Advanced Practice Providers: Raising Our Defenses Against the Rising Tide of Cirrhosis
Authors: Ashley M. Hyde, Michelle Carbonneau, Juan G. Abraldes, Puneeta Tandon
Journal: Hepatology (2019)

See Article on Page 225. Potential conflict of interest: Dr. Abraldes consults for and received lecture fees from Gilead. He consults for Genfit, Pfizer, and Theravance and received lecture fees from Fersing and Lupin. Dr. Tandon consults for Axcella and Lupin. The medical journey for patients with cirrhosis is complex and costly. In addition to the clinical complications related to hepatic dysfunction and portal hypertension, patients contend with extensive comorbidities, physical frailty, psychosocial factors, addictions, and the challenge of navigating through a web of often disconnected provider appointments and tests. Not surprisingly, patients with decompensated disease have high rates of rehospitalization with admission costs estimated at $25,0001 and approximately one third of patients receiving guideline‐concordant cirrhosis management.2 The reasons for gaps in care and resulting high acute care utilization are multifactorial, including the complexity of the patient population and challenges with care delivery. With an expected increase in the number of patients with cirrhosis, our traditional model of primary care and gastroenterology/hepatology‐based care delivery deserves closer evaluation.3 In other complex medical conditions, the involvement of advance practice providers (APPs; physician assistants, nurse practitioners) has resulted in benefits across clinical outcomes, patient satisfaction, and quality of life.4 There are limited data evaluating the impact of APPs on patient outcomes in cirrhosis care. In this issue of Hepatology, Tapper et al.5 present a retrospective analysis of the 2001‐2015 Optum Clinformatics database of patients with private insurance. Using the records of 389,257 adult patients with 2 or more cirrhosis claims, the authors performed a detailed statistical analysis to evaluate the effect of APP care on cirrhosis‐related outcomes (30‐day readmissions, survival) and quality‐of‐care metrics (hepatocellular carcinoma [HCC] and variceal screening, rifaximin use after discharge for hepatic encephalopathy [HE]). In addition to performing multiple analyses to control for the effect of specialist consultation, the authors used 1:1 propensity score matching for exposure to APP care. Of the patients, 57% had never seen an APP, 37% had ascites, and approximately 14% had varices. What Were the Main Findings? Consistent with other models of enhanced cirrhosis care,6 patients receiving APP‐based care (with or without specialist care and compared with no APP involvement) had higher rates of HCC screening (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.19‐1.27), variceal screening (OR, 1.20; CI, 1.13‐1.27), use of rifaximin after discharge for HE (OR, 2.09; CI, 1.80‐2.43), and reduced risk of 30‐day readmission (OR, 0.68; CI, 0.66‐0.70). After adjustment by propensity score matching, APP‐based care was also associated with a reduced risk of death (adjusted hazard ratio, 0.43; 95% CI, 0.41‐0.45). APP care alone was, however, inferior to specialist care alone for all metrics (except for 30‐day readmissions). A shared care model between specialists and APPs was the most successful strategy, offering higher rates of quality and lower 30‐day readmission (OR, 0.91; CI 0.87‐0.95) compared with subspecialty consultation without APPs. Notably, however, even in this APP and specialist group, less than 30% of patients met quality criteria for variceal screening or rifaximin use, identifying a clear need for further care optimization. Interestingly, compared with subspecialty management alone, APP involvement was associated with an almost 2‐fold increase in health care expenditures per person‐year ($9,619 compared with $4,450 for patients who were not comanaged by an APP) and was predominantly attributed to an increased number of procedures. Notwithstanding the accepted limitations associated with the retrospective use of administrative data and the inability to control for liver disease severity by Child‐Turcotte‐Pugh or Model for End‐Stage Disease, several additional considerations are required when interpreting study results. First, patients with cirrhosis were limited to those with private insurance and did not include patients receiving Medicaid or those who lost private insurance because of loss of employment. It is possible that the often more holistic APP‐based perspective on care may have been even more beneficial in this highest‐risk population.7 Second, APP‐based care is often associated with patient education, counseling, and care coordination. Although these factors may have contributed to the benefits, this deserves further exploration.8 Also unclear from the analysis is whether primary and specialty APP care are equivalent. This is important because the presented data have suggested that APP care without specialist involvement might have limited benefits. The nuances of this distinction could help to determine where limited resources would best be applied. Third, we agree that the finding of increased overall cost to the health care system with APP care requires further prospective evaluation. This is in keeping with the Morando study of enhanced “day hospital”–based care in which increased outpatient costs were outweighed by significant reductions in inpatient and thereby total costs.6 With only 37% of patients having ascites in the current analysis, this increased cost may have been related to the inclusion of a large number of patients with compensated disease. This also may explain the low inpatient charges seen per person per year. The final consideration is that, although these data support practice change, practical limitations of being able to generalize this intervention remain. As the authors acknowledged, the care of patients with cirrhosis varies worldwide. Specialists often centralize in metropolitan hubs, and not all jurisdictions have access to APPs, nor do APPs have the same role and autonomy in all places. What Are the Implications of the Current Study for Health Care Providers and Patients? As Tapper et al. state, “the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis.”5 As the prevalence of cirrhosis continues to rise, comprehensive care of this population that is mindful of their complex medical and psychosocial needs is essential. The authors provide evidence to justify improved quality and clinical outcomes with APP‐based care. More work is needed to determine the optimal role of APPs, in what model of care they best optimize outcomes, the frequency of APP‐based follow‐up, and the essential components of care. Given that APP‐based care is a limited resource, focusing this multidisciplinary resource on patients with decompensated cirrhosis will probably be associated with the most potential for clinical and cost‐benefit.9 Notably, even in the APP and specialist care group, the majority of patients did not meet quality‐of‐care metrics, emphasizing the need for a multifaceted approach in this population. Another publication by the University of Michigan team reported on the clinical care and survival benefit of Specialty Care Access Network‐Extension of Community Healthcare Outcome (SCAN‐ECHO), a telemedicine system in wide use across the Veterans Affairs meant to empower primary care physicians to care for patients with chronic liver disease.10 Additional approaches to build capacity in primary and subspecialty care, standardized order sets, an increased focus on broader health needs, and the codevelopment of patient and caregiver education tools are considerations for future interventions. Finally, care coordination is an often underrecognized yet critical element of care delivery across multiple providers. Role clarity between primary care physicians and specialists can be especially challenging and warrants attention in this high‐need, high‐cost population. In summary, there has been an increasing number of publications highlighting the impact of cirrhosis care gaps in the health system and clinical and patient‐reported outcomes. The study by Tapper et al. has moved the field of cirrhosis care optimization a step further, compelling us with evidence for APP and specialist care models to raise our defenses against the rising tide of cirrhosis. Author Contributions Conceptualization: A.M.H., M.C., and P.T.; Writing‐Original Draft: A.M.H., M.C., and P.T.; Writing‐Review & Editing: M.C., P.T., and J.G.A.