Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2018; 10(4): 40-48
Published online Apr 27, 2018. doi: 10.4240/wjgs.v10.i4.40
Adherence to surveillance endoscopy following hospitalization for index esophageal variceal hemorrhage
Brendan T Everett, Steven D Lidofsky
Brendan T Everett, Steven D Lidofsky, Gastroenterology and Hepatology Unit, University of Vermont Medical Center, Burlington, VT 05401, United States
Author contributions: Everett BT acquired and analyzed the data, and wrote the manuscript with Lidofsky SD, who designed the study.
Institutional review board statement: The study design was reviewed and approved by the University of Vermont Institutional Review Board (CHRMS 15-134) with a waiver of informed consent.
Informed consent statement: Patients were not required to give informed consent to the study as the research involved no more than minimal risk to the individual. Waiver of consent was approved by the University of Vermont Institutional Review Board.
Conflict-of-interest statement: The authors declare no conflicts-of-interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Steven D Lidofsky, MD, PhD, Professor, Gastroenterology and Hepatology Unit, University of Vermont Medical Center, Smith 251, 111 Colchester Avenue, Burlington, VT 05401, United States. steven.lidofsky@uvm.edu
Telephone: +1-802-8472554 Fax: +1-802-8474928
Received: February 6, 2018
Peer-review started: February 7, 2018
First decision: February 28, 2018
Revised: March 9, 2018
Accepted: April 11, 2018
Article in press: April 11, 2018
Published online: April 27, 2018
Abstract
AIM

To investigate patient adherence to surveillance endoscopy after index esophageal variceal hemorrhage and the extent to which adherence influences outcomes.

METHODS

We reviewed the records of patients with cirrhosis admitted to the medical intensive care unit between 2000 and 2014 for first time esophageal variceal hemorrhage treated with endoscopic variceal ligation who were subsequently discharged and scheduled for surveillance endoscopy at our medical center. Demographic and clinical data were obtained through the medical records, including etiology of cirrhosis, completion of variceal obliteration, attendance at surveillance endoscopy, zip code of primary residence, distance from home to hospital, insurance status, rehospitalization for variceal hemorrhage, beta-blocker at discharge, pharmacologically treated psychiatric disorder, and transplant free survival.

RESULTS

Of 99 consecutive survivors of esophageal variceal bleeding, the minority (33) completed variceal obliteration and fewer (12) adhered to annual surveillance. Completion of variceal obliteration was associated with fewer rehospitalizations for variceal rebleeding (27% vs 56%, P = 0.0099) and when rehospitalizations occurred, they occurred later in those who had completed obliteration (median 259 d vs 207 d, P = 0.0083). Incomplete adherence to endoscopic surveillance was associated with more rehospitalizations for variceal rebleeding compared to those fully adherent to annual endoscopic surveillance (51% vs 17%, P = 0.0328). Those adherent to annual surveillance were more likely to be insured privately or through Medicare compared to those who did not attend post-hospital discharge endoscopy (100% vs 63%, P = 0.0119).

CONCLUSION

Most patients do not complete variceal obliteration after index esophageal variceal hemorrhage and fewer adhere to endoscopic surveillance, particularly the uninsured and those insured with Medicaid.

Keywords: Liver cirrhosis, Endoscopy, Esophageal varices, Secondary prevention, Patient adherence

Core tip: We investigated adherence to surveillance endoscopy in 99 consecutive patients with cirrhosis who survived esophageal variceal bleeding, and the extent to which adherence influenced outcomes. We found that the minority (33%) completed variceal obliteration and fewer (12%) underwent annual surveillance. Completion of obliteration was associated with fewer and later rehospitalizations for variceal rebleeding. Those non-adherent to annual surveillance were more likely to be uninsured or to have coverage through Medicaid assistance. Our findings identify potential markers for socioeconomic factors that limit endoscopic adherence following variceal hemorrhage and lead to adverse outcomes. New approaches are needed to overcome barriers to adherence.