Quality of clinical care & documentation in patients with autoimmune hepatitis – a retrospective probing study

Introduction Autoimmune hepatitis (AIH) comes with variable clinical presentation and course requiring accurate assessment and documentation. Data from Austria is scarce and quality of clinical management has not been examined.

Material and Methods In this retrospective chart review demographic and clinical data of AIH patients from a single center were included and compared to larger cohort studies. Quality of clinical documentation was evaluated and compared before and after departmental SOP-changes 2018.

Results In total, 99 patients, mean age 53.5 years (SD15.7), 78% females were included. Overlap syndromes were found in 21%, PBC in 13% (literature: 8-9%)(1), and PSC in 7% (8%)(2). Cirrhosis was present in 31% (literature: 28-33% (3,4)), with a CHILD/MELD score documented in 59%. Reasoning for diagnosis was most often based on histology and immunology (22%) or histology alone (55%), as could be reconstructed from documentation, while a formal score was documented in only 2%. At least some immunology results were documented in 78.7%, histology in 86%, a full lab workup in 44%. Treatment was undocumented in 19% of cases. Remission as per EASL 2015 guidelines could be confirmed 69% (n=56) (literature: 80%(1)) and complete response according to IAIHG 2022 in 55% (n=45). No biopsies were documented for remission evaluation. A change of quality over time (diagnosis before/after 2018) could be identified, with documentation of immunology increasing from 37% to 92%, of histology results from 69% to 95%, and explicitly basing diagnosis on multiple parameters from 9% to 34%. Also, biopsies performed internally increased from 49% to 86% ([Abb. 1]).

Abb. 1  Bibliography

Conclusion Epidemiological and clinical characteristics of this cohort align well with the literature. While a trend for higher quality care and documentation over time could be identified, important documentation gaps remain. While the impact on clinical outcomes is unclear, they impair quality control and negatively impact (at least retrospective) research. Standardization of documentation should be considered.

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Artikel online veröffentlicht:
13. Mai 2025