Digestive Diseases and Sciences

, Volume 60, Issue 9, pp 2628–2635 | Cite as

Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination

  • Lauren A. Beste
  • Bonnie K. Harp
  • Rebecca K. Blais
  • Ginger A. Evans
  • Susan L. Zickmund
Original Article



Two-thirds of patients with cirrhosis do not receive guideline-concordant liver care. Cirrhosis patients are less likely to receive recommended care when followed exclusively by primary care providers (PCPs), as opposed to specialty co-management. Little is known about how to optimize cirrhosis care delivered by PCPs.


We conducted a qualitative analysis to explore PCPs’ attitudes and self-reported roles in caring for patients with cirrhosis.


We recruited PCPs from seven Veterans Affairs facilities in the Pacific Northwest via in-service trainings and direct email from March to October 2012 (n = 24). Trained staff administered structured telephone interviews covering: (1) general attitudes; (2) roles and practices; and (3) barriers and facilitators to cirrhosis management. Two trained, independent coders reviewed each interview transcript and thematically coded responses.


Three overarching themes emerged in PCPs’ perceptions of cirrhosis patients: the often overwhelming complexity of comorbid medical, psychiatric, and substance issues; the importance of patient self-management; and challenges surrounding specialty care involvement and co-management of cirrhosis. While PCPs felt they brought important skills to bear, such as empathy and care coordination, they strongly preferred to defer major cirrhosis management decisions to specialists. The most commonly reported barriers to care included patient behaviors, access issues, and conflicts with specialists.


PCPs perceive Veterans with cirrhosis as having significant medical and psychosocial challenges. PCPs tend not to see their role as directing cirrhosis-related management decisions. Educational efforts directed at PCPs must foster PCP empowerment and improve comfort with managing cirrhosis.


Primary care health Specialty care Chronic liver disease Attitudes 



The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Portions of this work were presented at The Liver Meeting (November 5, 2013), the annual meeting of the American Association for the Study of Liver Disease. This material is the result of work supported by resources from the VA Puget Sound Health Care System (Seattle, Washington). Funding was provided by the VA National Hepatitis C Resource Centers program, through the Office of HIV, Hepatitis C, and Public Health Pathogens.

Conflict of interest



  1. 1.
    Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143:e1171–e1173.CrossRefGoogle Scholar
  2. 2.
    Bell BP, Manos MM, Zaman A et al. The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance. Am J Gastroenterol. 2008;103:2727–2736.Google Scholar
  3. 3.
    Beste LA, Ioannou GN, Yang Y, Chang MF, Ross D, Dominitz JA. Improved surveillance for hepatocellular carcinoma with a primary care-oriented clinical reminder. Clin Gastroenterol Hepatol. 2015;13:172–179. doi: 10.1016/j.cgh.2014.04.033.
  4. 4.
    Seeff LB. Introduction: the burden of hepatocellular carcinoma. Gastroenterology. 2004;127:S1–S4.CrossRefPubMedGoogle Scholar
  5. 5.
    Sanyal AJ. How to close the gap between the numbers of patients agents who need liver care and the providers available. In: AASLD eNews. City; 2010.
  6. 6.
    Kanwal F, Kramer J, Asch SM et al. An explicit quality indicator set for measurement of quality of care in patients with cirrhosis. Clin Gastroenterol Hepatol. 2010;8:709–717. doi: 10.1016/j.cgh.2010.03.028.
  7. 7.
    Kanwal F, Kramer JR, Buchanan P, et al. The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs. Gastroenterology. 2012;143:70–77.CrossRefPubMedGoogle Scholar
  8. 8.
    Post PN, Wittenberg J, Burgers JS. Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review. Int J Qual Health Care. 2009;21:387–396.CrossRefPubMedGoogle Scholar
  9. 9.
    Singal AG, Yopp A, Skinner CS, Packer M, Lee WM, Tiro JA. Utilization of hepatocellular carcinoma surveillance among American patients: a systematic review. J Gen Intern Med. 2012;27:861–867.PubMedGoogle Scholar
  10. 10.
    Veterans Health Administration Primary Care Services. Accessed May 19, 2014.
  11. 11.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64–78.CrossRefGoogle Scholar
  12. 12.
    Benjamin F, Crabtree WLM. Doing qualitative research. City: SAGE; 1999.Google Scholar
  13. 13.
    Landis JKG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.Google Scholar
  14. 14.
    Lafata JE, Martin S, Morlock R, Divine G, Xi H. Provider type and the receipt of general and diabetes-related preventive health services among patients with diabetes. Med Care. 2001;39:491–499.CrossRefPubMedGoogle Scholar
  15. 15.
    Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med. 2002;347:1678–1686.CrossRefPubMedGoogle Scholar
  16. 16.
    Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer. 2004;101:1712–1719.CrossRefPubMedGoogle Scholar
  17. 17.
    Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med.. 2011;364:2199–2207.CrossRefPubMedGoogle Scholar
  18. 18.
    Zickmund S, Hillis SL, Barnett MJ, Ippolito L, LaBrecque DR. Hepatitis C virus-infected patients report communication problems with physicians. Hepatology (Baltimore Md.). 2004;39:999–1007.CrossRefGoogle Scholar
  19. 19.
    Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–568.CrossRefPubMedGoogle Scholar
  20. 20.
    Zuchowski JL, Rose DE, Hamilton AB et al. Challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med. 2014 [Epub ahead of print].Google Scholar
  21. 21.
    Stille CJ, Primack WA. Interspecialty communication: old problem, new hope? Arch Intern Med. 2011;171:1300.CrossRefPubMedGoogle Scholar
  22. 22.
    O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171:56–65.PubMedGoogle Scholar
  23. 23.
    Berendsen AJ, Benneker WH, Meyboom-de Jong B, Klazinga NS, Schuling J. Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Serv Res. 2007;7:4.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Mandl KD, Olson KL, Mines D, Liu C, Tian F. Provider collaboration: cohesion, constellations, and shared patients. J Gen Intern Med. 2014;29:1499–1505.CrossRefPubMedGoogle Scholar
  25. 25.
    Zickmund SL, Brown KE, Bielefeldt K. A systematic review of provider knowledge of hepatitis C: is it enough for a complex disease? Dig Dis Sci. 2007;52:2550–2556.CrossRefPubMedGoogle Scholar
  26. 26.
    Zickmund S, Ho EY, Masuda M, Ippolito L, LaBrecque DR. They treated me like a leper”. Stigmatization and the quality of life of patients with hepatitis C. J Gen Intern Med. 2003;18:835–844.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York (Outside the USA) 2015

Authors and Affiliations

  • Lauren A. Beste
    • 1
    • 2
    • 3
  • Bonnie K. Harp
    • 2
  • Rebecca K. Blais
    • 4
    • 5
  • Ginger A. Evans
    • 1
    • 3
  • Susan L. Zickmund
    • 6
    • 7
  1. 1.Primary Care ServiceVA Puget Sound Health Care SystemSeattleUSA
  2. 2.Health Services Research and DevelopmentVA Puget Sound Health Care SystemSeattleUSA
  3. 3.Division of General Internal MedicineUniversity of WashingtonSeattleUSA
  4. 4.Mental Health ServiceVA Puget Sound Health Care SystemSeattleUSA
  5. 5.Department of PsychologyUtah State UniversityLoganUSA
  6. 6.Center for Health Equity Research and PromotionVA Pittsburgh Health Care SystemPittsburghUSA
  7. 7.Departments of Medicine and Clinical and Translational ScienceUniversity of PittsburghPittsburghUSA

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