Introduction: Approaches to improve the quality of care for people with cirrhosis

It is widely quoted that it takes an average of 17 years for half of innovations to reach the public.1 Therefore, it is not surprising that despite significant scientific advances in the care for people with cirrhosis, the quality of care varies tremendously across clinics, providers, and patient populations. Too often, the blame is placed on patients or attributed to individual failures when, in fact, the issues are related to systematic factors. For example, between 20% and 80% of Veterans with cirrhosis receive HCC screening, entirely dependent on the Veterans Affairs (VA) hospital in which they are receiving care.2 Care in the US private sector is worse—while the current average rate of HCC screening in the VA is ~50%, in other hospital settings, rates are under 30%.3 Similar wide variances are seen for the management of portal hypertension and access to liver transplant evaluation, where there is inconsistent and disparate access to evidence-based care.4–9 Where there is doubt about the standard of care or where there are more complex evidence-based practices, addressing care quality and inequities becomes increasingly challenging.10,11 Despite these challenges in offering high-quality care, there are emerging methods to assist in ensuring access to such care. Implementation science is the systematic study of methods to improve the adoption, implementation, and sustainment of evidence-based care or practices.1 Implementation frameworks and tools offer guidance about how to conceptualize, measure, and address disparities in care. Implementation science has been conceptualized as a means of moving health equity research from first-generation work (describing disparities) toward third and fourth-generation work that addresses disparities.12 As evidence-based approaches to address disparities continue to emerge, we must support efforts to apply implementation and equity sciences in hepatology research and practice to address quality gaps in advanced liver care. The best example of national efforts to apply system-level thinking and such approaches to care are in the Veterans Health Administration, which has applied system-wide quality measures, data tools, and reminders to systematically address care for people with advanced liver disease.13–18 The purpose of this special series of Clinical Liver Disease is to address the current state and the methods to improve quality across the continuum of cirrhosis care. In this series, we review the current literature on different aspects of liver care—from improving diagnosis to treatment to end-of-life care. We focus on equitable access, following the concept that implementation is not successful unless it is equitable.12 As such, we pay particular attention to pharmacoequity, access to transplant for underserved populations, and addressing disparities across the liver disease care continuum, including pediatric patients. We hope that this collection of articles from national leaders in health services research will serve as a starting point for further investment in this population and lead to a measurable improvement well before the 17-year time lag that is so often described in health care implementation.