Guideline Adherence and Outcomes in Esophageal Variceal Hemorrhage Comparison of Tertiary Care and Non-Tertiary Care Settings

Background: Implementation of consensus guidelines for esophageal variceal hemorrhage yields improved outcomes. We evaluated guideline adherence and outcomes after variceal hemorrhage at a university hospital (UH) and a staff-model health maintenance organization (HMO). Study: Factors associated with short-term bleeding, infection, and death were retrospectively identified in UH (n = 160) and HMO (n = 123) patients with esophageal variceal hemorrhage from January 2000 to December 2006. A second analysis of factors associated with long-term rebleeding was conducted in patients who survived >= 14 days without rebleeding. Results: UH patients were younger, with more severe liver disease and overall illness (P < 0.01). UH patients more often received vasoactive agents and prophylactic antibiotics (P < 0.01), however the rate of endoscopic therapy did not differ. Infections at 14-days were similar (18.2% vs. 13.0%, P = 0.25), but UH patients had greater in-hospital rebleeding (16.4% vs. 5.7%, P < 0.01) and mortality (15.2% vs. 4.1%, P < 0.01). Poor liver function and overall illness predicted infection, rebleeding, and death (adjusted odds ratio 2.75 to 13.39). Long-term rebleeding occurred in 36.1% of UH patients and 25.9% of HMO patients. Secondary prophylaxis reduced late rebleeding (hazard ratio 0.37 to 0.41). Poor liver function did not predict late rebleeding. Adherence to secondary prophylaxis was greater at the HMO (P < 0.05), but late rebleeding did not differ (36% vs. 26%, P = 0.13). Conclusions: Irrespective of practice setting, poor liver function and critical illness predicted short-term bleeding, infection, and death after esophageal variceal hemorrhage, and secondary prophylaxis prevented long-term rebleeding. Differing guideline adherence did not influence outcomes between tertiary care and non-tertiary care centers.