Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination
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.
KeywordsPrimary 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
- 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.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.
- 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. http://www3.aasld.org/news/archive/022510/Pages/default.aspx.
- 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.
- 10.Veterans Health Administration Primary Care Services. http://www.va.gov/health/services/primarycare/index.asp. Accessed May 19, 2014.
- 12.Benjamin F, Crabtree WLM. Doing qualitative research. City: SAGE; 1999.Google Scholar
- 13.Landis JKG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.Google Scholar
- 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