Characterizing practice variations in the care of hospitalized patients with cirrhosis across the University of California Health

Despite publicly available practice guidelines, in-hospital cirrhosis care remains highly variable. Prior studies of cirrhosis guideline adherence have been limited by administrative claims data. We aimed to overcome these limitations by using a novel multicenter electronic health record (EHR) database, the University of California Health Data Warehouse (UCHDW), to compare guideline adherence in the 5 medical centers of the University of California Health (UCH). We identified adult patients with cirrhosis hospitalized from 2013 to 2022. We evaluated adherence to 5 care quality measures applicable to inpatients. We used t tests to compare pairwise differences between individual UCH sites. We assessed the impact of patient-level and center-level factors (transplant services) through multivariate logistic regressions. We identified 17,249 patients with cirrhosis with 31,512 admissions: 39% women, 43% White, 31% Hispanic/Latino, 11% Asian, 7% Black/African-American, and 8% Unknown/Other. In pairwise comparisons, we found differences in adherence rates across all measures except for antibiotics for gastrointestinal bleeding. In multivariate modeling, we found positive associations between care at transplant centers and receiving paracenteses for those admitted for ascites or HE, albumin/antibiotics for those admitted for spontaneous bacterial peritonitis, endoscopy for those admitted for gastrointestinal bleeding, and lactulose for those admitted for HE. In addition, we observed negative associations between Black/African-American race and guideline adherence for receiving paracenteses for ascites or HE. Through our analyses of high-dimensional EHR data, we found significant differences in care associated with admissions at the transplant center and race/ethnicity. Our use of high-dimensional EHR data indicates that there is still significant room for improvement in the provision of high-quality cirrhosis care.