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Cirrhosis Outcomes Better When Tx Guidelines Followed - below is full text Editorial and full text article, attached is pdf of published study
 
 
  Download the PDF here
 
MedPage Today
Published: August 31, 2010
 
Action Points
 
* Explain that current guidelines recommend screening liver cirrhosis patients for esophageal varices and beta-blocker treatment or variceal ligation -- for those patients found to be at risk for bleeding -- along with periodic follow-up endoscopy.
 
* Explain to interested patients that following screening and treatment guidelines led to lower-than-expected rates of variceal hemorrhage.
 
Routinely screening liver cirrhosis patients for esophageal varices and treating them according to published guidelines led to lower-than-expected rates of subsequent variceal hemorrhage, researchers found.
 
A review of patient charts in a center that showed strong compliance with cirrhosis management guidelines found that the actuarial two-year likelihood of variceal bleeding was 13% -- compared with a predicted rate of 27% calculated on the basis of liver dysfunction severity, variceal size, and so-called "red wale markings" seen on endoscopy (P<0.05), according to Jayavani Moodley, MD, of the Cleveland Clinic, and colleagues.
 
"In our population, management according to principles endorsed by a recently published practice guideline was associated with a lower bleeding rate than that expected in untreated patients," Moodley and co-authors wrote in the August issue of Clinical Gastroenterology and Hepatology.
 
Guidelines issued in 2007 jointly by the American Gastroenterological Association and the American Association for the Study of Liver Disease call for screening cirrhosis patients for esophageal varices and beta-blocker treatment or variceal ligation for patients found to be at risk for bleeding, along with periodic follow-up endoscopy.
 
Moodley's team reviewed charts from 179 patients evaluated for cirrhosis at the Cleveland Clinic from 2003 to 2006 and found that 80% had endoscopic screens for esophageal varices within six months of their initial visit, and a total of 94% had such screens at some point during treatment at the clinic.
 
A chart review of endoscopy results revealed that 83 patients had varices -- including 35 with medium to large lesions.
 
The review also indicated that treatments conforming to the AGA/AASLD guidelines were given to 91% of patients with medium or large varices. On the other hand, compliance with the guidelines was lower (60%) among patients with small varices.
 
Of those patients without bleeding episodes during follow-up, 82% had their screening endoscopy within six months of their initial visit -- whereas only 50% of the patients suffering hemorrhages received such prompt screening (P=0.016).
 
Hemorrhage from esophageal varices occurred in nine patients with varices at screening of 12 total bleeding episodes that occurred during the follow-up period.
 
Moodley and colleagues had calculated a two-year actuarial probability of 13% that patients with varices would have hemorrhages. In comparison -- under the standard North Italian Endoscopy Club model for predicting variceal hemorrhage rates -- 27% of the Cleveland Clinic patients with varices would have been expected to develop hemorrhages in two years. This model takes into account the severity of liver dysfunction, the size of varices, and whether red wale markings are present.
 
Moodley and colleagues noted that 80% of the clinic's patients with medium to large varices underwent ligation procedures as opposed to beta-blocker therapy.
 
In their report, they wrote that the clinic's institutional preference was "influenced by two meta-analyses which indicate superiority of esophageal variceal ligation in preventing initial bleeding." But they also noted that a study published last year found better outcomes for beta-blockers.
 
"This finding, if verified, will likely alter our treatment strategy in the future," Moodley and colleagues commented.
 
In an accompanying editorial, two physicians at Boston's Beth Israel Deaconess Medical Center noted an odd paradox in the study's findings.
 
Although the rate of variceal hemorrhage was low in patients receiving guideline-compliant recommendations (8%), wrote Michelle Lai, MD, MPH, and Nezam Afdhal, MD, it was even lower (6%) among 54 patients who were screened but did not receive the recommended treatment.
 
Lai and Afdhal also suggested that findings at a tertiary care center such as the Cleveland Clinic may not apply to community gastroenterology practices. As a result, they indicated, "the findings, therefore, need to be confirmed ... in future studies."
 
Primary source: Clinical Gastroenterology and Hepatology
Source reference:
Moodley J, et al "Compliance with practice guidelines and risk of a first esophageal variceal hemorrhage in patients with cirrhosis" Clin Gastrenterol Hepatol 2010; 8: 703-708.
 
Additional source: Clinical Gastroenterology and Hepatology Source reference:
Lai M, et al "Health care quality measurement in the care of patients with cirrhosis" Clin Gastrenterol Hepatol 2010; 8: 650-651.
 
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EDITORIAL
 
Health Care Quality Measurement in the Care of Patients With Cirrhosis
 
* Michelle Lai, MD, MPH
* Nezam H. Afdhal, MD
 
published online 17 May 2010.
 
In recent years, there has been increasing emphasis by the US government on health care quality assessment and improvement. Increased funding for the Agency for Healthcare Research and Quality has led to new initiatives by the agency to achieve its mission of improving the quality, safety, efficiency, and effectiveness of health care for Americans. After expanding its support of health information technology initiatives in 2004, the agency established the Effective Health Care Program in 2005 to conduct comparative effectiveness reviews and provide understandable and actionable information for patients, clinicians, and policy makers. The Patient Safety and Quality Improvement Act of 2005 established a system of patient safety organizations and a national patient safety database. More recently, the American Recovery and Reinvestment Act of 2009, known as the "Stimulus Package," created the Federal Coordinating Council for Comparative Effectiveness and Research and allocated $1.1 billion for "comparative effectiveness research" to provide patients, clinicians, and others with evidence-based information to make informed decisions about health care.
 
Third-party payors have followed the governmental agencies in their emphasis on quality assessment and improvement as shown by a move toward an outcomes and quality-based reimbursement model. This pay-for-performance model of payment links quality of care with the level of payment for health care services. California leads the way with the California Pay for Performance Program, now the largest pay-for-performance program in the country. Medicare also launched various pay-for-performance initiatives in physician offices, clinics, and hospitals. More than 100 private and federal pilot pay-for-performance programs are under way.
 
According to criteria defined by the Institute of Medicine, cirrhosis (and its complications) is recognized as a chronic disease that requires quality of care measurement to reduce practice variation and improve clinical outcomes.1 Although clinical guidelines put forth by a panel of experts who have reviewed all the evidence (ie, comparative effectiveness review) is an important first step in evidence-based health care quality assessment and improvement, they are not, in themselves, assessment of health care quality. Currently, there are limited data on how to define and measure quality of care for patients with cirrhosis. Recent data show that, despite the existence of evidence-based practice guidelines, there is poor adherence (54%) to the clinical guidelines of the use of β-blockers for primary and secondary prevention of esophageal variceal hemorrhage (EVH).2, 3, 4, 5, 6, 7 It also remains to be seen whether compliance with the guidelines leads to improved patient outcomes. It is important to go one step further and translate these guidelines into a quality-assessment tool. Two articles in this current issue of Clinical Gastroenterology and Hepatology address quality assessment in the care of patients with cirrhosis. Moodley et al8 examines the association of compliance with guidelines to patient outcome whereas Kanwal et al9 identify quality indicators in the care of patients with cirrhosis.
 
Although there have been studies examining the compliance rate with clinical guidelines on the management of varices,7, 10 Moodley et al report on whether compliance leads to improved patient outcome. They examined the compliance with practice guidelines for screening of esophageal varices (EV) in patients with cirrhosis and intervention to prevent EVH as well as the impact of compliance on the rate of first EVH. The authors reviewed the charts of a random sample of 179 adult patients newly evaluated for cirrhosis at a tertiary liver unit, excluding patients with a previous history of EV, EVH, or treatment with β-blockers. They looked at the association of compliance with practice guidelines to subsequent esophageal variceal hemorrhage rates. Moodley et al found a high rate of compliance with screening guidelines (94%; and 80% in the first 6 months) at this tertiary liver unit. Compliance with intervention guidelines (ie, β-blockers, esophageal variceal ligation, or follow-up esophagogastroduodenoscopy [EGD]) was 68% in all screened patients and higher (91%) in patients with large varices. Twelve of the 179 patients had an EVH. Of the 12 subjects who had an EVH, only 50% had a screening EGD within 6 months of evaluation compared with 82% of those without an EVH who had an EGD within 6 months. The authors concluded that this showed the effectiveness of early variceal screening. However, it appears that in the group of patient who were not screened (9%), there were no cases of EVH. All subjects who bled had undergone a screening EGD at some point and 75% also had practice guideline compliant management after the screening. In addition, patients screened but not compliant with practice guideline management had a lower rate of EVH (3 of 54; 5.6%) than subjects who were compliant with practice guideline management (9 of 114; 7.9%). These results are somewhat contradictory and suggest that more data are needed before concluding that early screening led to lower rates of first EVH. The high compliance rate found in this study likely is owing to the practice setting of a tertiary care center. The findings, therefore, need to be confirmed in community gastroenterology practices in future studies.
 
The second article by Kanwal et al is an ambitious study to identify a set of evidence-based quality indicators (QI) for cirrhosis in clinical practice. By using the RAND/UCLA Appropriateness method, a panel of 11 experts came up with a list of the 8 most important QIs in 3 domains: ascites, variceal bleeding, and hepatocellular carcinoma. A list of candidate QIs that were linked to clinically important outcomes was generated using existing clinical guidelines. A comprehensive literature review of data linking candidate QIs to outcomes then was performed and presented to the panel of experts. Through an iterative, evidence-based process, the panel of experts chose the final 8 QIs. There were 3 QIs in the ascites domain, which were timely antibiotic treatment for spontaneous bacterial peritonitis, management of ascites with diuretics and salt restriction, and diagnostic paracentesis for hospitalized patients with ascites. The 4 QIs in the domain of variceal bleeding were timely endoscopies for patients with cirrhosis and upper gastrointestinal bleeding, appropriate treatment of EVH, as well as both primary and secondary prevention of an esophageal variceal bleed. The quality indicator in the domain of hepatocellular carcinoma was adherence to the hepatocellular carcinoma screening guideline of imaging every 6 to 12 months. These quality indicators are constructed as "if-then" statements, where "if" characterizes the eligible patient population and "then" describes the care that should be given. This format allows them to be translated easily into a practical checklist to be used as a tool for practices to assess quality and improve quality. However, before the use of this list of QIs is implemented into quality-assessment processes, studies need to be performed to evaluate whether adherence to this list of QIs in clinical practice leads to improved patient outcome.
 
We have seen the current focus by both government agencies and payors of quality assessment and quality improvement. In light of this increasing emphasis on quality assessment and quality-based reimbursement models, it is important that researchers and professional societies identify the optimal tools for assessing health care quality and also tools for implementing guidelines. These 2 articles represent a good start toward identifying tools for assessing health care quality in the care of patients with cirrhosis.
 
-------------------------------------
 
Compliance With Practice Guidelines and Risk of a First Esophageal Variceal Hemorrhage in Patients With Cirrhosis
 
Jayavani Moodley, Cleveland Clinic Foundation, Department of Gastroenterology and Hepatology, 9500 Euclid Avenue, Cleveland, Ohio 44195. fax: (216) 445-5477, Rocio Lopez , William Carey
 
published online 12 March 2010.
 
Background & Aims
 
Esophageal variceal hemorrhage (EVH) is a serious complication of cirrhosis, with 20% mortality per episode. The 2007 American Association for the Study of Liver Disease and American College of Gastroenterology practice guidelines regarding esophageal varices in patients with cirrhosis recommend screening and intervention to prevent EVH. We assessed practice guideline compliance and its impact on the rate of first EVH.
 
Methods
 
An institutional review board-approved retrospective chart review was conducted on a random sample of adult patients newly evaluated for cirrhosis at the Cleveland Clinic from 2003 to 2006 (n = 179). Exclusion criteria were a previous diagnosis of esophageal varices or EVH and/or treatment with β-adrenergic antagonists. Patients were followed for 23 months (range, 9-38 months). Conformity with practice guidelines and subsequent bleeding rates were determined. Observed bleeding rates were compared to the North Italian Endoscopy Club (NIEC) model.
 
Results
 
Of the patients, 94% had a screening endoscopy, 80% within 6 months of the initial visit. Varices were present in 50% of the patients; 68% of all patients screened and 91% with large varices received a practice guideline-recommended treatment. Twelve patients (7%) had an episode of EVH; 82% of subjects without bleeding had their screening endoscopy within 6 months versus 50% of those with bleeding (P = .016). Actuarial likelihood of bleeding at 2 years was 13% versus 27% predicted by the NIEC model (P < .05).
 
Conclusion
 
Compliance with practice guideline recommendations is associated with reduction in first EVH in the first 2 years.
 
The risk of developing gastroesophageal varices in patients with cirrhosis is between 50% and 66%1 and 30%-40% of patients with varices suffer a variceal hemorrhage.2 Although the mortality rate associated with an episode of esophageal variceal hemorrhage (EVH) has decreased almost 3-fold in the past 2 decades owing to the combined use of endoscopic and pharmacological interventions, it is still high at 15%-20%.3, 4 If untreated, variceal hemorrhage portends a 70% risk of death within 1 year2; this high mortality rate makes primary prevention of bleeding the best approach to improving outcomes for these patients. The American Association for the Study of Liver Disease (AASLD) jointly with the American College of Gastroenterology (ACG) recently published practice guidelines (PG) (Supplementary Appendix A) that recommend screening and intervention for high risk EV.5 In 1988 the North Italian Endoscopy Club (NIEC) defined high risk varices as a composite measure of 3 variables: the severity of liver disease as determined by the Child-Pugh Score (CPS); the size of varices, with large varices being the most ominous; and the presence and severity of red wale markings or red signs (longitudinal dilated venules on the varix, similar to whip marks)6 (Supplementary Appendix B). In 2004 Zaman et al documented that self-reported PG compliance among gastroenterologists improved from 18% to 54% following the publication of the 1997 American College of Gastroenterology guidelines for the management of varices.7 Four years later the compliance rate in the same population still sits at 54%.8 There have been, however, no studies evaluating the impact improved compliance has on clinical outcomes such as rates of variceal hemorrhage or mortality among patients with cirrhosis. We undertook this study to assess actual compliance rates of gastroenterologists at a large tertiary institution with the current AASLD/ACG practice guidelines concerning EV screening and management. We also aimed to elucidate whether compliance resulted in improved patient outcomes, namely decreased risk of first variceal hemorrhage.
 
Methods
 
An institutional review board-approved retrospective chart review was conducted on 179 adult patients (age >18 years), selected by computerized randomization from 468 eligible patients, newly evaluated for cirrhosis at the Cleveland Clinic from 2003-2006. Exclusion criteria were a previous diagnosis of EV or EVH and/or treatment with β-adrenergic antagonists. The diagnosis of cirrhosis was based on historical, clinical, and pathological data.
 
The electronic database EPIC was used to retrieve relevant information spanning hepatology outpatient visits, hospital admissions, endoscopic procedures, and laboratory and other pathology-related data. Our analysis aimed to determine whether or not patients underwent timely screening for varices after initial evaluation by a hepatologist, follow-up surveillance endoscopies, and if found, were varices appropriately managed. Patients were followed for an average of 23.0 months (range, 9.2-37.8 months). Our endpoint was first EVH or last EPIC encounter. Information about bleeding episodes that occurred at the Cleveland Clinic was obtained directly from endoscopy reports, laboratory data, or hospital discharge summaries. If an episode of EVH occurred at another institution the data were documented by the hepatologist in the patient's outpatient record. The NIEC index was calculated for the patients who bled from EV, and the observed bleeding rates were compared with the NIEC predicted rates at 1 and 2 years.
 
For the purpose of appropriate data collection the following variables were defined.
 
Practice Guideline Recommended Management
 
In compliance with the 2007 AASLD/ACG PG (Supplementary Appendix A), effective screening required that patients have their screening endoscopy within 6 months of their initial visit to a hepatologist; patients should be placed on a noncardio-selective beta blocker (BB) or have esophageal variceal ligations (EVL) when needed; follow-up upper intestinal endoscopy (EGD) should be performed at appropriate intervals post esophageal variceal ligation (EVL); and for routine surveillance, BB should be titrated to the maximum tolerated dose. Clinically Significant Bleeding (Baveno IV Criteria)9
 
Transfusion requirement ≥2 units of blood within 24 hours of time zero, and systolic blood pressure <100 mm Hg or postural systolic change >20 mm Hg, and/or heart rate >100 beats/minute.
 
Endoscopic Findings and Description of Varices
 
The presence or absence of esophageal varices was noted. Varices were classified as small, medium, or large. A 5 mm diameter was used as the cutoff for designating small from medium and large varices. The presence or absence of gastric varices and red wale markings was also documented. Unlike in the NIEC study, red wale markings were not graded in the endoscopy records reviewed. For the purpose of calculating the NIEC index in patients who bled we assigned those with red wale markings to the mild category (Supplementary Appendix C). As such, patients with red wale markings may have been placed in a lower risk NIEC category.
 
Length of Follow-Up
 
Patients were followed until their first bleeding episode from EV or their last encounter in EPIC, with the average length of follow-up being 23.0 months (range, 9.2-37.8 months).
 
Statistical Analysis
 
Descriptive statistics were computed for all variables. These include median and percentiles for age and frequencies for categorical variables. Pearson's χ2 tests were used to assess association between compliance to practice guidelines and factors such as presence of varices and CPS. The same was done to study factors associated with the presence and size of varices. Kaplan-Meier estimates were used to study bleeding rates in patients with EV, and a log-rank test was used to compare NIEC groups. Time of follow-up was defined as months between EV diagnosis and either bleeding or last follow-up visit if no bleeding was observed. A P < .05 was considered statistically significant. SAS version 9.2 software (The SAS Institute, Cary, NC) and R version 2.4.1 (The R Foundation for Statistical Computing, Vienna, Austria) were used for all analyses.
 
Results
 
Records of 562 cirrhotic patients presenting for the first time to a tertiary care liver clinic were screened. Ninety-four were excluded because of a previous diagnosis of EV, having suffered an EVH, or being recently (within the previous 12 months) or currently treated with beta blockers. Of the remaining eligible 468 patients, 179 were randomly selected for detailed analysis.
 
Compliance With Practice Guidelines
 
Screening for varices was accomplished in 169 cases (94%), although only 143 (80%) were screened within 6 months of their first encounter with the hepatologist (Figure 1). Ten (6%) were never screened. Two thirds (68%) received PG recommended management after their screening endoscopy, 47 (28%) did not, and 7(4%) were lost to follow-up. PG compliance was found in 73.8% of patients with varices and 67.9% with no varices (P = .41). Ninety-one percent of patients with medium and large varices received a PG recommended treatment compared with 60% with small varices (P = .002). When stratified according to CPS, 75% of CPS A, 57% of CPS B, and 80% of CPS C received PG-recommended treatment (A vs B, P = .048; C vs B, P = .28). Failure of compliance to practice guidelines was noted in 57 patients. Reasons for fallout were due to physician-related factors in 47 patients (82%). Of these, 20 did not receive a follow-up surveillance endoscopy, 14 were not given BB (for CPS B/C with small varices), 10 did not have a screening EGD, and 3 did not receive either BB or EVL once diagnosed with varices. Eighteen percent (10 patients) had their subsequent EGD beyond the recommended interval due to nonphysician or indeterminate factors.
 
Findings at Screening Endoscopy
 
One hundred and sixty-nine patients had a screening EGD (Table 2). One was excluded because of incomplete records; there was no description of the size or appearance of varices in the endoscopy report. Eighty-four (50%) of the remaining 168 patients had varices. Seventy (58%) of CPS A had no varices while 6 (60%) of CPS C had medium/large varices. CPS A patients were more likely to have small varices than CPS B (P = .002) and CPS C (P = .003). The presence of red wale markings on varices was noted in 3 (2.5%) of CPS A patients and 2 (20%) of CPS C.
 
Bleeding
 
Twelve patients (7%) of the study population had an episode of clinically significant bleeding during the follow-up period. Nearly all (11/12) had either esophageal or gastric varices at the time of initial screening endoscopy. Thirteen percent (11/84) of those with varices at initial screening subsequently bled. Of the 9 patients with EV, 2 (17%) had small and 7 (58%) had medium or large varices. Eight subjects bled within 1 year, 3 in the second year, and 1 subject 2 years after their screening EGD. At screening, 6 (50%) patients with subsequent EVH were CPS A, 4 (33%) CPS B, and 2 (17%) CPS C. Six (50%) of the patients who bled had received a screening endoscopy within 6 months of initial diagnosis. Eighty-two percent (137/167) of subjects without bleeding had their screening EGD within 6 months of initial visit compared with 50% (6/12) of those with bleeding (P = .016). Seventy-five percent (9/12) of patients with EVH did receive a PG-recommended treatment after their screening EGD. There were 52 patients with a NIEC score ≤26 and 32 with a NIEC >26 (Table 3). Three patients (5.8%) in the lower NIEC category bled compared with 6 (18.8%) in the group with a NIEC >26 (P = .032), in conformity with previous predictions of increased bleeding risk with higher NIEC scores (Figure 2).6
 
Eleven percent (9/84) of subjects with EV had EVH compared with 26.5% in the NIEC study (P = .002). The cumulative actuarial likelihood of bleeding was 9.2% and 13.0% at 1 and 2 years respectively, significantly lower than predicted by the NIEC model namely 16% and 27% (P < .05). As the NIEC index was developed for patients with EV, only the 9 patients with EV were used in comparison studies with the original NIEC.
 
We observed no bleeding episodes attributable to band ligation. Eighteen percent of those with small varices were given beta blockers; eighty percent of those with medium/large varices were treated with EVL, indicating a preference in this facility for this management tool. Observed bleeding rates were not different between treatment groups.
 
Discussion
 
Our study confirms the high prevalence of esophageal varices (50%) in cirrhotic patients with no history of bleeding. Sixty-three percent of those with varices had features putting them at high risk for bleeding. These results are similar to findings in other screening programs.6 We further demonstrated that high compliance (80%-94%) with screening for esophageal varices among cirrhotic patients seen at a large tertiary care facility appears to translate into better patient outcomes. We are unaware of other published reports demonstrating actual compliance with esophageal varices screening practice guidelines. Two studies evaluating practice guideline compliance regionally and nationally among gastroenterologists found a low rate of reported adherence (54%).7, 8 These reports surveyed gastroenterologists (not hepatologists) from a variety of practice settings. Our study examined behavior of hepatologists in an academic center. Nearly all (94%) of newly diagnosed cirrhotic patients had a screening endoscopy, 80% within 6 months of being evaluated by a hepatologist. Endoscopic screening remains the gold standard for the diagnosis of varices.5 The ACG/AASLD PG recommend a screening EGD to assess the presence of EV when the diagnosis of cirrhosis is made. Subsequent management depends on the nature of the varices, that being their size and appearance, and the patient's CPS.
 
Both beta-blockers and EVL are advocated in the primary prophylaxis of first EVH, and use of these measures significantly reduces the risk of bleeding.10, 11, 12 Of the 168 patients who received a screening endoscopy (regardless of when) 114 (68%) received PG-recommended management including either beta-blockers, EVL and/or timely follow-up. Significantly, 91% of patients with medium or large varices compared with 60% with small varices were treated in compliance with PG (P = .002). This may reflect that practitioners consider small varices less threatening than larger ones and thus are less likely to treat them. However it is known that 4%-10% of small varices progress to large varices per year, and therefore appropriate and timely management is warranted.2
 
Our center prefers EVL to beta blocker therapy, a choice influenced by 2 meta-analyses which indicate superiority of EVL in preventing initial bleeding.12, 13 Of our patients with medium or large varices, 80% were treated with EVL and only 11% by beta-blocker therapy. Concern about major hemorrhage caused by EVL was not realized in this study population. There was no significant difference in early bleeding (within 3 months of initiation of treatment) in those who received EVL and BB (10% and 3.7%, respectively, P = .34) (Supplementary Table 4). We are aware of the recently published report of BB superiority compared with EVL in primary bleeding prophylaxis.14 This finding, if verified, will likely alter our treatment strategy in the future.
 
The most common reason for divergence from PG recommendations is lack of timely follow-up endoscopy for surveillance in patients with no or small esophageal varices, explained, in part, by the referral nature of this practice (Figure 3). Eighteen patients with Child-Pugh B or C had small varices, a group for whom intervention with beta blocker therapy (with dose titration) is recommended. In this group only 22% were given beta blockers. Reasons for noncompliance have not been systematically determined, but may relate to many factors including the complexity of the management algorithm, or unfamiliarity or disagreement with individual PG recommendations. More emphasis may be needed in the specific care of this subset of patients. Bringing to light these areas of noncompliance can help physicians identify those patients who fall into potential gray areas where management may be unclear.
 
The NIEC provides a rich and detailed prospective assessment of bleeding risk in cirrhotic patients with newly discovered varices.6 Based on this, a scoring system of bleeding risk has been constructed and validated.6, 15 Recently suggestions have been made that the original NIEC assigns too much weight to the CPS limiting its prognostic efficiency and accuracy.15, 16 Zoli et al16 propose that more leverage be assigned to the size and appearance of the varices instead and have proposed a revised NIEC index. The differences in predicted bleeding risk between the original and revised scoring systems seem small. Pending further studies, the original NIEC index remains the most widely used system and was selected for our analysis.
 
This study suggests that the significant reduction in observed bleeding rates may be related to adherence to PG-recommended care. Patients who did not bleed were more likely to have received their screening EGD within the 6 month window as compared with those who bled (82% vs 50%, P = .016), demonstrating the effectiveness of early variceal screening. Seventy-five percent of patients who bled (9/12) did actually receive PG-compliant management after their screening EGD. This finding underscores the fact that no currently available strategy will eliminate the risk of variceal hemorrhage. It is noteworthy that both patients found to have isolated gastric varices (IGV) suffered clinically significant bleeding from these culprit vessels. One patient was found to have bleeding from IGV at the time of initial EGD and subsequently underwent placement of a transjugular intrahepatic portosystemic shunt (Supplementary Table 4). Gastric varices are found in about 20% of patients with cirrhosis either alone as IGV or as gastroesophageal varices in direct continuity with their esophageal counterparts. IGV are less prevalent than gastroesophageal varices (10% versus 90%), but they have a greater propensity to bleed; bleeding is difficult to control and is associated with a high mortality rate.2, 17 Currently there is no consensus on optimum treatment of gastric varices, and therefore more studies are necessary to provide data for guidelines on appropriate prophylaxis.9, 17 In patients with IGV it is prudent to rule out the presence of splenic vein thrombosis.
 
Our data need to be confirmed and validated. Of note, our endoscopists most often describe red wale markings as either present or absent (rather than following the NIEC protocol of mild-moderate-severe), making use of the NIEC scoring system difficult and subject to possible interpretive errors (Supplementary Appendix B). We also note a discrepancy between the higher rates of red signs in the NIEC data, namely 41% in Child's A and 39% in Child's C patients compared with 2.5% and 20%, respectively, in our study. This may represent the possibility of underreporting of red signs by our endoscopists and pose a potential limitation of our study.
 
Retrospective studies sometimes lack "granularity," ie, the ability to capture nuances such as reasons for clinical decision-making. Compliance depends on factors other than physician recommendations and includes patient understanding, motivation, family support, and logistical issues such as financial means. From our data set it is difficult to attribute definitively the cause of failure to the physician or patient. Nevertheless, the cumulative effect of physician recommendation plus patient factors has been shown in this population to be highly effective in achieving the goals of practice guideline compliance. A future study is planned to attempt to better understand the relative roles of patient, environment, and physician factors associated with noncompliance.
 
In conclusion, this study confirms the high prevalence of esophageal varices in patients with cirrhosis and also finds high compliance rates with practice guidelines among hepatologists at a large tertiary institution regarding the prevention and management of EV. In our population, management according to principles endorsed by a recently published practice guideline was associated with a lower bleeding rate than that expected in untreated patients. It is recommended that efforts to promote increased awareness of and compliance to PG for the screening and management of EV are warranted.
 
 
 
 
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