomes, and 4) reevaluation and refinement at predefined intervals.(9) As QI for patients with cirrhosis matures, patient engagement may be an important method for identification of additional meaningful process measures and targets for primary prevention.

Selecting Targets

The most basic component of QI is its targets. The simplest expression of QI targets are transactional processes – procedures, prescriptions, tests – that result from healthcare encounters. Process measures have 3 key elements. They i) are an action which poses more benefit than risk as supported by a robust evidence base, ii) have variation in practice, and iii) can be reliably quantified using readily available clinical data. In general, process measures are selected by consensus. In 2010, Kanwal et al identified 41 process measures using a Delphi method.(2) In 2019, the American Association of Liver Disease (AASLD) endorsed a refined list of 26 measures developed by its Practice Metrics Committee.(4) Among these, those receiving the highest ranking for importance included diagnostic paracentesis for all patients admitted with ascites and symptoms or HE, timely therapeutic endoscopy and antibiotics for gastrointestinal bleeding, semiannual screening for hepatocellular carcinoma (HCC), and treatment of hepatitis C or B and substance use disorder when present. The 2019 document extended the field by enumerating 7 clinical outcomes and 13 PROs.(Figure 1) Clinical outcomes included survival, first and recurrent episodes of variceal bleeding, early stage diagnosis of HCC, hospitalization, and readmission. PROs were selected on the basis of a scoping review of the literature and refined with patient input and include factors such as confusion, depression, pruritis, muscle cramps, ability to avoid alcohol, medication side-effects, and falls.(4, 10)

Figure 1:

A Cross-section of Cirrhosis Practice Measures

FFP = fresh frozen plasma, HCC = hepatocellular carcinoma, HE = hepatic encephalopathy, LSM = liver stiffness measurement, plt = platelets, SBP = spontaneous bacterial peritonitis

Consensus on QI targets may change over time. The 2010 document included a measure for hepatitis A vaccination but the 2019 did not for lack of priority, while the 2019 document incorporated frailty assessment given emerging data regarding its impact on outcomes.(2, 4) Centers may also select specific processes based on local performance or priority. Even for persistently important measures such as HCC screening, if a center’s performance gap is narrow or becomes marginal after an intervention, it may be reasonable to prioritize other targets for measurement. Beyond this, an expanded focus on outcomes will foster re-evaluations of QI targets in the context of their potential to improve or extend the lives of patients.

Measuring the measures

Measuring gaps in quality can be challenging. The actual work of measurement in its most basic form are essentially periodic chart reviews, frequently with unpaid effort, conducted under the auspices of research by trainees. Some centers have a funded infrastructure for QI, employing quality officers that coordinate process measurement.(11, 12) There is substantial work to define the denominator - the population who should receive the process measure. Appropriate candidates are defined with reference to diagnosis codes and refined on the basis of exclusion criteria (e.g. age, disqualifying diagnoses, factors obtained from clinical notes). For example, HCC screening is indicated for patients with cirrhosis except for those patient who are Child C and not transplant candidates. The rate of measure completion is a proportion, such as the number of ultrasounds per candidate or the percentage of time under surveillance. However, even ultrasound attainment needs to be refined by counting cross-sectional imaging if performed and reconciling outside records. These challenges can be overcome but require careful planning and customization to the population of interest.

The difficulty of measurement is proportional to the scale of the measure’s focus. Transactional measures specific to a given patient (e.g. tests, procedures) may be ascertained from the electronic medical record. Conversely, population-based measures such as equity in care or access to liver transplantation require a higher level evaluation to assess the proportion satisfying the metric among the potential candidates within the population served by the health system. Recent studies have shown wide variance around these measures nationally, suggesting they are worthy targets for QI.(13, 14)

The optimal method for quality measurement is a real-time, widely accessible dashboard using web-enabled software. An exemplar dashboard was developed for tracking hepatitis C therapy and is currently used for monitoring the state of advanced liver disease management in the Veterans Affairs (VA).(15, 16) The dashboard allows users to access records for all patients meeting specific criteria (based on hepatitis C laboratories or validated administrative data algorithms for cirrhosis). The current use of this dashboard centers on tracking screening for HCC and varices. The pitfalls of dashboards are three-fold. 1) the need for personnel to maintain and manage, 2) lagging or missing elements needing abstraction from chart review such as unique exclusion criteria and reconciled outside records (e.g. off-site ultrasounds), and 3) the need for manual review and upload for some metrics, such as those based on clinical documentation. Solutions to these limitations include the use of structured fields in notes (radio buttons, smart text) or else paid effort is needed to supplement the dashboard with frequent manual data entry. Finally, the VA is uniquely mission-oriented and supportive of QI. Dashboard uptake in other settings has been more limited.

Quantifying Performance Gaps

Performance audits are helpful in guiding the center-specific allocation of resources or planning specific targets for quality improvement interventions. Quality measurement across systems using multicenter or claims data, conversely, could be used to evaluate metric impact on outcomes or inform guideline development. Many centers have published their own audits which are too numerous to detail here beyond some recent examples. Kardashian et al showed that, even at a major referral center, 24% of candidates were screened for HCC and 21% of persons surviving SBP received antibiotic prophylaxis.(11) In their multicenter audit, Serper et al showed that consistent HCC screening was conducted in 42% of candidates and only 31.9% of newly diagnosed patients with cirrhosis underwent screening endoscopy.(17) Kumral used chart review to show that most patients presenting with HE are not thoroughly evaluated for infection.(18) Rosenblatt evaluated multiple state inpatient databases and confirmed only 52.8% of persons presenting with ascites and kidney injury or HE underwent diagnostic paracentesis.(19) While treatment of HE with lactulose is recommended,(2) Bajaj et al found in a multicenter audit that many patients were not discharged with an outpatient prescriptions and Thomson et al showed that only 4.6% of commercially insured persons with prior HE received consistent lactulose.(20, 21)

Process measure audits clarify priorities for QI. In the case of varices management, Cahill found that >80% of candidates underwent screening endoscopy and Kardashian showed that 85% with varices received beta-blockade or band-ligation within 1 month.(11, 22) These metrics are unlikely to benefit from further intervention. In contrast, Kardashian also found 2% of patients with recent variceal hemorrhage underwent timely repeat procedures for variceal obliteration and Thomson showed that, while many patients received beta-blockade, most did not refill their medication.(11)

Selecting and measuring outcomes

Outcome assessment often requires substantially more effort than process measures and is further constrained by data availability. As it is more costly to obtain, payor incentives are key to outcome data availability. The financial incentivization of post-transplant survival has, in part, resulted in a clustering of center-specific 1-year survival around 90%.(23) Although it may be worthwhile to develop it, there is no such survival benchmark for cirrhosis more generally. Kwong et al recently examined the 1-year survival of the waitlisted (intention-to-transplant) population, revealing major disparities in a survival rates across centers.(23) Although tracking survival from waitlisting would still not apply to the majority of persons with cirrhosis, it would incentivize attention to the supportive care infrastructure for persons with cirrhosis. Indeed, as demonstrated by Serper,(17) nationalized networks such as the VA can track mortality. In her landmark multicenter study, Serper shows how outcome integration clarifies the value of process measures by linking reduced mortality with cancer and varices screening as well as timely outpatient follow-up.(17)

30-day readmissions, a focus of many QI programs, are the canonical example of policy’s influence on outcome prioritization. Beginning October 2012, Section 3025 of the Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP) which levied broad reductions in inpatient service payments to hospitals with excess 30-day readmissions for conditions such as pneumonia, myocardial infarction, and heart failure. Given the risk exposure for health care organization, systems to monitor readmissions were swiftly created. Although cirrhosis is not specifically enumerated by the HRRP, patients with cirrhosis are frequently readmitted and raise overall readmission rates for target conditions.(3, 24)

Little progress has been made in developing additional clinical outcome benchmarks. The first step forward would involve defining survival time from common landmarks; e.g. stage of HCC at diagnosis or diagnosis of ascites or HE. The second step involves scrutinizing outcomes. There is clear evidence that when survival is tied to financial incentives, centers are spurred to action. With any outcome based benchmark, careful consideration of misguided incentives and “gaming” the system must be considered to mitigate risk aversion and incentivize innovation.(25)

Finally, as with outcome measures, the infrastructure for PRO assessment in liver clinics is poorly developed. There are 3 principle options. First, using paper-based surveys, interviews by the clinician/clinical staff, or the use of tablet computers, patients can complete surveys in clinic or with a study coordinator. The multicenter Cirrhosis Quality Collaborative is collecting PROs using this method. This model requires institutional investment in training staff to administer these instruments on patient check-in and effort for manual data entry. Second, patients can complete surveys through a patient portal, which is linked to the electronic medical record. Since January 2020, Michigan Hepatology has been assessing alcohol use via portal surveys using the AUDIT-C in all patients presenting to our liver clinics. This option should be paired with education or a behavioral intervention to encourage timely use of the patient portal. Third, third-party messaging apps can integrate responses to structured text messages into the electronic health record.(26) This promising avenue requires substantial support from administrators and health-IT programmers and presupposes substantial tech-savviness that may be lacking among many patients with cirrhosis.

Closing Performance Gaps

We review the published interventions that prospectively assessed their impact on multiple process measures and clinical outcomes in Table 1. Below we review those for two exemplar measures: HCC screening and hospitalization.

Table 1 :

Quality Improvement Interventions

Target	Intervention	Study Design	Population; (n)	Results	Reference
Hospitalizations and readmissions	Standard education, case-management, nursing telemedicine	RCT	Decompensated cirrhosis; 40 intervention, 20 control	No reduction in admissions but improved clinic attendance, HCC screening, vaccinations	Wigg 2013(35)
	Day hospital for evaluation/management	Non-RCT	Decompensated cirrhosis; 40 intervention, 60 control	Reduced readmissions, cost, and mortality	Morando 2013(31)
	Electronic decision support to intensify HE treatment	Pre-Post	Cirrhosis; 626 pre, 470 checklist, 624 electronic phase	40% fewer readmissions with electronic intervention	Tapper 2016(51)
	APP-led paracentesis team	Pre-Post	Patients in ED with ascites: 15 pre, 30 post	Decreased admissions for ascites	Siddique 2019(30)
Improvement of vaccination rates	Case-management, counselling, on-site HAV/HBV vaccines	RCT	Methadone users; 489	Improved rates of hepatitis A and B vaccination	Masson 2013(52)
Improve screening for AUD	Educational outreach, templated document	Pre-post	Patients in liver clinic; 378 pre, 318 post	Higher inquiry about alcohol (92% vs 80%), diagnosis (49% vs 31%), referral (29% vs 8%)	Saraireh 2020(53)
Improve management of varices	Education, dedicated nurse coordinator	Pre-Post	Cirrhosis; 250 primary prevention, 46 with bleeding	Prophylactic endoscopy; antibiotics, octreotide and correct ward placement	Wundke 2010(54)
	Paper order set, clinician education	Pre-Post	Cirrhosis; 48 pre, 51 post	Rate of prophylactic antibiotics, octreotide	Johnson 2011(55)
	Standard ordering template with reserved procedure slots	Pre-post	Patients with variceal bleeding; 32 pre, 28 post	Endoscopy within 4 weeks	Moon 2019(56)
Improve HCC screening	Dedicated nurse, automated reminders	Pre-Post	Cirrhosis; 160 pre, 355 post	Utilization of HCC screening increased from 74% to 93%	Aberra 2013(57)
	Point-of-care electronic reminder	Non-RCT	Cirrhosis; 790 intervention (one site), 2094 control (7 sites)	51% increase in having 2 screenings over >6 months vs none in control	Beste 2015(28)
	Mailed outreach ± patient navigation or usual care	RCT	1,800 patients with cirrhosis (600 in each arm)	Outreach and navigation led to 23.% receiving HCC surveillance over 18-months compared to 7.3% in usual care	Singal 2019(29)
Improve SBP care	Mandatory GI co-management	Pre-Post	Patients with SBP; 30 pre, 26 post	Early paracentesis, albumin use, secondary prophylaxis	Desai 2014(58)
	Educational booklet	Pre-Post	Patients with ascites; 33 pre, 54 post	Early paracentesis	Rawson 2015(59)
	Educational outreach, paracentesis kit development	Pre-post	Patients with ascites; 109 pre, 76 post	Early (<12h) paracentesis improved from 48% to 81%	Jesudian 2019(60)
Multiple targets	Mandatory GI consult	Pre-Post	Decompensated cirrhosis; 379 pre, 316 post	Many. E.g. diagnostic paracentesis, timely endoscopy for bleeding	Ghaoui 2015(61)

AVH = acute variceal hemorrhage, GI = gastroenterology, GIB = gastrointestinal bleeding, HCC = hepatocellular carcinoma, RCT = randomized controlled trial, SBP = spontaneous bacterial peritonitis.

HCC Screening

HCC screening is considered by consensus to be a quality measure that has been associated with several outcomes including early detection and survival, yet has substantial performance gaps. Three studies have examined interventions to increase screening. Aberra demonstrated that establishing a population dashboard managed by a nurse to issue reminders for ultrasounds/AFP increased screening, increasing screening from 74% to 93%.(27) Patients established in a referral clinic, however, are highly selected. Beste evaluated the impact on a more stringent outcome - 2 screenings over >6 months – using an electronic reminder for clinicians to order screening when seeing patients with cirrhosis. She deployed her intervention at one facility and compared to 7 facilities with no reminder. This intervention reached a wider population and optimized workflow by reaching clinicians at the point-of-care. Screening rose from 18.2% to 27.6% compared to 16.1% to 17.5% at control facilities.(28) Singal performed the only randomized trial comparing 1:1:1 usual care, mailed-outreach, and mailed-outreach plus patient navigation for 1800 patients with cirrhosis using an even more stringent outcome of 18-months of semiannual HCC screening.(29) The rates of screening were 7.3%, 17.8%, and 23.3% in each arm. This study was conducted for underserved patients in a safety net hospital and showed the value of deliberate patient engagement.

Hospitalization

Successful efforts to reduce hospital admissions have focused on three modifiable targets: ascites, HE, and alcohol use disorder. In order to address the problem of hospitalization for symptomatic ascites, Siddique evaluated hospitalization rates and time spent in the emergency department before and after the implementation of a paracentesis team staffed by advanced practice providers.(30) This program eliminated admissions after emergency department visits for symptomatic ascites (0/30) during the 2-year evaluation period and as such it is the only study to explicitly reduce index hospitalizations for a cirrhosis complication. In 2016, Tapper et al evaluated the roles of checklists and the electronic medical record for reducing readmissions for HE in a pre-post study.(8) Decision support using default options in the medical record to preset the dose and frequency of lactulose for overt HE and indicate the role for Rifaxmin co-therapy was associated with a 40% decrease in 30-day readmissions compared pre-post to control periods with and with the HE protocol checklist intervention. Morando reduced hospitalizations with controlled, non-randomized, trial enrolling 100 patients, 40 of whom received a post-discharge intervention that included phone calls and opportunity to use a ‘day hospital’ with linked to care for AUD, intensified management for HE, and paracentesis availability.(31)

To safely reduce hospitalizations, interventions must both identify those at high hospitalization-risk and equip providers with the outpatient tools to address them. Identifying risk alone is inadequate. Without alternatives to emergency department referral to evaluate and address these symptoms, patients will be hospitalized as outpatient clinicians struggle to marshal the correct resources.(32) Remote monitoring through the phone or an app has not yet been shown to reduce readmissions.(33, 34) Thomson showed that an interactive telephone voice response system patients found that patients reporting weakness and weight gain ≥5 pounds to were at high-risk of hospitalization which could not be avoided.(33) Wigg enrolled 60 patients in a 2:1 RCT that compared usual care to standardized patient education, post-discharge phone calls and remote case-management.(35) The intervention improved quality measures like rates of clinic attendance and HCC screening but failed to reduce hospitalizations. Second, early post-discharge visits, a quality process measure in the VA, identify early decompensation and are actually associated with increased readmission risk but decreased mortality.(36) As above, Morando’s intervention reduced hospitalizations and improved survival at a lower overall cost by identifying at-risk patients and providing a safe, effective alternative to readmission.(31)

Future directions

QI for cirrhosis is at a crossroads. Quality measures have been endorsed by the AASLD and routine quality measurement has been adopted by many centers.(4) While experience with QI trials grows,(3) the definition of quality has matured to include novel clinical outcomes and PROs. This poses new challenges for both assessment and improvement initiatives. At the same time, the prevalence, severity, and costs of cirrhosis care have risen, raising the stakes for population management and the need to demonstrate return on investment.(37, 38) The National Academy of Medicine promotes the adoption of a learning health system paradigm wherein best practices are rapidly implemented through continual reassessment and to dynamically respond to challenges, anticipated and unanticipated.(39) The goal is an iterative process and a culture that supports the implementation of effective (and de-implementation of ineffective) practices, while continuing to refresh evidence base and personalization of care.(40) The need for this approach has been underscored by the COVID-19 pandemic. Without continuous reassessment, it would be unclear how previously successful strategies need to be adapted to changing environments. By assessing the reasons for noncompletion of HCC screening, the VA group led by Serper highlights a crucial role for continued subspecialty involvement, even for compensated patients connecting by telemedicine.(41)

There are two main barriers to achieving an iterative QI process. The first is cultural. Defining gaps in quality, reducing variation, and changing practice requires transparency, introspection, and willingness to change. Providers must be incentivized to adopt new approaches or improve quality through nudges, financial means, and simplifying tasks with attention to human factors.(3, 42) The second barrier is cost. The infrastructure needed to conduct QI, development of electronic medical record tools such as dashboards and protecting the effort of quality officers for process measurement and QI all requires institutional investment. The justification of the investment with improved patient outcomes and avoidance of costly admissions should be incentivized as has been attempted in various health care reimbursement models, such as Accountable Care Organizations. Ultimately, high level evidence of improvement in patient-centered outcomes behind the measures should drive the QI process. Additionally, time is a cost that matters equally to providers and patients. Explaining to patients the rationale justifying the time spent completing PRO assessments may be necessary. Further, it is crucial to ensure that it is easy to complete PROs at the point-of-care or that it is easy to access the assessments from home.

In Figure 2, we summarize the ways in which quality improvement can be modernized through novel approaches to measurement, program evaluation, and an expanded focus on prevention. Two under-developed components of QI relate to assessment methodology and preventative services.

Figure 2: The Future of Quality Improvement.

Improving quality improvement will involve enhancing our approach to:

a. Prevention: early diagnosis and linkage-to-care for cirrhosis, pre-emptive beta-blockers to prevent bleeding and possibly ascites, integrated care for alcohol-use disorder (AUD) by either training the workforce in pharmacotherapy and behavioral interventions or streamlining referrals, and expanding access to nutrition services and integrating remote monitoring for decompensations.

b. Measurement: creating real-time metric dashboards, tracking patient reported outcomes (PROs) as we have for AUD, and benchmarking center performance for clinical outcomes.

c. Evaluation: the effectiveness of interventions must be tested utilizing robust methods for program evaluation such as stepped-wedge (pictured) and cluster-randomized designs.

d. Linkage-to-care: quality efforts should focus on delivery of care proven to improve outcomes such as AUD therapy, lifestyle change, and transplant evaluation

Methods for Demonstrating improvement

QI must be studied rigorously to demonstrate impact and justify the resources required for implementation. The simplest approach and the minimum standard for assessment of QI programs is the pre-post or time-series design. Comparison to contemporaneous controls strengthen this design. Stepped-wedge designs involve the staggered (not necessarily randomized) roll-out of an intervention across centers to create multiple pre-post assessments with built-in contemporaneous controls.(5, 7) Randomization is the most effective design to demonstrate efficacy but can be challenging to apply. Cluster randomization is a simplified approach well-suited to quality improvement that randomizes sites – centers or wards – not individual patients to conduct the study intervention.

Emphasis on Prevention

Primary prevention encompasses both identification of those patients with cirrhosis or at high risk of cirrhosis and preventing or lessening the severity of decompensation in patients with known cirrhosis. Cirrhosis diagnosis is missed in up to 50% of patients who present with decompensation or HCC, so possible earlier diagnosis could allow for disease modification (i.e. viral hepatitis treatment, weight loss) or preventative care (i.e. HCC screening).(43) While liver disease prevention or identification is not yet formally integrated into process measurements for cirrhosis care, several health systems have adopted automated flags for patients meeting certain criteria, including use of noninvasive fibrosis markers, for high risk of liver fibrosis.(44) The Intelligent Liver Function Test system (iLFT), has been used in the UK, where abnormal liver enzymes in the primary care setting trigger an automated serological work-up and subsequent care pathway. The initial analysis of the iLFT system showed it was cost-effective and able to increase liver disease diagnoses in the primary care setting by 43%, however data are lacking regarding the generalizability and accuracy of such a system as well as its effect on linkage to care in other settings.(45)

Preventing cirrhotic decompensations and hospitalization has gained increasing importance with focus on PROs and clinical outcomes. Further, in the context of the COVID-19 pandemic, access to hospital-based services and procedures can be challenging.(38) Both of these forces raise the value of interventions that safely reduce risks, decrease avoidable emergency room or urgent care visits, and eliminate the need for elective procedures. In practice, prevention entails an intensification of the care provided to persons with compensated cirrhosis coordinated by Hepatology practices and focusing on pharmacological prophylaxis, nutritional optimization, counseling, and substance use disorder therapy. Preventing the first variceal bleed in accordance with the new AASLD quality metrics in the setting of limited endoscopy access may involve embracing data in support of early initiation of non-selective beta-blockers in persons with clinical signs of portal hypertension (low platelets, high liver stiffness).(46) Whereas nutritional consultative services are widely available to persons on the transplant waitlist, general Hepatology patients would benefit as well. Similarly, behavioral interventions to foster adherence to low-sodium diets can reduce the burden of ascites and high-protein diets can improve HE and possibly forestall frailty.(47, 48) Finally, while counselling to avoid alcohol is an established process measure, recent data has uncovered grossly inadequate linkage of persons with alcohol-use disorder (AUD) to effective therapy, behavioral and/or pharmacological.(49, 50) Whether the path forward involves an expanded role for hepatology clinical staff in the management of AUD or integration with mental health services is likely to depend on local resources. In the VA, Rogal et al plan to expand the liver disease dashboard to track linkage-to-care for AUD.(7)

Conclusion

Quality care for cirrhosis has matured over the past 10 years. We now enter a new era. This era will be characterized by an expanded focus on outcomes, clinical and patient reported, higher standards for measurement and assessment as well as a population that is larger and sicker than ever before. To meet and exceed these demands, we must apply and adhere to a consistent quality philosophy