Access to care


Center variation in the use of non-standardized MELD exception points

David S. Goldberg1,2, George A. Makar1,Benjamin French2;

1Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia,FA; 2Clinical Center for Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA

The MELD score is an imperfect prognosticator of waitlist dropout, thus transplant centers may apply for exception points. Exception applications are categorized as recognized exceptional diagnoses (REDs; e. g. HGG) and non-REDs (e. g. recurrent cholangitis). While prior work has demonstrated regional variation in the use of exceptions, no work has examined the between-center variability in the use, and subsequent approval, of non-RED exceptions. We analyzed all new waitlist candidates from 2/27/02-6/3/11, to explore variation in the use of non-REDs, for which no strict exception criteria exist. Of 58, 641 new waitlist candidates, 4, 356 (7. 4%) applied for a non-RED exception. The number of applications increased over time, as did the approval rates for such applications—nearly 50% in 2002 to 75% in 2010.Adjusting for patient factors, there was significant variability (P<0.001) in the use of non-RED exceptions in 7/11 UNOS regions, and in the approval of these exceptions in 6/11しNOS regions. In 3 しNOS regions, the absolute difference in the adjusted proportion of approved non-RED exceptions between centers with the highest and lowest approval rates was >30%. Variability in the use and approval of non-REDs was clinically significant—waitlist candidates with approved exceptions were significantly more likely to be transplanted (68. 3% vs. 53. 4%, P<0.001) and less likely to be removed for death or clinical deterioration (10.4% vs. 16. 2%, P<0.001). While increased median MELD at transplantation within a donor service area was associated with increased odds of applying for exceptions, no other center factors were associated with applying for, or having non-RED exceptions approved.


Figure 1: Within-region variability in waitlist candidates applying for non-RED exceptions per center


Figure 2: Within-region variability in non-RED approvals between centers with at least 20 applications

Disclosures: The following people have nothing to disclose: David S. Goldberg, George A. Makar, Benjamin French


The Educational Impact of SCAN-ECHO

Reena Salgia1,Patricia B. Mullan2, Heather McCurdy3, Anne E. Soles3, 4, Richard H. Moseley1,3, Grace L. Su1, 3

1Internal Medicine, University of Michigan, Ann Arbor, MI; 2Medical Education, University of Michigan, Ann Arbor, MI; 3VA Ann Arbor Healthcare Systems, Ann Arbor, Ml; 4VA center for Clinical Management Research, Ann Arbor, MI

Background: With the aging of the HCV cohort and increasing prevalence of NAFLD, the burden on primary care providers (PGPs) to care for patients with chronic liver disease and cirrhosis is growing nationwide. In response to this problem, the Veterans Health Administration implemented a series of innovative initiatives focusing on primary care-specialty referral to increase PGP competency in the management of complex chronic medical diseases. One such initiative, the SGAN-EGHO program, was implemented in mid-2011 to transfer subspecialfy knowledge to primary care providers through case-based distance learning combined with real-time consultation. Although this program has now been implemented widely, there is limited information regarding its ability to engage PGPs to learn and influence their clinical practice. Aims: We surveyed primary care providers in order to assess the factors which led to their participation in the SCAN-ECHO program and the educational impact of their participation. Results: Out of 51 potential provider participants, 24 responded to an anonymous web-based survey. More than 75% of respondents had participated more than once in the program. Greater than 20% indicated that liver disease affects more than 15% of their patients. Providers indicated they were motivated to participate mainly by a desire to learn more about liver disease, to be able to apply the knowledge they gained to future patients, and to save their patient time traveling to another VA medical center for specialty consultation. Seventy-one percent of providers responded that both the didactic component and case-based discussion were equally important, and the vast majority would still participate even if the didactic component was removed. Providers noted that topics of greatest priority for them in the primary care setting include NAFLD, alcoholic liver disease, and the general management of patients with cirrhosis. The mark of success for this program, however, was the unexpected finding (given the program is still early in implementation) that participation changed clinical practice. Remarkably, 75% of providers indicated they had personally discussed the information they learned from the case presentations with their colleague (s), and 42% indicated they helped a colleague care for their patient with the knowledge they learned during the discussions of other participants' cases. Discussion: This study shows that a SCAN-ECHO program involving videoconferencing between PCPs and specialists can educate PCPs in the delivery of specialty care from a distance and potentially improve healthcare delivery.


Heather McCurdy - Speaking and Teaching: Onyx Pharmaceuticals, Bayer Health


The following people have nothing to disclose: Reena Salgia, Patricia B. Mullan,

Anne E. Sales, Richard H. Moseley, Grace L. Su


A novel nurse-led approach does not increase initiation of therapy in injection drug users with chronic hepatitis c in East London

Jan Kunkel1, Heather Lewis1, Mandie Wilkinson2, Graham R. Foster1

1Hepatology, Centre for Digestive Diseases, Queen Mary, University of London, London, United Kingdom; 2Blood Borne Virus Team, East London NHS Foundation Trust, London, United Kingdom

Background and Aims While the prevalence of chronic infection with hepatitis C virus (HCV) in injection drug users (IDUs) is high (60-90%), treatment rates in this hard-to-reach group of patients remain disappointingly low. It has been shown that uptake can be improved by approaching and treating patients in a community setting, and in East London IDUs with HCV are first seen by specialist nurses and then referred to a hepatologist for consideration of treatment. Even though the hepatologist clinics are held regularly and in a community setting, the treatment rate is still only 17%. It was therefore hypothesised that a protocol allowing specialist nurses to start treatment of low-risk patients in their outreach clinics would increase rates of treatment initiation and completion. Methods Participants were cluster-randomised by outreach clinic into two arms: While the standard of care (SOC) arm received a standard treatment as detailed above, the nurse-led (NL) arm was offered treatment initiation by specialist nurses in a community setting unless exclusion criteria including cirrhosis, anaemia and major psychiatric condition were present. Results 142 patients were assessed, 78 in the SOC arm and 64 in the NL arm. There were no significant differences in genotype or sex, but the NL group was significantly younger (median 4 years). 21/64 patients (33%) did not fulfil the safety criteria for NL treatment, eight of these due to medical and eight due to psychiatric comorbidity. 13/78 patients (17%) were unsuitable for treatment in the SOC arm, ten of these due to medical comorbidity. Of those offered treatment in the SOC arm 63% (38/60) accepted treatment and 12% (9/60) started treatment. In the NL arm 47% (18/38) accepted and 21% (8/38) started treatment (p=ns). One patient in the SOC arm and two patients in the NL arm had to discontinue treatment early. Conclusions Treatment rates were low in both arms, and nurse led therapy did not significantly increase the number of patients starting treatment. Further results including SVR rates are awaited as the trial is still on-going.


Graham R. Foster - Advisory Committees or Review Panels: GlaxoSmithKline, Novartis, Boehringer Ingelheim, Tibotec, Chughai, Gilead, Janssen, Idenix, GlaxoSmithKline, Novartis, Roche, Tibotec, Chughai, Gilead, Merck, Janssen, Idenix, BMS; Board Membership: Boehringer Ingelheim; Grant/Research Support: Chughai, Roche, Chughai; Speaking and Teaching: Roche, Gilead, Tibotec, Merck, BMS, Boehringer Ingelheim, Gilead, Janssen

The following people have nothing to disclose: Jan Kunkel, Heather Lewis, Mandie Wilkinson


Demographics and self-reported risk factors associated with anti-HCV positivity in a community based testing program in Southwest Philadelphia

Stacey B. Trooskin1, Sophie G. Feller2, Annajane Yolken3, 4, Nojio Luqmon3, 4, Julio Harvey3, 4, Hwajin Lee3, 4, Amy Nunn3, 4

1 Infectious Diseases, Drexel University College of Medicine, Philadelphia, FA; 2Jefferson Medical College, Philadelphia, FA; 3Infectious Diseases, Brown University School of Medicine, Providence, Rl; 4The Miriam Hospital, Providence, Rl

Purpose: Fifty to 75% of individuals chronically infected with HGV are unaware they are infected. New GDG guidelines recommending HCV testing for baby boomers will help promote HCV testing among individuals who already access primary care; however, many individuals at highest risk for HGV do not have a primary care provider and therefore may never be tested for HGV. Understanding the demographic factors and risk behaviors of HCV positive individuals in the most heavily impacted communities of the US can help inform development of HCV testing, linkage to care and treatment programs for individuals with limited access to health services. Methods: The “Do One Thing” Campaign is a testing, linkage to care, and treatment program that stimulates demand for and provides HIV and HCV testing in non-clinical settings across an entire zip code in a heavily impacted neighborhood of Southwest Philadelphia. From December 2012 to May 2013, 466 participants 18 years and older were screened for HCV using the Oraquick rapid HGV antibody test; we also conducted confirmatory testing for all individuals with reactive results. After providing informed consent, individuals completed a 20-minute survey. Demographic and risk behavior data was collected on an iPad via an online secure survey. We used multivariable logistic regression models to explore the strongest predictors of testing positive for HCV. Results: Anti-HCV seroprevalence in this population was 4%. Ninety percent of individuals tested were African American, 62% were insured, and 53% were male. Only 34% of the population reported ever undergoing HGV testing. Antibody-positive individuals were more likely to be 47-67 years old (OR 10.61 [95% GI 3. 08, 36. 54], p=0.0002), report a history of injection drug use (OR 14. 73 [95% GI 3. 41, 63. 67], p=0.0003), a history of crack or cocaine use (OR 3. 93 [95% GI 1. 15, 13. 47], p=0.029), report sex with an HIV-positive or injecting drug using partner (OR 10.48 [95% GI 3. 79, 29. 00], p =0.0001), or a history of incarceration (OR 6. 78 [95% GI 2. 17, 21. 21], p=0.001). Conclusions: The strongest predictors of testing HCV positive in this non-clinical HGV testing program were history of injection drug use and cocaine use, incarceration, sex with a high-risk partner. Do One Thing program has successfully tested a highrisk population that otherwise might not have undergone HCV testing or been linked to HGV care. Non-clinical HGV testing and linkage to care programs are important means to diagnose, link to care, and treat some of the most high-risk populations in heavily impacted communities in the US.


Stacey B. Trooskin - Grant/Research Support: Gilead Sciences

Amy Nunn - Consulting: Mylan; Grant/Research Support: Gilead

The following people have nothing to disclose: Sophie C. Feller, Annajane Yolken, Najia Luqman, Julia Harvey, Hwajin Lee


Mortality due to Chronic Liver Disease among American Indians and Alaska Natives in the United States, 1999-2009

Anil Satyaprasad1, Kathy K. Byrd1, John T. Redd2, David G. Ferdue3, 4, M. Michele Monos5, Brian J. McMohon6, 7

1Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA; 2Santa Fe Public Health Service Indian Hospital, Indian Health Service, Santa Fe, NM; 3The American Indian Goncer Foundation, Minneapolis, MN; 4Minnesota Gastroenterology PA. Minneapolis, MN; 5Kaiser Permanente Division of Research, Oakland, GA; 6Liver Disease ond Hepatitis Program, Alaska Native Tribal Health Consortium, Alaska Native Medical Center, Anchorage, AK; 7Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Anchorage, AK

Background and Aims: Chronic liver disease (CLD) is a leading cause of death among American Indian and Alaska Natives Peoples (AI/ANs). The precision of mortality estimates, however, is limited by the underestimation of GLD cases with narrow definitions in mortality data and the misclassification of AI/ANs in death records. We employed a previously-validated definition of GLD deaths, based on comprehensive diagnostic disease codes, and used techniques to improve AI/AN race classification to describe disparities and compare trends in GLD mortality during 1999-2009 between AI/ANs and NHWs in the United States. Methods: CLD deaths and causes in AI/ANs and NHWs were identified from death certificates using the comprehensive codes. GLD deaths with a primary liver cancer code were classified as hepatocellular carcinoma (HCC), and all others classified as cirrhosis. To improve AI/AN race classification, the National Death Index was linked to Indian Health Service (IHS) enrollment records and analyses were restricted to Contract Health Service Delivery Areas, which contain or are adjacent to federally-recognized tribal reservations. Death rates (per 100, 000) were directly age-adjusted to the 2000 し. S. standard population and were calculated in six geographic regions. Trends were described using Joinpoint regression techniques. Results: From 1999-2009, GLD death rates increased by 24. 1% in AI/ANs and 14. 2% in NHWs, increasing annually in both (P-value <0.05). The overall GLD death rate in AI/ANs was 66. 1/100, 000 (95% Confidence Interval [CI] 64. 7-67. 6). The overall GLD death rate ratio (RR) of AI/ANs to NHWs was 3. 7 (95% GI 3. 7-3. 8) and varied across regions. The death RR was greater in females (4. 7, 95% GI 4. 6-4. 9), ages 25-44 years (7. 4, 95% GI 7. 1-7. 8), Northern Plains residents (6. 4, 95% GI 6. 1—6. 8), and persons dying with cirrhosis (4. 0, 95% GI 3. 9-4. 1) versus hepatocellular carcinoma (2. 5, 95% GI 2. 3-2. 7), particularly in ages 25-44 years (7. 7, 95% GI 7. 3-8. 1). Cirrhosis-related GLD death rates were significantly higher in AI/ANs than NHWs for deaths with underlyingalcoholic liver disease (RR 5. 2, 95% GI 5. 0-5. 4), hepatitis G (RR 2. 5, 95% GI 2. 3-2. 7), and hepatitis B (RR 2. 4, 95% GI 3. 1). Conclusions: GLD mortality is nearly four times greater in AI/ANs than NHWs. Death rate disparities were greatest among cirrhosis deaths, compared to HCC deaths and greater in females and Northern Plains residents. The disparity in premature GLD mortality between AI/ANs and NHWs is especially concerning. These findings can guide resource allocation urgently needed for comprehensive prevention and care strategies, to stem the GLD epidemic in this population.


M. Michele Manos - Grant/Research Support: Vertex, Merck, Gilead

The following people have nothing to disclose: Anil Suryaprasad, Kathy K. Byrd, John T. Redd, David G. Perdue, Brian J. McMahon


Establishing Referral Guidelines for Hepatology Specialty Care: Consensus Using the Delphi Method

Chanda Ho, Christy Boscardin, Nathaniel Gleason, Norah Terroulf/ Ralph Gonzales

UCSF, Son Francisco/ GA

Background: Chronic liver disease (GLD) in the US contributes increasingly to referrals from primary care physicians (PCPs) to hepatologists and improved referrals are essential for efficient and quality care. Currently, broad guidelines for standardized diagnostic workup of GLD prior to referral are lacking. Methods: We conducted a Delphi study to establish consensus for referral guidelines, employing an expert panel of 3 PGPs and 8 hepatologists from 3 academic hospitals, who participated in 3 iterative rounds of electronic surveys. We used the University of Michigan referral guidelines for Abnormal Liver Enzymes (cholestatic, hepatitic), Hepatitis B, and Hepatitis C as a starting point. All tests were ranked on a 5-point Likert scale (strongly disagree to strongly agree) and experts also added 3 other GLD diagnoses needing guidelines: Fatty Liver Disease, Liver Mass and Cirrhosis. Consensus was defined as >/0% of experts scoring >4 (agree or strongly agree). Results: Findings are shown in Table 1. For Abnormal Liver Enzymes, SPEP was lower priority, while stopping potential medications was most important, with median (mdn) score 5, followed by GGT, α1 antitrypsin and iron studies (all mdn 4). For HBV, the panel proposed HIV, Ultrasound and HGV Ab (all mdn 5). For HGV, RNA (mdn 5) and HIV (mdn 5) were chosen, while iron studies (mdn 3) were eliminated. For Fatty Liver Disease and Liver Mass, all tests were endorsed (mdn 5). For Cirrhosis, AMA and Ceruloplasmin were eliminated. For all diagnoses, GBG, Liver Function Tests, Chemistries, and PT/INR were considered necessary. Conclusions: Broad agreement on referral guidelines for GLD was established between PGPs and hepatologists. These guidelines are a first step in improving the quality of hepatology referrals. Our next steps include implementation and dissemination of these guidelines and evaluating their impact on care efficiency in CLD.

DiagnosesOriginal Tests Proposed and RetainedAdditional Tests Proposed and RetainedTests Proposed and Eliminated
Abnormal Liver Enzymes
CholestaticANA, AMA, RUQ U/SGGT
Hepatitic AST/ALT<5x UしNHBsAg, HCVAb, RUQ U/S, Ceruloplasmin, ASMA, ANAStop potential medications, a1 antitrypsin, Iron studiesSPEP
Hepatitic AST/ALT>5x ULNIgM Anti-HAV, HBsAg, IgM Anti-HBc, HCV Ab, ASMA
Hepatitis BHBeAg, Anti HBeAg, HBV DNAHIV, RUQ U/S, HCVAb
Hepatitis CGenotype, HBsAg, AFP and RUQ U/S if cirrhosisHCV RNA, HIVIron Studies
Fatty Liver DiseaseHBsAg, HBsAb, Lipids, HgbAlc, >1 imaging study last 12 months
Liver MassHBsAg, HCVAb, AFP, >1 imaging study last 3 months
CirrhosisHBsAg, HCVAb, AFP, Iron Studies. ANA, a1 Antitrypsin AMA, Ceruloplasmin

ANA: AntinuclearAb, AMA: Anti-mitochondrialAb; ASMA: Anti-smooth muscle Ab: RUQ U/S: Right Upper Quadrant Ultrasound SPEP: Serum protein electrophoresis; ULN: Upper Limit of Normal


Norah Terrault - Advisory Committees or Review Panels: Eisai, Biotest; Consulting: BMS; Grant/Research Support: Eisai, Biotest, Vertex, Gilead, AbbVie, Novartis

The following people have nothing to disclose: Chanda Ho, Christy Boscardin, Nathaniel Gleason, Ralph Gonzales


Successful Introduction of Telemedicine to Improve Access to Hepatology Specialty Services for Veterans with Liver Disease

Astrid Knott1, Eric Dieperink1, 2, Christine Pocha1, 2

1Minneopolis VAHCS, Minneapolis, MN; University of Minnesota, Minneapolis, MN

Purpose To improve provision of specialty hepatology care for Veterans living at a distance, the Minneapolis VA Health Care System implemented a Cirrhosis Care Collaborative consisting of a liver video-telehealth (Vtel) clinic and monthly education for primary care providers (PCPs). Methods To establish a personal relationship with providers and introduce the project, site visits to outpatient clinics and medical centers were conducted. Based on a need assessment that showed lack of basic knowledge in cirrhosis care of PCPs, an educational curriculum was developed. Monthly 45 minute video-education sessions covering basic liver and hepatitis topics were provided. GME credit was available. Sessions were evaluated using online feedback. Case discussions were added at provider's request. Liver Vtel clinic visits were conducted by one hepatologist. A nurse provided patient education via Vtel. The clinic was evaluated using administrative records and a patient satisfaction survey. After screening consults request for appropriateness for Vtel initially a specialized Vtel consult was developed. Preliminary results are reported. Results From Nov. 2011 to May 2013, 75 Vtel visits were conducted. Most patients had hepatitis G or cirrhosis diagnoses. The no show rate was similar for Vtel (10%) and in-person clinic appointments (7%). 40 patients completed satisfaction surveys with a mean score of 4. 5 (out of 5). By using Vtel, patients saved on average 260 miles in travel per visit and the VA saved $108 in travel reimbursement per visit. /5 clinicians attended education sessions. 52 completed evaluations, rating the helpfulness of the education sessions for clinical practice high (4. 5 out of 5) and indicating that they would make practice changes (44%, 23/51). Barriers to practice change included: not applicable to the practice (12/52), limited resources (2/51), and further training needed (2/51). In addition, 39 providers attended the case discussions. Conclusions Improving access for specialty hepatology care takes time to set up (acquiring technology, setting up clinical/administrative processes, etc.), but is clearly facilitated by provider educationand relationship building. The main facilitator was a dedicated project administrator. Vtel visits were well accepted by patients and providers. Patient travel time and travel costs were reduced. Provider education on liver health was well received and a significant percentage of providers indicated that they would change their practice, which may reduce referral to specialty care. Video-telemedicine is a useful tool for chronic disease management and may be considered for other medical conditions.


The following people have nothing to disclose: Astrid Knott, Eric Dieperink, Christine Pocha


Efficacy of Screening for Hepatitis B Infection and Immunity in Low Resource Settings with an Inexpensive Point-of-care Immunoassay

Julio A. Gutierrez1, Natali Navarro1, Kayla Giang2, David S. Adler2, Binh Tran2, Robert G. Gish1

1Department of Hepatology, UCSD, La Jolla, GA; 2Skaggs School of Pharmacy, UCSD, La Jolla, CA

INTRODUCTION: The hepatitis B virus (HBV) is often endemic in developing nations and access to diagnostic testing is often limited. Additionally, when these same individuals immigrate to developed nations they tend to have limited access to health care. Rapid point-of-care testing (POGT) has the potential to reduce HBV associated morbidity and mortality by identifying infected individuals who might not otherwise be tested and subsequently can be linked to receive care. Currently, there is no FDA-approved POGT for detecting HBV infection or immunity. In this study, we screened at risk patients with a low cost POCT for hepatitis B infection and immunity. METHODS: The study was performed under informed consent. 279 individuals at risk for HBV were tested for Hepatitis B Surface Ag (HBsAg) and Antibody (anti-HBs) with both standard of care (SOC) serologic testing through a commercial laboratory (Quest Diagnostics EIA) and POCT from Bioland (Seoul, South Korea). The POCT are chromatographic immunoassay kits for rapid and qualitative detection of HBsAg and anti-HBs from human serum or plasma via incubation of the strip for 10-15 minutes. They are inexpensive at a cost of $1. 30 for both tests. A trained technician under the supervision of a pharmacist or physician performed and read results of POCT. RESULTS: Most tested were Vietnamese (72%) attending community outreach events at churches and health fairs. The mean age was 54 years and most (66%) tested were females. Only 4% reported being born in the US and 42. 4% reported having access to healthcare. POCT was 43. 8% sensitive and 98. 4 % specific for detection of anti-HBs. The positive (PPV) and negative predictive values (NPV) were 97. 4 and 57%, respectively. Overall, 6. 4% tested by SOG were positive for HBsAg. POGT was 73. 7% sensitive and 97. 8% specific for detection of HBsAg, and PPV was 70% and NPV was 98. 2% respectively. POGT failed to detect 26% of positive cases of HBV infection, but identified 98% of those requiring vaccination. The cost of SOC was 5 times higher than POG, costing $126. 43 vs. $25. 30 per positive case. GONCLUSIONS: Although both strips demonstrated high specificity, false negatives were frequent. The limitations of the device could be related to operator error, low HBsAg levels, assay degeneration, or other issues such as lot variation. The inaccuracy of the aniti-HBs should stimulate redesign of this test component. However, this POCT could serve as an effective screening test in high prevalence groups for HBsAg. False positives were also uncommon. This is significant for a reportable and stigmatized disease and may lower the barriers to testing and linkage to care.


Robert G. Gish - Advisory Committees or Review Panels: Merck, Genentech, Roche, BMS, Gilead, Arrowhead; Stock Shareholder: Hepahope, Kinex, Arrowhead

The following people have nothing to disclose: Julio A. Gutierrez, Natali Navarro, Kayla Giang, David S. Adler, Binh Tran


Binge Drinking, Alcohol Abuse and Dependence: Screening Study in an Emergency Department

Laura Peraro, Erik Rosa Rizzotto, Diego Caroli, Francesca Polato, Franca De Lazzari, Salvatore Lobello

Dpt of Hospital and territory, Gastroenterology Unit, St Anthony Hospital, Padova, Italy

BACKGROUND and AIMS: People with alcohol related problems as consequence of short-term exposure to alcohol as well as consequences of long term alcohol use often belong to Hospital Emergency Departments. In Italy studies that consider emergency departments as the first step to recognize alcoholrelated disorders are still lacking. The aims of our study are to investigate the pattern of alcohol consumption among emergency room patients and the characteristics of alcohol consumption subgroup. MATERIALS and METHODS: The study was carried out at Emergency Room Department of S. Anthony Hospital (Padua) from 8th January 2012 to 16th May 2012, 4 weeks were randomly selected. Patient solder than 18 were questioned with both AUDIT and CAGE after they had been triaged, before or after being visited. Patients who accepted to perform the tests themselves were given AUDIT and CAGE, the others were interviewed by just one interviewer. Pearson test analysis were used. RESULTS: 1520 patients were evaluated, 1000 (65. 8%) were examined and 874 (87. 4%) were interviewed. 19. 5% of interviewed patients had alcohol related problems, 30% had abuse or dependence. Higher rates were found for men (p < 0.001), young people aged 18-20 years (p < 0.028), divorced or single (p < 0.003), unemployed (p< 0.001), homeless (p = 0.005), immigrants (p < 0.001). GONCLUSIONS: Emergency Department may be the initial point of healthcare contact for patients with alcohol problems. Social outcast persons present higher risk of alcohol disorders. Screening can be useful to provide the first step of intervention in this group and is needed for early prevention and health care intervention.


The following people have nothing to disclose: Laura Peraro, Erik Rosa Rizzotto, Diego Caroli, Francesca Polato, Franca De Lazzari, Salvatore Lobello


HCV positive injection drug users and linkage to care: a missed opportunity

Sophie G. Feller1, Rocel Concepcion2, Mary O'Rourke3, Stacey B. Trooskin4

1Jefferson Medical College, Philadelphia, PA; 2Drexel University, Philadelphia, FA; 3Thomas Jefferson University, Philadelphia, PA; 4lnfecfious Diseases,Drexel University College of Medicine, Philadelphia, PA

Purpose: Within 5 years of beginning to inject, 50-80% of injection drug users (IDU)are infected with hepatitis G virus (HGV). If tested for HGV, only 20% of IDUs are further assessed for treatment. While many IDUs express a willingness to undergo treatment for HGV, there remain significant obstacles. These barriers may be patient, provider or health system based. Methods: しsing a self-administered questionnaire, we surveyed 188 past or current IDUs who are clients of a syringe exchange program in Philadelphia. Participants were required to be 18 years of age or older and able to read English. The questionnaire included questions about demographics, past and current drug use, HCV testing history, utilization of health care services and potential barriers to care. Results: Ninety four percent of participants reported that they had been tested for HCV at least once in the past. Of those who had been tested, 31% reported their last HCV test was 1 to 6 months ago. Sixty-six percent reported their HGV status as positive. Of the HGV positive participants, 36% were uninsured, 62% had never seen an HCV specialist and only 15% had received HGV treatment. Additional barriers reported by participants included the inability to afford the copay for a doctor's visit and the transportation to a provider's office. Conclusions: With 94% of this IDし population reporting having been tested for HGV, it is clear that the barriers to care lie in the steps that follow screening. IDUs who are not able to engage in subspecialty care have missed an opportunity for education, risk reduction counseling and secondary prevention measures. With more effective and tolerable treatments on the horizon, there is a greater need than ever for addressing the barriers to care among IDUs.


Stacey B. Trooskin - Grant/Research Support: Gilead Sciences

The following people have nothing to disclose: Sophie C. Feller, Rocel Concepcion, Mary O'Rourke


Stigma in Cirrhosis Associated with Diminished Quality of Life, Social Support, Healthcare Seeking and Depression

Valerie Vaughn-Sandler1, Carey W. Sherman2, Andrew Aronsohn3, Michael Volk4

1Internal Medicine, University of Michigan Health System, Ann Arbor, Ml; 2Institute for Social Research, University of Michigan Health System, Ann Arbor, Ml; 3Center for Liver Diseases, University of Chicago, Chicago, IL; 4Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI

Background and Aims: Among patients with diseases such as HIV, cancer and mental illness, perceived stigma is common and is linked to quality of life, depression and healthcare seeking behavior. Our clinical experience suggests that stigma is also an important problem among patients with cirrhosis, but no formal studies exist on the topic. We aimed to determine the prevalence and consequences of stigma in patients with cirrhosis. Methods: A survey was developed and mailed to 150 patients with what are traditionally held to be "behaviorrelated” diagnoses (hepatitis G and alcohol) and 150 patients with "non behavior-related” diagnoses (non-alcoholic fatty liver disease, cryptogenic, autoimmune, other). Stigma was measured using a composite of previously validated scales. Results: 89% of respondents chose "agree” or "strongly agree” for at least one of the 18 stigma-related questions, indicating they felt stigmatized in at least one aspect of their lives. Patient factors associated with more perceived stigma on multivariable analysis included younger age (p=0.014) and "behavior-related” diagnosis (p=0.001). As depicted in our Conceptual Model of Cirrhosis in Figure 1, patients with higher levels of perceived stigma had less social support (r2=0.898, p<0.001), were less likely to seek medical care (r2=O. 1O8, p<0.001), suffered from more depression (i2=0.17, p<0.001) and had worse quality of life (i2=0.175, p<0.001). Conclusions: Perceived stigma is common among patients with cirrhosis, and is associated with multiple downstream effects that could lead to worse clinical outcomes. Healthcare providers need to be aware of these perceptions and their potential impact on patients' interaction with the medical system in order to improve overall patient care.

Figure 1. Conceptual Model of Stigma. r2 values calculated using pairwise correlations to determine relationships to stigma. * indicates associations that are not statistically significant.



īhe following people have nothing to disclose: Valerie Vaughn-Sandier, Carey W. Sherman, Andrew Aronsohn, Michael Volk


An Assessment of the Management of Chronic Hepatitis B at the Primary Care Level: Results of a Practice Audit Initiative at 14 Canadian Primary Care Clinics

Morris Sherman1, Phuong Nguyen1, Jean Palmart2

1Medicine, University of Toronto, Toronto, ON, Canada; 2Advisory Physicians, Victoria, BC, Canada

Introduction: Despite better tools for the management of chronic hepatitis B (CHB) patients are still presenting with cirrhosis and late stage HCC, suggesting poor management of CHB by primary care providers. We sought to determine the extent to which CHB management at primary care clinics (PCPs) was aligned with the guidelines, published by the Canadian Association for the Study of the Liver (GASL). 1 Methods: A practice review was conducted in 2012 at 14 Canadian PGPs (13 Ontario, 1 British Columbia). Researchers reviewed charts to extract data pertinent to the management of CHB. Clinics with high prevalence of CHB were chosen (mainly Asian physicians). For all HBsAg-+ patients, data collected included demographic information; serial HBV DNA, ALT, HBeAg status; serology; liver histology data; liver biopsy; transient elastography; and imaging. Data was analyzed and the patient population at the practice was characterized according to the CASL guidelines. Results: 1, 843 GHB patients were identified out of a total of 49, 919 cases reviewed (3. 7%). 25, 908 patients (51. 9%) had not been screened for hepatitis B. Among the HBsAg-+ patients, 588 (31. 9%) had an incomplete work-up for hepatitis B (missing HBeAg status, HBV DNA, ALT and/or platelet count). 27. 4% had not had any viral load testing done. 41. 9% had INR test results and 54. 3% had had albumin results. AFP testing had been performed in 68. 0% (median: 30 mos. since the most recent result). 604 patients (32. 8%) had a high viral load that warranted consideration of treatment based on CASL guidelines. 38. 2% of high viral load patients had been referred to a specialist, and only 15. 6% were on treatment. 651 patients (35. 3%) were managed according to the GASL Guidelines, based on their viral load and histology. 88. 2% had had an ultrasound (median interval of 14 months prior). Of those with ultrasounds, 55. 3% were completely normal, and 22. 4% showed fatty liver. 44 patients (2. 4%) of all patients had diagnostic data (US, GT, biopsy, transient elastography) consistent with cirrhosis, 27 of whom (61. 4%) were on therapy. Conclusions: Based on this small sample of 14 clinics, adoption of the CASL Guidelines for the management of CHB has been poor at the primary care level in Canada. Physicians are frequently not screening for GHB, not testing patients, nor assessing viral replication adequately. When viral replication was assessed, two-thirds of patients who might require treatment were not being treated. Screening for HGG was also not well done. Education of PGPs in the management of GHB is urgently needed, and communication between PGPs and specialists can be improved to ensure better patient management.


Morris Sherman - Advisory Committees or Review Panels: Merck, Tibotec, Roche, Gilead, Celsion, Janssen; Speaking and Teaching: Gilead, Bristol Myers Squibb, Bayer


Jean Palmart - Independent Contractor: Gilead Sciences Canada


A primary care-based collaborative hepatitis C clinic: Clinical structure and virologic outcomes with direct acting antiviral therapy

Samuel B. Ho, Adrian Dollarhide, Hilda Thorisdottir, James Michelsen, Christina Perry, David Kravetz, Ann Herrin, Laurie A. Carlson, Sue Hadley, Daniel Montoyo, Shannon Robinson, Courtney M. Sanchez, Enresto Enrique, Erik J. Groessl

VA Son Diego Healthcare System, San Diego, CA

Background: Currently 4 million persons in the US have active hepatitis C infection and world- wide there may be as many as 170 million people with this infection. Most patients have never been treated and newer therapies herald the potential for wider uptake and acceptance of treatment. Primary care providers will be needed to help expand access to care, but few models of collaborative primary care hepatitis C practices exist. Methods: Retrospective analysis of collaborative primary care clinic for evaluation and treatment of patients with chronic hepatitis C at a single VA medical center. A single half-day clinic was organized with 4 primary care MDs, two nurse practitioners, one nurse case manager, and 1-2 hepatologists. A co-located psychiatrist and one pharmacist were integrated into the clinic, and bi-monthly noon meetings were held to discuss treatment issues. Clinic productivity and outcomes related to the number of patients who initiated and completed treatment with direct acting antivirals (DAA) and pegylated interferon and ribavirin from July 2011 through December 2012. Results: This clinic had 1890 confirmed HGV registry patients and a total of 1690 clinic visits during this 18 month time period. Clinic capacity included 215 patient slots per month. Same week appointment access was provided. During this time 74 patients with HGV genotype 1 initiated DAA antiviral therapy. Primary care providers treated 47 patients (32% cirrhotic) vs. 27 patients treated by hepatologists (48% cirrhotic). The percentage of patients that completed 0-19 weeks, 20-28 weeks, 29-36 weeks, and greater than 36 weeks of antiviral treatment 25. 9%, 36. 2%, 10.3%, and 27. 6, respectively. Final SVR rate was 46% (33. 3% cirrhotics vs 55. 2% noncirrhotics). SVR rates were higher in patients with primary care providers (60%) compared with hepatology providers (25%), likely due to the higher incidence of cirrhosis in the latter group. Early treatment termination due to adverse events occurred in 6. 6%, and treatment termination for virologic non-response was observed in 21. 6% patients. Conclusions: This primary care and mid-level providerbased clinic with co-located hepatologists and one psychiatrist demonstrated high patient volumes and access. DAA antiviral therapy administered by primary care providers achieved SVR rates of 60%, approaching published clinical trials. These data illustrate the potential for a collaborative clinic with effective state of the art therapies for patients with high prevalence of comorbidities. Similar models may be useful for expanding access to effective HCV care in other clinic and hospital settings.


Samuel B. Ho - Grant/Research Support: Roche, Genentech, Vital Therapies, Aspire Bariatrics

Erik J. Groessl - Stock Shareholder: Gilead, Bristol Myers Squibb

The following people have nothing to disclose: Adrian Dollarhide, Hilda Thorisdottir, James Michelsen, Christina Perry, David Kravetz, Ann Herrin, Laurie A. Carlson, Sue Hadley, Daniel Montoya, Shannon Robinson, Courtney M. Sanchez, Enresto Enrique


Care of Patients with cirrhosis - How are we doing?

Deepak N. Amarapurkar1, Madhuri R. Chandnani1, Mrudul V. Dharod1, Rajiv Baijal2, Praveen Kumar2, Nikhil Patel3, Praful Kamani4, Sanjeev Issar5, Mayank Jain6, Sonali Gautam1, Apurva Shah1, Nimish Shah2, Deepak T. Gupta2, Sandeep S. Kulkarni2, Soham S. Doshi2

1Gastroenterology, Bombay Hospital & Medical Centre, Mumbai, India; 2Gastroenterology, Jagjivanram Hospital, Mumbai, India; 3GAstroenterology, Jivandeep Hospital,, Anand, India; 4Gastroenterology, Wockhardt hospital,, Rajkot, India; 5GAsttoenferology, Jawahar Lal Nehru Hospital & Research Gentre,, Bhilai, India; 6Gastroenterology, Choitharam hospital and research centre,, Indiore' India

Background: Surveillance practices for complications of cirrhosis have been developed on the basis of large number of randomized control trials. Compliance with the practice guidelines for surveillance has shown to be associated with a significant improvement in survival in patients with variceal bleeding and hepatocellular carcinoma. In spite of this overwhelming evidence the guidelines in the management of cirrhosis are not followed properly. Methods and aims: This prospective study was conducted at 5 tertiary referral centers in India, over a 3 month period to assess how appropriately we are caring for patients with cirrhosis. 416 patients with cirrhosis (median age 53 years, 316 males) were included in the study. Patients were divided into three groups and were assessed for the surveillance practices as follows: Group 1: -Patients newly diagnosed as cirrhosis during the study period after writing the protocol. Group 2: Patients previously diagnosed by the study centers, the surveillance practices before the study period were assessed. Group 3: patients diagnosed by centers other than the study centers, their surveillance practices were assessed. The study was approved by institutional review boards and statistical analysis was done using students unpaired t test. Results: Patients in the 3 groups were similar in terms of age and gender ratio. There was significant difference between variceal screening practices (91%, 65% and 40% in groups 1,2, 3; (p value< 0.0001) amongst groups. Primary prophylaxis for large varices with beta-blocker or variceal ligation was similar in 3 groups (90%, 77%, 85% in groups 1,2, 3) with p values being insignificant. Ultrasound surveillance for ascites varied significantly amongst 3 groups (100%, 73. 5%, 49% in groups 1,2, 3), (p value< 0.0001)amongst 3 groups. There was significant difference between antibiotic prophylaxis practice in high risk ascites patients between groups 1 & 2 (>90% vs 36%, p value< 0.0001). Similarly, there was difference between evaluation of renal function with serum creatinine in 3 groups (100%, 72%, 82% in groups 1,2, 3; (p value< 0.0001) between groups 1 & 2 and 1 & 3). AFP levels at baseline were done equally in groups 1 and 2 (43% vs 38%), but significantly poor in group 3 (6%). 33. 5% patients in group 2 and 20% in group 3 underwent surveillance ultrasonography for HGG. Conclusions: Surveillance practices for esophageal varices, ascites, renal function, HCC vary widely even in tertiary care centers and private clinics and falls well short of goals. Following protocols based on practice guidelines helps in improving the way we care for our patients with cirrhosis.


The following people have nothing to disclose: Deepak N. Amarapurkar, Madhuri R. Chandnani, Mrudul V. Dharod, Rajiv Baijal, Praveen Kumar, Nikhil Patel, Praful Kamani, Sanjeev lssar, Mayank Jain, Sonali Gautam, Apurva Shah, Nimish Shah, Deepak T. Gupta, Sandeep S. Kulkarni, Soham S. Doshi.


Development of an algorithm based on ICD-9 codes to identify patients with decompensated cirrhosis

Wodh chacra1, David Rabin1, James J. Yang2, Stuart G. Gordon1

1Gastroenterology and hepatology, Henry Ford Hospital, Detroit, Ml; 2Public health sciences, Henry Ford Health system, Detroit, Ml

Purpose: We sought to develop an algorithm to identify viral hepatitis patients with decompensated cirrhosis based on ICD-and GPT diagnosis and procedure codes as a useful tool to facilitate clinical research. Methods: A random sample of 283 patients with chronic hepatitis B (GHB) or G (CHC) was identified from the CHeCS (Chronic Hepatitis Cohort Study) database that includes patients from four large US based health systems. A chart review was conducted independently by two gastroenterology fellows and each patient was classified into one of three categories: non-cirrhotic, compensated cirrhotic, or decompensated cirrhotic. Any disagreement on the classification triggered a review by a clinical hepatologist for final adjudication. Separately, we electronically collected diagnosis and procedure codes typically associated with cirrhosis and decompensated cirrhosis from the patients' medical records. We then developed a logistic regression model for decompensated cirrhosis based on the presence or absence of these codes in the patient's medical record. Forward, backward and stepwise model selection were used to determine the final model. Results: There were 255 CHC patients, 23 CHB patients, and 5 GHB/GHG coinfected patients in the sample. The 41 diagnosis and procedure codes were clustered into ten binary variables based on the presence or absence of the following conditions: C1 liver transplant, C2 hepatocellular carcinoma, C3 liver failure, C4 hepatic encephalopathy, C5 portal hypertension, C6 bleeding esophageal varices, G7 other gastrointestinal hemorrhage, C8 ascites, C9 other sequelae of chronic liver disease, and C10 cirrhosis. The final multivariable model retained C1, C2, C6 and C8 as independent predictors of decompensated cirrhosis. Area under the receiver operating curve (AUC) was 0.90.For practical application, we also developed a simplified model using a single predictor variable Z. When Z1=G1+G2+G6+G8, the AUG was 0.89 and the positive predictive value (PPV) of Z1 > 2 for decompensated cirrhosis was 94%. When C1 and C2 were excluded from the model, the AUG for G6 and G8 alone was 0.75. A third model where Z2=G4+G6+G8+G10 had an AUG of 0.83 and a PPV of 87% for Z2 > 2. Conclusion: Algorithms based on ICD-9 codes related to bleeding esophageal varices and ascites were associated with a high likelihood of identifying CHB and CHC patients with decompensated cirrhosis. This model could constitute a useful tool for epidemiological research and could also be used as a quality improvement measure to electronically prompt timely specialty referrals and monitor evidence based care of this patient population.


Stuart C. Gordon - Advisory Committees or Review Panels: Tibotec; Consulting: Merck, CVS Caremark, Gilead Sciences, BMS; Grant/Research Support: Roche/Genentech, Merck, Vertex Pharmaceuticals, Gilead Sciences, BMS, Abbott, Intercept Pharmaceuticals, Exalenz Sciences, Inc.

The following people have nothing to disclose: Wadih Chacra, David Rabin, James J. Yang