ABSTRACT
Background and Aims: Decompensation events, such as portal hypertensive bleeding, are associated with increased morbidity and mortality among persons living with cirrhosis. Current practice guidelines recommend surveillance for esophageal varices in the setting of clinically significant portal hypertension. The Advanced Liver Disease Dashboard (ALDD) is a national online database developed and maintained by the Department of Veterans Affairs (VA) to facilitate tracking of hepatocellular cancer and esophageal variceal surveillance exams. This online database has potential to optimize workflow through appropriate triage of patients to direct endoscopy or hepatology clinic. The COVID-19 epidemic served as an impetus to utilize a population-based approach to variceal surveillance given delays in access to EGD procedures and limited face-to-face patient encounters. We report the results of our experience at a single VA tertiary care center. Methods: This is a retrospective chart review quality improvement initiative conducted from May 2020 to May 2021 at the San Diego VA Medical Center of patients identified via the ALDD as overdue for esophageal variceal screening. Patients were selected for review by cohort (variceal surveillance/management), platelet filter (none), and category (no EGD (>3Y)). After identifying the study population, patients were managed in three expectant ways: Group 1. Direct EGD referral for esophageal varices screening, Group 2. Direct hepatology clinic referral for further evaluation of diagnosis/ procedure discussion, Group 3. Omit from screening due to age, comorbidities, and/or confirmation of hepatology care at an outside institution. Results: A total of 153 patients were identified during the study period. 11 patients were excluded due to not carrying a cirrhosis diagnosis. 27 patients (19.0%) were directly referred for EGD for esophageal varices screening, 61 patients (43.0%) were directly referred to hepatology clinic for further evaluation of advanced liver disease status and/or discussion of EGD, and 54 patients (38.0%) were omitted from further screening due to age, comorbidities, and/or receiving care with an outside hepatologist. Of the 61 patients referred to hepatology clinic, 12/61 (19.7%) needed to confirm cirrhosis diagnosis. Conclusions: Using an online database of advanced liver disease patients allows for identification of patients overdue for appropriate cirrhosis screening measures and specialist-directed triage to optimize workflow. In the future, the ALDD can be used to improve patient adherence to EGD, increased implementation of pharmacological prophylaxis with non-selective beta blockers in select cases and utilize ALDD review on a recurring basis to minimize missed opportunities for preventive care. (Figure Presented)