Downloadable Content

Download PDF
Last Modified
  • March 20, 2019
  • Liu, Tsai-Ling
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
  • Cirrhosis of the liver is a leading cause of morbidity and mortality in the United States. The number of patients with cirrhosis is expected to increase driven by the dual epidemics of diabetes and obesity leading to nonalcoholic fatty liver disease. Approximately 40% of patients with compensated cirrhosis have diabetes. Patients with both cirrhosis and diabetes may have an increased risk of decompensation events (i.e., ascites, spontaneous bacterial peritonitis, variceal bleeding, and hepatic encephalopathy), hepatocellular carcinoma, and acute renal failure. However, large studies of dually-diagnosed patients’ risk of decompensation over time are lacking (Aim 1). Given the complexity of these dual comorbidities, dually-diagnosed patients may be managed more effectively by multiple physician specialties including primary care physicians (PCPs), and/or specialists such as gastroenterologists (GIs) and endocrinologists (ENDOs). However, little is known about who cares for these patients. This study seeks to better understand the treatment practices (Aim 2), and how physician mix affects the care and health outcomes of dually-diagnosed patients (Aim 3). Patients aged 18 years and older with compensated cirrhosis and diabetes were identified through 2000 – 2013 Marketscan® Commercial Claims and Encounters and Medicare Supplemental Database. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to first diagnosis of cirrhosis (Aim1) and first dual diagnosis (Aims 2 and 3) were excluded. The analytical approach included logistic regression and Cox proportional hazard models (Aim 1), a multinomial probit model (Aim 2), and logistic regression with a two-stage residual inclusion (Aim 3). The study found that patients dually diagnosed with compensated cirrhosis and diabetes had a higher risk of having decompensation events than patients with cirrhosis only. A large proportion of dually-diagnosed patients visited only PCPs. Dually-diagnosed patients who were managed by both PCPs and GI/ENDOs had better outcomes. These findings suggest that careful management of diabetes in patients with liver disease may reduce the risk of clinical decompensation in this population. Our findings support the importance of cross-specialty care, which is central to Patient-Center Medical Homes.
Date of publication
Resource type
Rights statement
  • In Copyright
  • Trogdon, Justin
  • Fried, Bruce
  • Weinberger, Morris
  • Barritt, Alfred, IV
  • Paul, John
  • Doctor of Public Health
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2016

This work has no parents.