COVID-19 Pandemic–Related Disruptions in Routine Cirrhosis Care and Associated Clinical Outcomes among San Francisco Bay Area Veterans

TL;DR

The study found that the COVID-19 pandemic disrupted routine care for cirrhosis patients in the San Francisco Bay Area, leading to fewer clinic visits and potential long-term health risks.

Contribution

The study quantifies pandemic-related disruptions in cirrhosis care and their clinical implications using a Veterans Affairs cohort.

Findings

Adherence to cirrhosis care quality indicators declined during the pandemic, with fewer hepatology visits and increased telehealth use.

Mortality rates increased during the pandemic, though liver-related outcomes like decompensation and HCC diagnosis decreased.

The pandemic phase was associated with lower odds of new hepatic decompensation and HCC diagnosis.

Abstract

The COVID-19 pandemic disrupted health-care delivery for chronic conditions managed in specialty care and particularly among socioeconomically disadvantaged and Veteran populations. Clinical outcomes in cirrhosis are highly dependent on routine care, including clinic visits, labs, and imaging. This study examines the pandemic's impact on adherence to cirrhosis-related quality indicators and clinical outcomes among Bay Area Veterans receiving hepatology care.

We conducted a retrospective cohort study of Veterans with cirrhosis seen at San Francisco and Palo Alto Veterans Affairs hepatology clinics (March 2017–March 2023). Adherence to quality indicators—hepatocellular carcinoma (HCC) screening, lab monitoring, and hepatology visits—was compared between prepandemic (2017–2020) and pandemic-postpandemic (2020–2023) periods. Multivariable logistic regression assessed the effect of time and pandemic phase on clinical outcomes, including new hepatic decompensation, new HCC, and liver-related hospitalizations or death.

Among 1501 Veterans with cirrhosis (median age 67 years, 97% male), adherence to quality indicators declined during the pandemic, with hepatology visits decreasing from 1.5/year to 1.0/year, and telehealth use increasing sevenfold. Overall mortality rates were higher during the pandemic (21% vs 17%) possibly related to nonliver causes, since on multivariable models, the pandemic phase was associated with lower odds of new decompensation (adjusted odds ratio (aOR) 0.87, 95% confidence interval (CI) 0.5–0.9, P = .01) and HCC diagnosis (aOR 0.7, 95% CI 0.5–0.95, P = .02); liver-related hospitalizations or death also declined over (aOR 0.98, 95% CI 0.97–0.99, P < .001).

The pandemic significantly disrupted cirrhosis care among Bay Area Veterans, potentially resulting in “health debt” that may affect outcomes in coming years. Targeted interventions should re-engage patients, addressing these care gaps and improving clinical outcomes.

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