IDDF2024-ABS-0137 Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: a Singapore nationwide audit

<h3>Background</h3> AASLD introduced acute variceal bleeding quality indicators (AVB-QI) to promote quality care delivery in cirrhosis patients. However, large-scale nationwide audit providing representative data and evaluating the clinical impact of full adherence to AVB-QI is still lacking. We aim to determine whether full adherence to AVB-QI could improve 6-week survival in cirrhosis patients with AVB. <h3>Methods</h3> We performed a nested-cohort study within the Singapore Nationwide AVB audit which included adult cirrhosis patients admitted for AVB in all public hospitals in Singapore between 2015 and 2020. The primary predictor was full adherence to all the five AVB-QIs (prophylactic antibiotic, somatostatin analogues, timely endoscopy, endoscopic hemostasis and non-selective beta-blocker after AVB). Using a 1:1 propensity-matched cohort, we compare the predicted and observed 6-week mortality based on calibrated MELD and Child-Turcotte-Pugh (CTP) scores between the full and suboptimal adherence groups. <h3>Results</h3> A total of 989 patients were included from 7 participating institutions. Adherence to individual QI was high, but full adherence to all AVB-QI was suboptimal (IDDF2024-ABS-0137 Figure 1. Adherence to individual acute variceal bleeding quality indicators). The overall 6-week mortality was 13.8%. The 1:1 propensity-matched cohort included 610 patients with balanced baseline characteristics. Full adherence was associated with a lower adjusted 6-week mortality (OR: 0.34, 95%CI: 0.22-0.52), infection (OR: 0.68, 95%CI: 0.47-0.99), early rebleeding (0.49, 95%CI: 0.26-0.92) and 1-year mortality (IDDF2024-ABS-0137 Figure 2. The clinical outcomes of the unmatched top and matched below cohort of patients with acute variceal bleeding). Full adherence remained significantly associated with lower 6-week mortality in various sensitivity analyses using different adjustment methods (Optimal matching, changing calliper, and landmark analyses) and subgroup analyses (CTP-class and HCC status). While the full adherence group had a lower observed 6-week mortality, the non-adherence group had a higher mortality than predicted despite a lower predicted risk of mortality (IDDF2024-ABS-0137 Figure 3). Despite full adherence, patients with CTP-C remained at high-risk of rebleeding, 6-week and 1-year mortality (IDDF2024-ABS-0137 Figure 4). <h3>Conclusions</h3> Full adherence to the AVB QI was associated with lower 6-week mortality. Full adherence should be the target for quality improvement in AVB. Definitive treatment is needed in CTP-C patients with AVB.