A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage
To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH).
Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (≤12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices.
We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ≤5 d), length of stay, and 30-day readmission.
Guideline adherence was variable: endoscopy ≤12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P≤0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks.
Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.
Tapper EB, Friderici J, Borman ZA, Alexander J, Bonder A, Nuruzzaman N, Ramdass S, Ghaoui R. A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage. J Clin Gastroenterol. 2018 Feb;52(2):172-177.