Only half of patients with SBP received albumin per guidelines, VA study finds

Use of albumin for spontaneous bacterial peritonitis (SBP) was lower for Black veterans than White veterans, but higher when consults from gastroenterology, hepatology, or nephrology occurred, a study found.

To characterize IV albumin use for SBP over time and investigate its association with patient and hospital-level factors, researchers conducted a retrospective cohort study of Veterans Affairs (VA) patients between 2008 and 2021. They evaluated albumin use among patients with cirrhosis hospitalized for SBP confirmed with ascitic fluid criteria. Results were published by the American Journal of Gastroenterology on Nov. 12.

Among 3,871 studied veterans with SBP, 803 (20.7%) did not receive albumin, 1,119 (28.9%) received albumin but not according to guidelines, and 1,949 (50.3%) received albumin according to guidelines. Use increased from 66% in 2008 to 88% in 2022. Veterans who identified as Black were less likely than those who identified as White to receive guideline-recommended albumin in all analyses (odds ratio [OR], 0.76; 95% CI, 0.59 to 0.98).

Guideline-recommended albumin was more likely to be administered to patients with Child-Turcotte-Pugh (CTP) class B (OR, 1.39; 95% CI, 1.17 to 1.64) or C (OR, 2.21; 95% CI, 1.61 to 3.04) liver disease compared to CTP class A and to patients with acute kidney injury (AKI) that was stage 1 (OR, 1.48; 95% CI, 1.22 to 1.79), stage 2 (OR, 2.17; 95% CI, 1.62 to 2.91), or stage 3 (OR, 1.68; 95% CI, 1.18 to 2.40) compared to no AKI. GI/hepatology consultation (OR, 1.60; 95% CI, 1.29 to 1.99), nephrology consultation (OR, 1.60; 95% CI, 1.23 to 2.07), or both GI/hepatology and nephrology consultations (OR, 2.17; 95% CI, 1.60 to 2.96) were associated with greater likelihood of albumin administration.

In adjusted exploratory analyses, guideline-recommended use of albumin was associated with lower in-hospital mortality (hazard ratio, 0.90; 95% CI, 0.85 to 0.96) but no significant difference in incidence of respiratory failure in either the primary cohort (0.16% vs. 0.00%; P=0.31) or in an expanded cohort that included volume-overloaded patients (0.16% vs. 0.00%; P=0.23).

The study authors wrote that despite increasing albumin use over time, there was notable regional and risk-adjusted facility-level variation, although albumin use for SBP was higher in VA facilities than reported in the private health care sector.

“Our analysis uncovered healthcare disparities, broadly defined as inequitable differences between groups in access to care or quality of care: in this case, lower odds of receiving a guideline-recommended indicator for SBP among Veterans who identified as Black,” the authors wrote. “Care variation has long been recognized as a source of health disparities and is a key target to improve health.”