Diabetes Is Associated with Clinical Decompensation Events in Patients with Cirrhosis.

OBJECTIVES: Liver cirrhosis is a leading cause of morbidity and mortality in the USA. Diabetes is common and increasing in incidence. Patients with compensated cirrhosis and diabetes may be at greater risk of clinical decompensation. We examined the risk of decompensation among a large sample of working-aged insured patients dually diagnosed with compensated cirrhosis and diabetes. METHODS: This retrospective study used MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases (2000-2013). Decompensation events included incident ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy, acute renal failure, and hepatocellular carcinoma. Dually diagnosed patients were defined as patients with cirrhosis and diabetes using previously published ICD-9 coding strategies. Adjusted odds ratios (ORs), hazard ratios (HRs), and confidence intervals (CI) were estimated using logistic regression and Cox proportional hazard models. RESULTS: Of 72,731 patients with compensated cirrhosis, 20,477 patients (28.15 %) were diagnosed with diabetes. After controlling for patient characteristics and medication usage, the odds of developing any decompensation event were 1.14 times higher for patients with cirrhosis and diabetes than for patients with cirrhosis only (95 % CI 1.08-1.21, P value <0.01). In the Cox proportional hazard model, patients who were dually diagnosed with diabetes had a 1.32 times higher HR (95 % CI 1.26-1.39, P value <0.01) after controlling for time-to-event. CONCLUSIONS: Patients dually diagnosed with compensated cirrhosis and diabetes had a higher risk of having decompensation events. Careful management of diabetes in patients with liver disease may reduce the risk of clinical decompensation in this population.

Organizational characteristics and preventive service delivery in private practices: a peek inside the "black box" of private practices caring for children.

OBJECTIVE: Although privately owned practices provide the majority of primary care for children, little is known about the organizational characteristics of these practices or how these characteristics affect the quality of care for children. The purpose of this study was to describe selected organizational characteristics and preventive service delivery features that might affect the quality of primary care for children in private practices. METHODS: A cross-sectional study of 44 private pediatric and family medicine practices in 2 regions of North Carolina was performed. Preventive service performance was assessed through chart abstraction for 60 randomly selected children between 24 and 30 months of age, for evaluation of immunizations and anemia, tuberculosis, and lead screening delivery by 2 years of age. Organizational characteristics were determined through surveys of all physicians and staff members. We used descriptive statistics and scatter plots to describe variations in organizational characteristics and preventive services. RESULTS: Overall, practices demonstrated low levels of preventive service performance, with substantial variation among practices. Only 39% of children received 3 of the 4 recommended preventive services measured (practice range: 2-88%). Few practices demonstrated evidence of a systematic approach to prevention. For example, only 12 (27%) of the 44 practices used >1 of 5 recommended preventive service delivery strategies. Furthermore, practices varied greatly with respect to many of the measured organizational characteristics, which were consistent with organizational stress in some cases. For example, turnover of clinicians and staff members was remarkably high, with practices losing an average of 27% of their clinicians every 4 years (range: 0-170%) and 39% of their office staff members every 2 years (range: 0-170%). CONCLUSIONS: Private practices caring for children in North Carolina demonstrated low overall performance for the 4 recommended preventive services examined, with large variations among practices. Few practices had evidence of comprehensive systems for prevention. There was also evidence of substantial variation in many organizational characteristics. Some organizational characteristics were at levels that might impede delivery of high-quality primary care for children. These findings suggest a growing need for research that examines the impact of organizational characteristics on the quality of care in private practices.