Outcome indicators in liver cirrhosis: Application of value-based medicine in a large multicenter study (VBMH study)

Introduction: Liver Cirrhosis (LC) is responsible for high morbidity, mortality and costs, with increasing need to improve quality of care. Aim of our study (Value Based Medicine in Hepatology Study, VBMH) was to identify outcome indicators (OIs) able to measure quality in liver diseases, including compensated (CC) and decompensated (DC) LC. Methods: A panel of hepatologists identified a list of 7 OIs for LC according to experience and published evidence, using a modified Delphi method and a standard 9-pointRANDappropriateness scale. Then, these 7 OIs were tested in clinical practice in a prospective multicenter observational study involving three tertiary centers in Italy, using a web-based electronic medical record. 1751 LC patients were enrolled in 18 months: 1004 CC and 747 DC. 92% of patients had at least two consultations in 17 months median follow-up. Results: Annual rate of decompensation in CC was 12% (OI#1). Annual incidence of 1st variceal bleeding (VB) was 2% for low-risk and 3% for high-risk varices (OI#2) indicating a significant success of primary profilaxis. Annual incidence of HCC in CC was 4.3%, with 81% patients found at early stage (OI#3), underlining the accuracy of oncologic surveillance. One-year survival after the first decompensation episode (ascites in 74% of cases) was 96%, 81% and 59% stratified for CPT score A, B, C respectively (OI#4), and 94%, 56% stratified for MELD below or above 15 (OI#5). 4% of DC patients had an episode of VB with 90% survival after 6 weeks, and 33% recurrence (OI#6). Similarly, 3% ofDCpatients had spontaneous bacterial peritonitis with 6 weeks survival of 86% and 13% recurrence (OI#7). Conclusions: The value-based OIs generated in this study performed well in a large cohort of consecutive patients, and could represent a reference tool for healthcare providers to improve care in LC.