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Barfod O'Connell M, Brødsgaard A, Matthè M, Hobolth L, Wullum L, Bendtsen F, Kimer N. A randomized controlled trial of a postdischarge nursing intervention for patients with decompensated cirrhosis. Hepatol Commun 2024; 8:e0418. [PMID: 38668732 DOI: 10.1097/hc9.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/22/2023] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Few randomized trials have evaluated the effect of postdischarge interventions for patients with liver cirrhosis. This study assessed the effects of a postdischarge intervention on readmissions and mortality in patients with decompensated liver cirrhosis. METHODS We conducted a randomized controlled trial at a specialized liver unit. Adult patients admitted with complications of liver cirrhosis were eligible for inclusion. Participants were allocated 1:1 to standard follow-up or a family-focused nurse-led postdischarge intervention between December 1, 2019, and October 31, 2021. The 6-month intervention consisted of a patient pamphlet, 3 home visits, and 3 follow-up telephone calls by a specialized liver nurse. The primary outcome was the number of readmissions due to liver cirrhosis. RESULTS Of the 110 included participants, 93% had alcohol as a primary etiology. We found no significant differences in effects in the primary outcomes such as time to first readmission, number of patients readmitted, and duration of readmissions or in the secondary outcomes like health-related quality of life and 6- and 12-month mortality. A post hoc exploratory analysis showed a significant reduction in nonattendance rates in the intervention group (RR: 0.28, 95% CI: 0.13-0.54, p=0.0004) and significantly fewer participants continuing to consume alcohol in the intervention group (p=0.003). After 12 months, the total number of readmissions (RR: 0.76, 95% CI: 0.59-0.96, p=0.02) and liver-related readmissions (RR: 0.55, 95% CI: 0.36-0.82, p=0.003) were reduced in the intervention group. CONCLUSIONS A family-focused postdischarge nursing intervention had no significant effects on any of the primary or secondary outcomes. In a post hoc exploratory analysis, we found reduced 6-month nonattendance and alcohol consumption rates, as well as reduced 12-month readmission rates in the intervention group.
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Affiliation(s)
- Malene Barfod O'Connell
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Anne Brødsgaard
- Department of Paediatrics and Adolescent Medicine & Gynaecology and Obstetrics, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
- Nursing and Health Care, Institute of Public Health, Aarhus University, Aarhus, Denmark
- Omicron Aps, Roskilde, Denmark
| | - Maria Matthè
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Lise Hobolth
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
| | - Laus Wullum
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
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Hjorth M, Svanberg A, LoMartire R, Kaminsky E, Rorsman F. Patient perceived quality of cirrhosis care- adjunctive nurse-based care versus standard medical care: a pragmatic multicentre randomised controlled study. BMC Nurs 2024; 23:251. [PMID: 38637755 PMCID: PMC11027520 DOI: 10.1186/s12912-024-01934-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/12/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Cirrhosis treatment implies prevention and alleviation of serious disease events. Healthcare providers may, however, fail to meet patients' expectations of collaboration and specific needs of information and support. Individualised nursing care could meet patients' needs. The aim was thus to measure patient-perceived quality of care after adjunctive registered nurse-based intervention Quality Liver Nursing Care Model (QLiNCaM) compared with standard medical care. METHODS This pragmatic multicentre study consecutively randomised patients to either adjunctive registered nurse-based care, or standard medical care for 24 months (ClinicalTrials.gov NCT02957253). Patients were allocated to either group at an equal ratio, at six Swedish outpatient clinics during 2016-2022. Using the questionnaire 'Quality of care from the patient's perspective', patients rated their perceived lack of quality for the adjunctive registered nurse-based intervention compared with the control group at 12 and 24 months, respectively. RESULTS In total, 167 patients were recruited. Seven out of 22 items in the questionnaire supported the finding that 'lacking quality' decreased with adjunctive registered nurse-based care (p < 0.05) at 12 months follow-up; however, these differences could not be established at 24 months. CONCLUSION Additional structured registered nurse-based visits in the cirrhosis outpatient team provided support for improved patient-perceived quality of care during the first 12 months. Registered nurses increase patient involvement and present easy access to cirrhosis outpatient care. Patients express appreciation for personalised information. This study reinforces registered nurses' role in the outpatient cirrhosis team, optimising patient care in compensated and decompensated cirrhosis. TRIAL REGISTRATION Registered at Clinical Trials 18th of October 2016, [ https://www. CLINICALTRIALS gov ], registration number: NCT02957253.
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Affiliation(s)
- Maria Hjorth
- Centre for Clinical Research in Dalarna, Uppsala University, Falun, Sweden.
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | | | - Riccardo LoMartire
- Centre for Clinical Research in Dalarna, Uppsala University, Falun, Sweden
- School of Health and Wellfare, Dalarna University, Falun, Sweden
| | - Elenor Kaminsky
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Rorsman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Wigg AJ, Narayana S, Woodman RJ, Adams LA, Wundke R, Chinnaratha MA, Chen B, Jeffrey G, Plummer JL, Sheehan V, Tse E, Morgan J, Huynh D, Milner M, Stewart J, Ahlensteil G, Baig A, Kaambwa B, Muller K, Ramachandran J. A randomized multicenter trial of a chronic disease management intervention for decompensated cirrhosis. The Australian Liver Failure (ALFIE) trial. Hepatology 2024:01515467-990000000-00820. [PMID: 38825975 DOI: 10.1097/hep.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND AND AIMS Improving the care of decompensated cirrhosis is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). The secondary aims were to assess model effects on quality-of-care and patient-reported outcomes. APPROACH AND RESULTS The study design was a 2-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a decompensated cirrhosis admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. A total of 147 participants (intervention=75, control=71) were recruited with a median Model for End-Stage Liver Disease score of 19. For the primary outcome, there was no difference in the overall LREA rate for the intervention group versus the control group (incident rate ratio 0.89; 95% CI: 0.53-1.50, p=0.666) or in actuarial survival (HR=1.14; 95% CI: 0.66-1.96, p=0.646). However, there was a reduced risk of LREA due to encephalopathy in the intervention versus control group (HR=1.87; 95% CI: 1.18-2.96, p=0.007). Significant improvement in quality-of-care measures was seen for the performance of bone density (p<0.001), vitamin D testing (p<0.001), and HCC surveillance adherence (p=0.050). For assessable participants (44/74 intervention, 32/71 controls) significant improvements in patient-reported outcomes at 3 months were seen in self-management ability and quality of life as assessed by visual analog scale (p=0.044). CONCLUSIONS This CDM intervention did not reduce overall LREA events and may not be effective in decompensated cirrhosis for this end point.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Sumudu Narayana
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Richard J Woodman
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Leon A Adams
- Liver Transplant Unit, Sir Charles Gardiner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Mohamed A Chinnaratha
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, Australia
| | - Bin Chen
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, Australia
| | - Gary Jeffrey
- Liver Transplant Unit, Sir Charles Gardiner Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Joan-Lee Plummer
- Medical School, University of Western Australia, Perth, Australia
| | - Vanessa Sheehan
- Medical School, University of Western Australia, Perth, Australia
| | - Edmund Tse
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Joanne Morgan
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Dep Huynh
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Margery Milner
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jeffrey Stewart
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Golo Ahlensteil
- Department of Gastroenterology and Hepatology, Blacktown & Mt Druitt Hospitals, Sydney, Australia
- Blacktown Clinical School, Western Sydney University, Sydney, Australia
| | - Asma Baig
- Department of Gastroenterology and Hepatology, Blacktown & Mt Druitt Hospitals, Sydney, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Kate Muller
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine Unit, Southern Adelaide Local Health Network, Adelaide, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
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Beal EW, McNamara M, Owen M, McAlearney AS, Tsung A. Interventions to Improve Surveillance for Hepatocellular Carcinoma in High-Risk Patients: A Scoping Review. J Gastrointest Cancer 2024; 55:1-14. [PMID: 37328730 DOI: 10.1007/s12029-023-00944-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) is most often a sequela of chronic liver disease or chronic hepatitis B infection. Among high-risk patients, surveillance for HCC every 6 months is recommended by international guidelines. However, rates of HCC surveillance are suboptimal (11-64%). Barriers at the patient, provider, and healthcare delivery system levels have been identified. METHODS We performed a systemic scoping review to identify and characterize interventions to improve HCC surveillance that has previously been evaluated. Searches using key terms in PubMed and Embase were performed to identify studies examining interventions designed to improve the surveillance rate for HCC in patients with cirrhosis or chronic liver disease that were published in English between January 1990 and September 2021. RESULTS Included studies (14) had the following study designs: (1) randomized clinical trials (3, 21.4%), (2) quasi-experimental (2, 14.3%), (3) prospective cohort (6, 42.8%), and (4) retrospective cohort (3, 21.4%). Interventions included mailed outreach invitations, nursing outreach, patient education with or without printed materials, provider education, patient navigation, chronic disease management programs, nursing-led protocols for image ordering, automated reminders to physicians and nurses, web-based clinical management tools, HCC surveillance databases, provider compliance reports, radiology-led surveillance programs, subsidized HCC surveillance, and the use of oral medications. It was found that HCC surveillance rates increased after intervention implementation in all studies. CONCLUSION Despite improvements in HCC surveillance rates with intervention, compliance remained suboptimal. Further analysis of which interventions yield the greatest increases in HCC surveillance, design of multi-pronged strategies, and improved implementation are needed.
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Affiliation(s)
- Eliza W Beal
- Departments of Surgery and Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, 4100 John R, Mailcode: HW04HO, Detroit, MI, 48201, USA.
| | - Molly McNamara
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Mackenzie Owen
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Ann Scheck McAlearney
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- Department of Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, University of Virginia, Charlottsville, VA, 22908, USA
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Fabrellas N, Künzler-Heule P, Olofson A, Jack K, Carol M. Nursing care for patients with cirrhosis. J Hepatol 2023; 79:218-225. [PMID: 36754211 DOI: 10.1016/j.jhep.2023.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
Cirrhosis represents a major cause of morbidity and mortality, leading to a marked impairment in the quality of life of patients and their caregivers, and resulting in a major burden on healthcare systems. Currently, in most countries, nurses still play a limited role in the care of patients with cirrhosis, which is mainly restricted to the care of patients hospitalised for acute complications of the disease. The current manuscript reviews the established and potential new and innovative roles that nurses can play in the care of patients with cirrhosis. In the hospital setting, specialised nurses should become an integral part of interprofessional teams, helping to improve the quality of care and outcomes of patients with cirrhosis. In the primary care setting, nurses should play an important role in the care of patients with compensated cirrhosis and also facilitate early diagnosis of cirrhosis in those at risk of liver diseases. This review calls for an improved global liver disease education programme for nurses and increased awareness among all healthcare providers and policymakers of the positive impacts of advanced or specialist nursing practice in this domain.
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Affiliation(s)
- Núria Fabrellas
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Patrizia Künzler-Heule
- Nursing Science, Department of Public Health, Medical Faculty, University of Basel, Basel, Switzerland; Department of Gastroenterology/Hepatology and Department of Nursing, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Kathryn Jack
- Nottingham University Hospital NHS Trust, Notthingham, UK
| | - Marta Carol
- Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques AugustPi-Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Beal EW, Owen M, McNamara M, McAlearney AS, Tsung A. Patient-, Provider-, and System-Level Barriers to Surveillance for Hepatocellular Carcinoma in High-Risk Patients in the USA: a Scoping Review. J Gastrointest Cancer 2023; 54:332-356. [PMID: 35879510 DOI: 10.1007/s12029-022-00851-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Hepatocellular carcinoma has a dismal prognosis, except in patients diagnosed early who are candidates for potentially curative therapies. Most HCC cases develop in patients with chronic liver disease. Therefore, expert society guidelines recommend surveillance every 6 months with ultrasound with or without serum alpha-fetoprotein for high-risk patients. However, fewer than 20% of patients in the USA undergo appropriate surveillance. METHODS A systematic scoping review was performed with the objective of identifying barriers to screening among high-risk patients in the USA including mapping key concepts in the relevant literature, identifying the main sources and types of evidence available, and identifying gaps in the literature. A total of 43 studies published from 2007 to 2021 were included. Data were extracted and a conceptual framework was created. RESULTS Assessment of quantitative studies revealed poor surveillance rates, often below 50%. Three categories of barriers to surveillance were identified: patient-level, provider-level, and system-level barriers. Prevalent patient-level barriers included financial constraints, lack of awareness of surveillance recommendations, and scheduling difficulties. Common provider-level barriers were lack of provider awareness of guidelines for surveillance, difficulty accessing specialty resources, and time constraints in the clinic. System-level barriers included fewer clinic visits and rural/safety-net settings. Proposed interventions include improved patient/provider education, patient navigators, increased community/academic collaboration, and EMR-based reminders. CONCLUSION Based on these findings, there is a crucial need to implement and evaluate proposed interventions to improve HCC surveillance.
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Affiliation(s)
- Eliza W Beal
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA.
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA.
| | - Mackenzie Owen
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Molly McNamara
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Ann Scheck McAlearney
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
- The Department of Family and Community Medicine, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Allan Tsung
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
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O’Connell MB, Bendtsen F, Nørholm V, Brødsgaard A, Kimer N. Nurse-assisted and multidisciplinary outpatient follow-up among patients with decompensated liver cirrhosis: A systematic review. PLoS One 2023; 18:e0278545. [PMID: 36758017 PMCID: PMC9910708 DOI: 10.1371/journal.pone.0278545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Liver cirrhosis represents a considerable health burden and causes 1.2 million deaths annually. Patients with decompensated liver cirrhosis have a poor prognosis and severely reduced health-related quality of life. Nurse-led outpatient care has proven safe and feasible for several chronic diseases and engaging nurses in the outpatient care of patients with liver cirrhosis has been recommended. At the decompensated stage, the treatment and nursing care are directed at specific complications, educational support, and guidance concerning preventive measures and signs of decompensation. This review aimed to assess the effects of nurse-assisted follow-up after admission with decompensation in patients with liver cirrhosis from all causes. METHOD A systematic search was conducted through February 2022. Studies were eligible for inclusion if i) they assessed adult patients diagnosed with liver cirrhosis that had been admitted with one or more complications to liver cirrhosis and ii) if nurse-assisted follow-up, including nurse-assisted multidisciplinary interventions, was described in the manuscript. Randomized clinical trials were prioritized, but controlled trials and prospective cohort studies with the intervention were also included. Primary outcomes were mortality and readmission, but secondary subjective outcomes were also assessed. RESULTS AND CONCLUSION We included eleven controlled studies and five prospective studies with a historical control group comprising 1224 participants. Overall, the studies were of moderate to low quality, and heterogeneity across studies was substantial. In a descriptive summary, the 16 studies were divided into three main types of interventions: educational interventions, case management, and standardized hospital follow-up. We saw a significant improvement across all types of studies on several parameters, but currently, no data support a specific type of nurse-assisted, post-discharge intervention. Controlled trials with a predefined intervention evaluating clinically- and practice-relevant endpoints in a real-life, patient-oriented setting are highly warranted.
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Affiliation(s)
- Malene Barfod O’Connell
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
- * E-mail:
| | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
| | - Vibeke Nørholm
- Clinical Research Department, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
| | - Anne Brødsgaard
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
- Department of Public Health, Section for Nursing, Aarhus University, Aarhus, Denmark
| | - Nina Kimer
- Gastrounit, Medical Division, Copenhagen University Hospital Amager Hvidovre, Hvidovre, Denmark
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Use of a Cirrhosis Admission Order Set Improves Adherence to Quality Metrics and May Decrease Hospital Length of Stay. Am J Gastroenterol 2023; 118:114-120. [PMID: 35971218 DOI: 10.14309/ajg.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Quality metrics for inpatient cirrhosis management have been created to improve processes of care. We aimed to improve adherence to quality metrics by creating a novel clinical decision support (CDS) tool in the electronic health record (EHR). METHODS We developed and piloted an alert system in the EHR that directs providers to a cirrhosis order set for patients who have a known diagnosis of cirrhosis or are likely to have cirrhosis. Adherence to process measures and outcomes when the CDS was used were compared with baseline performance before the implementation of the CDS. RESULTS The use of the order set resulted in a significant increase in adherence to process measures such as diagnostic paracentesis (29.6%-51.1%), low-sodium diet (34.3%-77.8%), and social work involvement (36.6%-88.9%) ( P < 0.001 for all). There were also significant decreases in both intensive care and hospital lengths of stay ( P < 0.001) as well as in-hospital development of infection ( P = 0.002). There was no difference in hospital readmissions at 30 or 90 days between the groups ( P = 0.897, P = 0.640). DISCUSSION The use of CDS in EHR-based interventions improves adherence to quality metrics for patients with cirrhosis and could easily be shared by institutions through EHR platforms. Further studies and larger sample sizes are needed to better understand its impact on additional outcome measures.
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Evaluation of CirrhoCare® - a digital health solution for home management of individuals with cirrhosis. J Hepatol 2023; 78:123-132. [PMID: 36087864 DOI: 10.1016/j.jhep.2022.08.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Individuals with cirrhosis discharged from hospital following acute decompensation are at high risk of new complications. This study aimed to assess the feasibility and potential clinical benefits of remote management of individuals with acutely decompensated cirrhosis using CirrhoCare®. METHODS Individuals with cirrhosis with acute decompensation were followed up with CirrhoCare® and compared with contemporaneous matched controls, managed with standard follow-up. Commercially available monitoring devices were linked to the smartphone CirrhoCare® app, for daily recording of heart rate, blood pressure, weight, % body water, cognitive function (CyberLiver Animal Recognition Test [CL-ART] app), self-reported well-being, and intake of food, fluid, and alcohol. The app had 2-way patient-physician communication. Independent external adjudicators assessed the appropriateness of CirrhoCare®-based decisions. RESULTS Twenty individuals with cirrhosis were recruited to CirrhoCare® (mean age 59 ± 10 years, 14 male, alcohol-related cirrhosis [80%], mean model for end-stage liver disease-sodium [MELD-Na] score 16.1 ± 4.2) and were not statistically different to 20 contemporaneous controls. Follow-up was 10.1 ± 2.4 weeks. Fifteen individuals showed good engagement (≥4 readings/week), 2 moderate (2-3/week), and 3 poor (<2/week). In a usability questionnaire, the median score was ≥9 for all questions. Five CirrhoCare®-managed individuals had 8 readmissions over a median of 5 (IQR 3.5-11) days, and none required hospitalisation for >14 days. Sixteen other CirrhoCare®-guided patient contacts were made, leading to clinical interventions that prevented further progression. Appropriateness was confirmed by adjudicators. Controls had 13 readmissions in 8 individuals, lasting a median of 7 (IQR 3-15) days with 4 admissions of >14 days. They had 6 unplanned paracenteses compared with 1 in the CirrhoCare® group. CONCLUSIONS This study demonstrates that CirrhoCare® is feasible for community management of individuals with decompensated cirrhosis with good engagement and clinically relevant alerts to new decompensating events. CirrhoCare®-managed individuals have fewer and shorter readmissions justifying larger controlled clinical trials. IMPACT AND IMPLICATIONS As the burden of cirrhosis grows worldwide, increasing demands are being placed on limited healthcare resources, necessitating the adoption of more sustainable care models that allow for at-home patient management. The CirrhoCare® management system was developed to fill this care gap, deploying a novel combination of hardware, apps, and algorithms, to monitor and intervene in individuals at risk of new decompensation. This study highlights the possibility of reducing hospital readmissions for cirrhosis by optimising specialist community care, reducing the need for interventions such as paracentesis, while providing a more sustainable care pathway that is acceptable to patients. However, given the pilot and non-randomised nature of this study, the outcomes require further validation in a larger randomised controlled trial, to assess both clinical effectiveness and cost-effectiveness. Moreover, the data generated will also facilitate data modelling and further research to refine the CirrhoCare® algorithms to increase their detection sensitivity and utility.
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Hansen L, Chang MF, Hiatt S, Dieckmann NF, Mitra A, Lyons KS, Lee CS. Symptom Classes in Decompensated Liver Disease. Clin Gastroenterol Hepatol 2022; 20:2551-2557.e1. [PMID: 34813941 PMCID: PMC9120261 DOI: 10.1016/j.cgh.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/26/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with decompensated liver disease have been categorized by disease severity. This analysis sought to classify patients with end-stage liver disease based on symptoms rather than disease state and to identify distinct severity classes of physical and psychological symptoms. METHODS Patients with a model for end-stage liver disease-sodium score of 15 or higher were recruited from liver clinics in 2 health care organizations. They completed the Condensed Memorial Symptom Assessment Scale, Revised Ways of Coping Checklist, Patient Health Questionnaire, Life Orientation Test-Revised, and the Short-Form Health Survey. Cross-sectional data were analyzed using latent class mixture modeling. RESULTS The sample (N = 191; age, 56.6 ± 11.1 y; 33.5% ETOH; 28.3% nonalcoholic fatty liver disease; 13.1% autoimmune/primary biliary cholangitis/primary sclerosing cholangitis) was predominantly male (64.2%), Child-Turcotte-Pugh class C (49.5%), with an average model for end-stage liver disease-sodium score of 18.7 ± 4.9. Three distinct classes of symptoms were identified, as follows: mild (26.7%), moderate (41.4%), or severe (31.9%) symptoms. Symptom classes were independent of disease severity and demographic characteristics, except age. All Condensed Memorial Symptom Assessment Scale symptoms and Patient Health Questionnaire scores were significantly different across the 3 classes (P < .05). The symptom classes also differed significantly in physical and mental quality of life, optimism, and avoidance coping behaviors (all P < .001). CONCLUSIONS Patient-reported symptom severity occurred independent of disease severity, contrary to common assumptions. Focusing on the moderate and severe symptom classes as well as patient history of end-stage liver disease complications may enhance providers' ability to improve symptom management for this population.
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Affiliation(s)
- Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon.
| | - Michael F Chang
- Gastroenterology and Hepatology, VA Portland Health Care System, Portland, Oregon
| | - Shirin Hiatt
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Nathan F Dieckmann
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Arnab Mitra
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Karen S Lyons
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts
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11
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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Figredo A, Hunter J, Elford A, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Liew D, Rogers B, Sievert W, Bell S, Le S. A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial. Trials 2022; 23:744. [PMID: 36064596 PMCID: PMC9444080 DOI: 10.1186/s13063-022-06679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06679-x.
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Affiliation(s)
- Natalie Ly Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Anita Figredo
- Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Jo Hunter
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Alexander Elford
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Corner of North Terrace & George St, Adelaide, South Australia, 5000, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.,Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
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12
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Measuring Medication Use, Obstacles, and Knowledge in Individuals With Cirrhosis. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00821-7. [PMID: 36055568 PMCID: PMC9971355 DOI: 10.1016/j.cgh.2022.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/25/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although patient knowledge is modifiable, there are no widely accepted tools to measure patient understanding during cirrhosis care. We aimed to develop and validate "My Cirrhosis Coach" (MCC), a personalized, self-administered questionnaire to evaluate cirrhosis-related medication use, obstacles, and understanding. METHODS Adults with cirrhosis were prospectively enrolled at 3 tertiary centers from July 2016 through July 2020. Psychometrics including confirmatory factor analysis was used to develop and validate a final questionnaire. Content validity was measured via the content validity index and expert performance. Discriminant validity was assessed by comparing scores between groups hypothesized to have varying performance. RESULTS The MCC was tested in a diverse cohort (n = 713) with cirrhosis and its complications including ascites (45%) and hepatic encephalopathy (33%) with median Model for End-Stage Liver Disease-Sodium 10 (interquartile range, 9-15). A 6-factor model of the MCC fit the data well (root mean square error of approximation, 0.22; comparative fit index, 0.96; standardized root mean squared residual, 0.104; final domains: Medication Use & Accessibility, Medication Obstacles, Lactulose Use, Diuretic Use, Beta Blocker Use, and Dietary Sodium Use). The MCC had excellent content validity (content validity index, 81%-94%) and accuracy (91%-100%) ratings by experts. Mean domain scores ranged from 1.1 to 2.6 (range, 0-3; 3 indicating better performance). Those with a cirrhosis complication scored higher in the relevant medication domain (ie, diuretic use score in ascites). Compared with outpatients, inpatients scored higher in all knowledge domains except salt use and reported more medication obstacles. Scores differed by income, education level, and having an adult at home. CONCLUSIONS In a large, diverse cohort, we validated the MCC, which can serve to standardize medication use and knowledge measurement in clinical practice and education-based studies in cirrhosis.
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Mikkonen K, Yamakawa M, Tomietto M, Tuomikoski A, Utsumi M, Jarva E, Kääriäinen M, Oikarinen A. Randomised controlled trials addressing how the clinical application of information and communication technology impacts the quality of patient care—A systematic review and meta‐analysis. J Clin Nurs 2022. [DOI: 10.1111/jocn.16448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/04/2022] [Accepted: 06/23/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Kristina Mikkonen
- Research Unit of Health Sciences and Technology University of Oulu Oulu Finland
- The Finnish Centre for Evidence‐Based Health Care: A JOANNA Briggs Institute Centre of Excellence Helsinki Finland
- Medical Research Center Oulu Oulu University Hospital and University of Oulu Oulu Finland
| | - Miyae Yamakawa
- Department of Evidence‐Based Clinical Nursing Division of Health Sciences Graduate School of Medicine Osaka University Asakayama General Hospital Osaka Japan
| | - Marco Tomietto
- Department of Nursing, Midwifery and Healthcare Faculty of Health and Life Sciences Northumbria University Newcastle upon Tyne UK
- Research Unit of Nursing Science and Health Management University of Oulu Oulu Finland
| | - Anna‐Maria Tuomikoski
- The Finnish Centre for Evidence‐Based Health Care: A JOANNA Briggs Institute Centre of Excellence Helsinki Finland
- Oulu University Hospital Oulu Finland
| | - Momoe Utsumi
- Department of Evidence‐Based Clinical Nursing Division of Health Sciences Graduate School of Medicine Osaka University Asakayama General Hospital Osaka Japan
| | - Erika Jarva
- Research Unit of Health Sciences and Technology University of Oulu Oulu Finland
- The Finnish Centre for Evidence‐Based Health Care: A JOANNA Briggs Institute Centre of Excellence Helsinki Finland
| | - Maria Kääriäinen
- Research Unit of Health Sciences and Technology University of Oulu Oulu Finland
- The Finnish Centre for Evidence‐Based Health Care: A JOANNA Briggs Institute Centre of Excellence Helsinki Finland
- Medical Research Center Oulu Oulu University Hospital and University of Oulu Oulu Finland
| | - Anne Oikarinen
- Research Unit of Health Sciences and Technology University of Oulu Oulu Finland
- The Finnish Centre for Evidence‐Based Health Care: A JOANNA Briggs Institute Centre of Excellence Helsinki Finland
- Medical Research Center Oulu Oulu University Hospital and University of Oulu Oulu Finland
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Verma M, Brahmania M, Fortune BE, Asrani SK, Fuchs M, Volk ML. Patient-centered care: Key elements applicable to chronic liver disease. Hepatology 2022. [PMID: 35712801 DOI: 10.1002/hep.32618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 12/08/2022]
Abstract
Chronic liver disease (CLD) is a progressive illness with high symptom burden and functional and cognitive impairment, often with comorbid mental and substance use disorders. These factors lead to significant deterioration in quality of life, with immense burden on patients, caregivers, and healthcare. The current healthcare system in the United States does not adequately meet the needs of patients with CLD or control costs given the episodic, reactive, and fee-for-service structure. There is also a need for clinical and financial accountability for CLD care. In this context, we describe the key elements required to shift the CLD care paradigm to a patient-centered and value-based system built upon the Porter model of value-based health care. The key elements include (1) organization into integrated practice units, (2) measuring and incorporating meaningful patient-reported outcomes, (3) enabling technology to allow innovation, (4) bundled care payments, (5) integrating palliative care within routine care, and (6) formalizing centers of excellence. These elements have been shown to improve outcomes, reduce costs, and improve overall patient experience for other chronic illnesses and should have similar benefits for CLD. Payers need to partner with providers and systems to build upon these elements and help align reimbursements with patients' values and outcomes. The national organizations such as the American Association for Study of Liver Diseases need to guide key stakeholders in standardizing these elements to optimize patient-centered care for CLD.
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Affiliation(s)
- Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | | | - Brett E Fortune
- Montefiore Einstein Center for Transplantation, Bronx, New York, USA
| | | | - Michael Fuchs
- Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Michael L Volk
- Loma Linda University Health, Loma Linda, California, USA
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15
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Orman ES, Yousef A, Xu C, Shamseddeen H, Johnson AW, Nephew L, Ghabril M, Desai AP, Patidar KR, Chalasani N. Palliative Care, Patient-Reported Measures, and Outcomes in Hospitalized Patients With Cirrhosis. J Pain Symptom Manage 2022; 63:953-961. [PMID: 35202730 PMCID: PMC9124687 DOI: 10.1016/j.jpainsymman.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT Studies of palliative care (PC) in hospitalized patients with cirrhosis have been retrospective, with limited evaluation of patient-reported measures and outcomes. OBJECTIVES To examine the relationship between PC, patient-reported measures (quality of life and functional status), and outcomes. METHODS We performed a prospective cohort study of patients with cirrhosis hospitalized from 2014 to 2019. We recorded PC consultation details, quality of life (chronic liver disease questionnaire), and functional status (functional status questionnaire). Patients were followed for 90 days to assess readmissions, costs, and mortality. RESULTS Seventy-four of 679 patients saw PC, often later in the hospitalization (median hospital day 8; IQR 4-16). Those who saw PC had greater Charlson comorbidity index (mean 6.8 vs. 5.9), MELD (mean 25 vs. 20), and prior 30-day admission (47% vs. 35%). Compared to those who did not see PC, PC patients had greater impairments in intermediate activities of daily living (83% vs. 72%), social activity (72% vs. 59%), quality of interactions (49% vs. 36%), abdominal symptoms (mean score 3.1 vs. 3.6), activity (mean 3.3 vs. 3.6), and overall quality of life (mean 3.6 vs. 3.8). PC was associated with fewer transfusions and upper endoscopies and with greater completion of advanced directives. After multivariable adjustment, PC was not associated with intensive care, 30-day readmissions, 90-day costs, or mortality. CONCLUSION PC occurs infrequently and late in those with more severe liver disease and functional impairment. PC may be associated with reduction in utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC for this population.
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Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA.
| | - Andrew Yousef
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Chenjia Xu
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
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16
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Orman ES, Ghabril MS, Desai AP, Nephew L, Patidar KR, Gao S, Xu C, Chalasani N. Patient-Reported Outcome Measures Modestly Enhance Prediction of Readmission in Patients with Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:e1426-e1437. [PMID: 34311111 PMCID: PMC8784569 DOI: 10.1016/j.cgh.2021.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis have high rates of hospital readmission, but prediction models are suboptimal and have not included important patient-reported outcome measures (PROMs). In a large prospective cohort, we examined the impact of PROMs on prediction of 30-day readmissions. METHODS We performed a prospective cohort study of adults with cirrhosis admitted to a tertiary center between June 2014 and March 2020. We collected clinical information, socioeconomic status, and PROMs addressing functional status and quality of life. We used hierarchical competing risk time-to-event analysis to examine the impact of PROMs on readmission prediction. RESULTS A total of 654 patients were discharged alive, and 247 (38%) were readmitted within 30 days. Readmission was independently associated with cerebrovascular disease, ascites, prior hospital admission, admission via the emergency department, lower albumin, higher Model for End-Stage Liver Disease, discharge with public transportation, and impaired basic activities of daily living and quality-of-life activity domain. Reduced readmission was associated with cancer, admission for infection, children at home, and impaired emotional function. Compared with a model including only clinical variables, addition of functional status and quality-of-life variables improved the area under the receiver-operating characteristic curve from 0.72 to 0.73 and 0.75, with net reclassification indices of 0.22 and 0.18, respectively. Socioeconomic variables did not significantly improve prediction compared with clinical variables alone. Compared with a model using electronically available variables only, no models improved prediction when examined with integrated discrimination improvement. CONCLUSIONS PROMs may marginally add to the prediction of 30-day readmissions for patients with cirrhosis. Poor social support and disability are associated with readmissions and may be high-yield targets for future interventions.
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Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chenjia Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
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Rising Healthcare Costs and Utilization among Young Adults with Cirrhosis in Ontario: A Population-Based Study. Can J Gastroenterol Hepatol 2022; 2022:6175913. [PMID: 35308801 PMCID: PMC8926479 DOI: 10.1155/2022/6175913] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Chronic diseases account for the majority of healthcare spending. Cirrhosis is a chronic disease whose burden is rising, especially in young adults. This study aimed at describing the direct healthcare costs and utilization in young adults with cirrhosis compared to other chronic diseases common to this age group. METHODS Retrospective population-based study of routinely collected healthcare data from Ontario for the fiscal years 2007-2016 and housed at ICES. Young adults (aged 18-40 years) with cirrhosis, inflammatory bowel disease (IBD), and asthma were identified based on validated case definitions. Total and annual direct healthcare costs and utilization were calculated per individual across multiple healthcare settings and compared based on the type of chronic disease. For cirrhosis, the results were further stratified by etiology and decompensation status. RESULTS Total direct healthcare spending from 2007 to 2016 increased by 84% for cirrhosis, 50% for IBD, and 41% for asthma. On a per-patient basis, annual costs were the highest for cirrhosis ($6,581/year) compared to IBD ($5,260/year), and asthma ($2,934/year) driven by acute care in cirrhosis and asthma, and drug costs in IBD. Annual costs were four-fold higher in patients with decompensated versus compensated cirrhosis ($20,651/year vs. $5,280/year). Patients with cirrhosis had greater use of both ICU and mental health services. CONCLUSION Healthcare costs in young adults with cirrhosis are rising and driven by the use of acute care. Strategies to prevent the development of cirrhosis and to coordinate healthcare in this population through the development of chronic disease prevention and management strategies are urgently needed.
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Yoder L, Mladenovic A, Pike F, Vuppalanchi R, Hanson H, Corbito L, Desai AP, Chalasani N, Orman ES. Attendance at a Transitional Liver Clinic May Be Associated with Reduced Readmissions for Patients with Liver Disease. Am J Med 2022; 135:235-243.e2. [PMID: 34655539 PMCID: PMC8840978 DOI: 10.1016/j.amjmed.2021.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Patients with liver disease have high rates of early hospital readmission, but there are no studies of effective, scalable interventions to reduce this risk. In this study, we examined the impact of a Physician Assistant (PA)-led post-discharge Transitional Liver Clinic (TLC) on hospital readmissions. METHODS We performed a cohort study of all adults seen by a hepatologist during admission to a tertiary care center in 2019 (excluding transplant patients). We compared those who attended the TLC with those who did not, with respect to 30-day readmission and mortality. Propensity score-adjusted modeling was used to control for confounding. RESULTS Of 498 patients, 98 were seen in the TLC; 35% had alcoholic liver disease and 58% had cirrhosis. Attendees were similar to non-attendees with respect to demographics, liver disease characteristics and severity, comorbidities, and discharge disposition. Thirty-day cumulative incidence of readmissions was 12% in TLC attendees, compared with 22% in non-attendees (P = .02), while 30-day mortality was similar (2.0% vs 4.3%; P = .29). In a model using propensity score adjustment, TLC attendance remained associated with reduced readmissions (subhazard ratio 0.52; 95% confidence interval, 0.27-0.997; P = .049). The effect of TLC was greater in women compared with men (P = .07) and in those without chronic kidney disease (P = .02), but there were no differences across other subgroups. CONCLUSIONS Patients with liver disease seen in a PA-led TLC may have a significant reduction in the 30-day readmission rate. Randomized trials are needed to establish the efficacy of PA-led post-discharge transitional care for this population.
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Affiliation(s)
- Lindsay Yoder
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Andrea Mladenovic
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis
| | - Francis Pike
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Raj Vuppalanchi
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Haleigh Hanson
- Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Laura Corbito
- Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Archita P Desai
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis
| | - Eric S Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis; Digestive & Liver Disorders, Indiana University Health, Indianapolis.
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Ramachandran J, Lawn S, Tang MSS, Pati A, Wigg L, Wundke R, McCormick R, Muller K, Kaambwa B, Woodman R, Wigg A. Nurse Led Clinics; a Novel Model of Care for Compensated Liver Cirrhosis: A Qualitative Analysis. Gastroenterol Nurs 2022; 45:29-42. [PMID: 34369404 DOI: 10.1097/sga.0000000000000620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/26/2021] [Indexed: 11/27/2022] Open
Abstract
A nurse-led cirrhosis clinic model for management of stable, compensated cirrhotic patients is practised in our unit since 2013, wherein these patients are reviewed every six months by specialist nurses in community clinics under remote supervision of hepatologists. We evaluated the experiences of patients and healthcare providers involved in the model to understand the acceptability, strengths, and limitations of the model and obtain suggestions to improve. A qualitative design using in-depth interviews was employed, followed by thematic analysis of eight patients, one attending physician both nurse and hospital clinics, four hepatologists, and three experienced specialist nurses running the nurse-led cirrhosis clinic. Patients expressed satisfaction and a good understanding of the nurse-led cirrhosis clinic, preferring it to hospital clinics for better accessibility and the unique nurse-patient relationship. Upskilling and provision of professional care in a holistic manner were appreciated by specialist nurses. The hepatologists expressed confidence and satisfaction, although they acknowledged the difference between the medical training of specialist nurses and hepatologists. The greater availability of hospital clinic time for sick patients was welcomed. Increased specialist nurse staffing, regular forums to promote specialist nurse learning, and formalization of the referral process were suggested. No adverse experiences were reported by patients or staff. The nurse-led cirrhosis clinic model for compensated liver cirrhosis was well received by patients, hepatologists, and specialist nurses. Wider implementation of the model could be considered after further investigations in other settings.
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Affiliation(s)
- Jeyamani Ramachandran
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Sharon Lawn
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Matilda Swee Sun Tang
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Anuradha Pati
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Luisa Wigg
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Rachel Wundke
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Rosemary McCormick
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Kate Muller
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Billingsley Kaambwa
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Richard Woodman
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Alan Wigg
- Jeyamani Ramachandran, PhD, MD, MBBS, DM, FRACP, is Consultant Hepatologist, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Sharon Lawn, PhD, is Professor, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Matilda Swee Sun Tang, MBBS, is an intern, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Anuradha Pati, SACE, is Second-Year Medical Student, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Luisa Wigg, IBDP, is Second-Year Medical Student, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Rachel Wundke, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Rosemary Mccormick, BNurs, is Clinical Practice Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Kate Muller, PhD, FRACP, is Consultant, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Billingsley Kaambwa, PhD, is Associate Professor and Head of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- Richard Woodman, PhD, is Professor, Department of Biostatistics and Epidemiology, Flinders University, Bedford Park, South Australia
- Alan Wigg, PhD, FRACP, is Professor and Head, Hepatology and Liver Transplant Unit, Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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Bloom PP, Ventoso M, Tapper E, Ha J, Richter JM. A Telemonitoring Intervention for Cirrhotic Ascites Management Is Cost-Saving. Dig Dis Sci 2022; 67:854-862. [PMID: 34018070 PMCID: PMC8136259 DOI: 10.1007/s10620-021-07013-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with cirrhosis and ascites experience frequent hospital admissions, leading to poor quality of life and high healthcare costs. Monitoring weight is a component of ascites care and telemonitoring may improve outcomes and costs. Goals We aimed to evaluate the cost and outcomes of current care compared to a telemonitoring system for ascites. Study We developed a decision-analytic model that examined 100 simulated patients over a 6-month horizon. We compared usual care to a new telemonitoring program, which we estimate costs $50,000/6 months. RESULTS The cost of standard of care for 100 patients with cirrhotic ascites over a 6-month period is $167,500 more expensive than telemonitoring. By varying parameter probabilities by ± 10% and outcome costs by ± 20%, we found that standard of care remains more expensive than care with a telemonitoring intervention by $9400 to $340,200 per 6-month period. Standard of care leads to 9 more admissions (range 4 to 12) than a telemonitoring intervention, while telemonitoring leads to 9 more outpatient visits (range 6 to 9) and 28 additional outpatient large volume paracenteses (LVPs) (range 17 to 28). With more and less expensive telemonitoring interventions, standard of care remained more expensive. With 50% adherence to the intervention, standard of care was $89,848 more expensive. CONCLUSIONS In almost all probability and cost scenarios, a telemonitoring intervention is cost-saving for the management of cirrhotic ascites. Using hospital admissions as a surrogate for quality of care, patient outcomes are improved primarily though more proactive medical intervention and more LVPs.
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Affiliation(s)
- Patricia P. Bloom
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Martin Ventoso
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Elliot Tapper
- Gastrointestinal Unit, University of Michigan, Taubman Center, Floor 1, Reception G, 1500 E. Medical Center Dr., Ann Arbor, MI USA
| | - Jasmine Ha
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
| | - James M. Richter
- Department of Medicine, Harvard Medical School, Boston, USA ,Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
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21
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Gonzalez JJ, DiBattista J, Gomez V, Gonzalez E, Zhang Q, Vaughn VM, Tapper EB. Impact of Inpatient Attending Specialty and Gastroenterology Consultation on Quality of Care of Patients Hospitalized with Decompensated Cirrhosis. Am J Med 2021; 134:1270-1277.e2. [PMID: 34144013 PMCID: PMC10838397 DOI: 10.1016/j.amjmed.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data suggest hospitalists are less adherent to quality indicators for decompensated cirrhosis, and gastroenterology consultation may improve adherence. We sought to evaluate the impact of inpatient attending specialty and gastroenterology consultation on quality of care for decompensated cirrhosis. METHODS This was a retrospective cohort study of patients with decompensated cirrhosis admitted to gastroenterology or hospitalist service at the University of Michigan between 2016-2020. The primary outcome was adherence to nationally recommended inpatient quality indicators for ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and gastrointestinal bleeding. Performance was calculated per patient admission as the proportion of quality indicators met vs quality indicators for which the patient was eligible. Quality indicator scores were compared between services using t-tests. We also evaluated the effect of gastroenterology consultation on quality indicator scores for patients admitted to hospitalist service. Clinical outcomes were compared using multivariable models adjusted for patient characteristics. RESULTS Two hundred eighty-eight admissions were included (155 to gastroenterology service; 133 to hospitalist service). Quality indicator score for all admissions was 69.9% (standard deviation [SD] ± 24.2%). Quality indicator scores were similar between gastroenterology (69.9%, SD ± 23.6%) and hospitalist (69.8%, SD ± 25.1%) services (P = .913). There was no difference in quality indicator subscores for each complication between services. Hospitalists placed a gastroenterology consultation in 53.4% of admissions, and it was associated with higher albumin administration for patients with spontaneous bacterial peritonitis (57.1% vs 25%, P = .044). Patients admitted to gastroenterology service had higher readmissions within 30 days (adjusted odds ratio = 1.95) and shorter length of hospitalization (adjusted rate ratio = 0.85). CONCLUSIONS Hospitalists provided comparable quality of care to gastroenterologists for inpatients with decompensated cirrhosis.
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Affiliation(s)
- Juan J Gonzalez
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
| | - Jacob DiBattista
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Emelie Gonzalez
- Facultad de Medicina Dr. Jose Edmundo Vasquez, Universidad Dr. Jose Matias Delgado, La Libertad, El Salvador
| | - Qisu Zhang
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Medical School, Salt Lake City
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Tapper EB, Parikh ND. The Future of Quality Improvement for Cirrhosis. Liver Transpl 2021; 27:1479-1489. [PMID: 33887806 PMCID: PMC8487907 DOI: 10.1002/lt.26079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 01/21/2023]
Abstract
Cirrhosis has a significant and growing impact on public health and patient-reported outcomes (PROs). The increasing burden of cirrhosis has led to an emphasis on the quality of care with the goal of improving overall outcomes in this high-risk population. Existing evidence has shown the significant gaps in quality across process measures (eg, hepatocellular carcinoma screening), highlighting the need for consistent measurement and interventions to address the gaps in quality care. This multistep process forms the quality continuum, and it depends on clearly defined process measures, real-time quality measurement, and generalizable evaluative methods. Herein we review the current state of quality care in cirrhosis across the continuum with a focus on process measurement methodologies, developments in PRO evaluation on quality assessment, practical examples of quality improvement initiatives, and the recent emphasis placed on the value of primary prevention.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan
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23
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Case BC, Yang M, Qamer SZ, Kumar S, Yerasi C, Forrestal BJ, Chezar-Azerrad C, Medranda GA, Bernardo NL, Rogers T, Satler LF, Hashim H, Satoskar RS, Lalos AT, Waksman R, Ben-Dor I. Pre-Operative Cardiovascular Testing before Liver Transplantation. Am J Cardiol 2021; 152:132-137. [PMID: 34103158 DOI: 10.1016/j.amjcard.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
End-stage liver disease (ESLD) is increasingly prevalent and shares many risk factors with coronary artery disease (CAD). No specific guidelines exist for pre-liver transplant evaluation of CAD, and pretransplant cardiovascular testing varies widely. The aim of this study is to characterize pre-transplant cardiac testing practices with post-transplant clinical outcomes. We retrospectively reviewed patients undergoing initial liver transplantation at our transplant center between January 2015 and March 2019. Patients with previous liver transplantation or multi-organ transplantation were excluded. Electronic medical records were reviewed for relevant demographic and clinical data. We included 285 patients with a mean follow-up of 2.4 years. Of 274 patients (96.1%) with pre-transplant transthoracic echocardiogram (TTE), 18 (6.6%) were abnormal. Non-invasive ischemic testing was performed in 193 (68%) patients: 165 (58%) underwent stress TTE, 24 (8%) underwent myocardial perfusion imaging, 3 underwent coronary computed tomography, and 1 underwent exercise electrocardiogram. Sixteen patients (6%) had left heart catheterization of which 10 (63%) were abnormal and 5 proceeded to revascularization before transplant. There were 4 (1.4%) deaths within 30 days of transplant and 23 deaths (8.1%) in total. ST-elevation myocardial infarction was seen in 1 patient within 30 days and 1 patient after 30 days (0.7% total). No cardiovascular deaths were observed. Among patients undergoing liver transplantation, pre-transplantation cardiovascular testing is exceedingly common and post-transplant cardiovascular complications are rare. Additional research is needed to determine the optimal testing and surveillance in this patient population.
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24
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Carbonneau M, Davyduke T, Congly SE, Ma MM, Newnham K, Den Heyer V, Tandon P, Abraldes JG. Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization. CANADIAN LIVER JOURNAL 2021; 4:38-50. [PMID: 35991472 PMCID: PMC9203164 DOI: 10.3138/canlivj-2020-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/27/2020] [Indexed: 09/15/2023]
Abstract
BACKGROUND Multidisciplinary care has the potential to improve outcomes among patients with cirrhosis, yet its impact on this population remains unclear, with existing studies demonstrating discrepant results. Using data from the multidisciplinary outpatient Cirrhosis Care Clinic (CCC) at the University of Alberta Hospital, we aimed to evaluate acute care utilization and survival outcomes of patients followed by the CCC compared with those receiving standard care (SC). METHODS We performed a retrospective chart review of 212 patients with cirrhosis admitted to University of Alberta Hospital between 2014 and 2015. CCC patients (n = 36) were followed through the CCC before index admission. SC patients (n = 176) were managed outside of the CCC. Readmission time in hospital was collected until 1 year, death, or liver transplant. RESULTS CCC patients had more advanced liver disease (higher prevalence of ascites, encephalopathy, and varices). Despite this, acute care utilization was significantly lower among CCC patients (adjusted length of stay lower by 3 days, p = 0.03, and adjusted survival days spent in hospital lower by 9%, p = 0.02). CCC patients also had improved 1-year transplant-free survival, with an adjusted 1-year relative risk reduction of 53% (p = 0.03). Total mean cost of care was lower in the CCC group by $2,280 per patient-month of life. DISCUSSION For patients admitted with cirrhosis, specialized post-discharge multidisciplinary outpatient care is associated with decreased acute care utilization, improved 1-year transplant-free survival probability, and the potential for cost savings to the system.
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Affiliation(s)
| | - Tracy Davyduke
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Stephen E Congly
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Mang M Ma
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Newnham
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vanessa Den Heyer
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
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25
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Saleh ZM, Bloom PP, Grzyb K, Tapper EB. How Do Patients With Cirrhosis and Their Caregivers Learn About and Manage Their Health? A Review and Qualitative Study. Hepatol Commun 2021; 5:168-176. [PMID: 33553967 PMCID: PMC7850304 DOI: 10.1002/hep4.1621] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 02/04/2023] Open
Abstract
The complexity of cirrhosis requires patients and their caregivers to be well educated to improve outcomes. Data are lacking regarding how to best educate patients and their caregivers in the setting of cirrhosis. Our aim is to understand (both through existing literature and by asking patients and their caregivers) how patients learn about their disease, barriers in their education and disease management, and self-management strategies. We performed a structured search of published articles in PubMed (1973 to 2020) using keywords "cirrhosis" plus "barriers", "education", "self-management", or "self-care". Additionally, we conducted a focus group of a representative sample of patients and their caregivers to understand how knowledge about cirrhosis is found and incorporated into self-management. Of 504 returned manuscripts, 11 pertained to barriers in cirrhosis, interventions, or educational management. Barriers are well documented and include disease complexity, medication challenges, comorbid conditions, and lack of effective education. However, data regarding addressing these barriers, especially effective educational interventions, are scarce. Current strategies include booklets and videos, patient empowerment, and in-person lectures. Without widespread use of these interventions, patients are left with suboptimal knowledge about their disease, a sentiment unanimously echoed by our focus group. Despite linkage to subspecialty care and consistent follow-up, patients remain uncertain about their disease origin, prognosis, and therapies to manage symptoms. It is clear that more data are needed to assess effective strategies to address unmet educational needs. Existing strategies need to be blended and improved, their effectiveness evaluated, and the results distributed widely.
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Affiliation(s)
- Zachary M Saleh
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Patricia P Bloom
- Division of GastroenterologyMassachusetts General HospitalBostonMAUSA
| | - Katie Grzyb
- Quality and Continuous Improvement TeamDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Elliot B Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMIUSA
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26
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Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes. J Clin Gastroenterol 2020; 54:850-856. [PMID: 33030855 DOI: 10.1097/mcg.0000000000001422] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.
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27
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Tauseef A, Zafar M, Rashid B, Thirumalareddy J, Chalfant V, Farooque U, Mirza M. Correlation of Fasting Lipid Profile in Patients With Chronic Liver Disease: A Descriptive Cross-Sectional Study in Tertiary Care Hospital. Cureus 2020; 12:e11019. [PMID: 33214947 PMCID: PMC7671171 DOI: 10.7759/cureus.11019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction: Chronic liver disease (CLD) is a term used to describe a wide spectrum of disorders, including idiopathic, infectious, genetic, drug-induced, toxin-induced, and autoimmune disorders. The common consequence of chronic damage to the liver is cirrhosis. Cirrhotic patients are further classified by their severity based on the Child-Pugh scoring system. Currently, Child-Pugh scoring consists of ascites, hepatic encephalopathy (HE), prothrombin time, serum albumin level, and total bilirubin level. Lipid panel in CLD is a great marker in determining the severity of CLD. Method and methodology: It was a descriptive cross-sectional study conducted at a tertiary care hospital. A sample size of 122 was calculated by using a RaoSoft Digital Sample Size Calculator (RaoSoft, Inc., Seattle, WA) in which we used 5% as a margin of error, 95% as confidence interval (CI), 178 as population size, and response distribution as 50%. Non-complicated CLD patients having age in between 15 and 80 years with no cirrhotic complications including HE, spontaneous bacterial peritonitis, hepato-pumonary, or hepato-renal syndrome were included in our study; the rest of the CLD patients were excluded from our study. Results: The mean age of the study population was 47.09 ± 12.30 years with more than half of the patients lying among the age group 25-50 years. The study population included 76% of males (n=93) and 24% of females (n=29), with a mean age of females higher than the males. Diabetes mellitus (58.19%) was the most frequent comorbidity associated with CLD in subjects included in our study. Parameters of lipid panel were decreased exponentially as the severity of CLD increases from Child score A to C. Total cholesterol, low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), high-density lipoprotein (HDL), and triglyceride (TG) level decreased as the severity increases in our study. The mean model for end-stage liver disease (MELD) score increased as per hypothesized as the severity increases from Child score A to Child score C, respectively. Conclusion: Our study concluded that as the severity of CLD increases from Child class A to Child class C, the lipid panel profile decreases exponentially which proved the idea that had been hypothesized at the beginning of our study.
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Affiliation(s)
- Abubakar Tauseef
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Maryam Zafar
- Internal Medicine, Dow International Medical College, Dow University Hospital, Dow University of Health Sciences, Karachi, PAK
| | - Behzad Rashid
- Internal Medicine, Dow International Medical College, Dow University Hospital, Dow University of Health Sciences, Karachi, PAK
| | | | - Victor Chalfant
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Umar Farooque
- Neurology, Dow International Medical College, Dow University Hospital, Dow University of Health Sciences, Karachi, PAK
| | - Mohsin Mirza
- Hospital Medicine, Creighton University School of Medicine, Omaha, USA
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28
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Hayward KL, Weersink RA. Improving Medication-Related Outcomes in Chronic Liver Disease. Hepatol Commun 2020; 4:1562-1577. [PMID: 33163829 PMCID: PMC7603526 DOI: 10.1002/hep4.1612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic liver disease (CLD) are becoming increasingly complex due to the rising prevalence of multimorbidity and polypharmacy. Medications are often essential to manage the underlying liver disease, complications of cirrhosis and portal hypertension, and comorbidities. However, medication-related problems (MRPs) have been associated with adverse patient outcomes, including hospitalization and mortality. Factors that can contribute to MRPs in people with CLD are variable and often entwined. This narrative literature review discusses key barriers and opportunities to modify risk factors and improve medication-related outcomes for people with CLD.
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Affiliation(s)
- Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine The University of Queensland, Translational Research Institute Brisbane QLD Australia.,Department of Gastroenterology and Hepatology Princess Alexandra Hospital Brisbane QLD Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy Deventer Hospital Deventer The Netherlands
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29
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Hayward KL, Valery PC, Patel PJ, Horsfall LU, Wright PL, Tallis CJ, Stuart KA, David M, Irvine KM, Cottrell WN, Martin JH, Powell EE. Effectiveness of patient-oriented education and medication management intervention in people with decompensated cirrhosis. Intern Med J 2020; 50:1142-1146. [PMID: 32929822 PMCID: PMC7540524 DOI: 10.1111/imj.14986] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/10/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
People with chronic disease often have poor comprehension of their disease and medications, which can negatively affect health outcomes. In a randomised-controlled trial, we found that patients with decompensated cirrhosis who received a pharmacist-led, patient-oriented education and medication management intervention (n = 57) had greater knowledge of cirrhosis and key self-care tasks compared with usual care (n = 59). Intervention patients also experienced improved quality of life. Dedicated resources are needed to support implementation of evidence-based measures at local centres to improve outcomes.
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Affiliation(s)
- Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Patricia C Valery
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Cancer and Chronic Disease Research Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Preya J Patel
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Leigh U Horsfall
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Penny L Wright
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Caroline J Tallis
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael David
- Centre for Human Drug Research, School of Medicine and Public Health, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Katharine M Irvine
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - W Neil Cottrell
- Macrophage Biology Research Group, Mater Research, The University of Queensland, Brisbane, Queensland, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Jennifer H Martin
- Centre for Human Drug Research, School of Medicine and Public Health, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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30
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Ramachandran J, Smith D, Woodman R, Muller K, Wundke R, McCormick R, Kaambwa B, Wigg A. Psychometric validation of the Partners in Health scale as a self-management tool in patients with liver cirrhosis. Intern Med J 2020; 51:2104-2110. [PMID: 32833278 DOI: 10.1111/imj.15031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM Liver cirrhosis is a chronic disease complicated by recurrent hospital admissions. Self-management skills could facilitate optimal disease management. At present there is no validated instrument for measuring self-management in these patients. Hence, we evaluated the internal reliability and construct validity of the Partners in Health (PIH) scale, a chronic condition self-management tool in cirrhotic patients. METHODS In this prospective cohort study, the PIH scale was administered to 133 consenting patients within a Chronic Liver Failure Program of a tertiary hospital from February 2017 to May 2018. A Bayesian confirmatory factor analysis was used to evaluate a priori four-factor structure. Omega coefficients and 95% credible intervals (CrI) were used to assess internal reliability. Known-group validity was assessed in patients receiving active case management (n = 60) versus those without (n = 73). RESULTS The mean (± standard deviation (SD)) age of the participants was 62 (±11) years. Model fit for the hypothesised model was adequate (posterior predictive P-value = 0.073) and all hypothesised factor loadings were substantial (>0.6) and significant (P < 0.001). Omega coefficients (95% CrI) for the PIH subscales of Knowledge, Partnership, Management and Coping were 0.88 (0.82-0.91), 0.68 (0.57-0.76), 0.92 (0.89-0.94) and 0.89 (0.85-0.92) respectively. The mean (±SD) overall PIH score was higher in patients receiving case management compared to those without case management (81 ± 12 vs 73 ± 17, P < 0.001). CONCLUSION The dimensionality, known-group validity and reliability of the PIH scale for measuring self-management in patients with liver cirrhosis were confirmed. Its clinical predictive value requires further assessment.
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Affiliation(s)
- Jeyamani Ramachandran
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
| | - David Smith
- College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
| | - Richard Woodman
- College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
| | - Kate Muller
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Rosemary McCormick
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
| | - Alan Wigg
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public health, Flinders University, Adelaide, South Australia, Australia
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31
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Boudreault S, Chen J, Wu KY, Plüddemann A, Heneghan C. Self-management programmes for cirrhosis: A systematic review. J Clin Nurs 2020; 29:3625-3637. [PMID: 32671877 DOI: 10.1111/jocn.15416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Liver cirrhosis severely decreases patients' quality of life. Since self-management programmes have improved quality of life and reduce hospital admissions in other chronic diseases, they have been suggested to decrease liver cirrhosis burden. METHODS We performed a systematic review and meta-analysis to evaluate the clinical impact of self-management programmes in patients with liver cirrhosis, which followed the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes include health-related quality of life (HRQOL) and hospitalisation. We searched MEDLINE, CENTRAL, Embase, CINAHL, PsycINFO and two trial registers to July 2017. RESULTS We identified four randomised trials (299 patients) all rated at a high risk of bias. No difference was demonstrated for HRQOL (standardised mean difference -0.01, 95% CI: -0.48 to 0.46) and hospitalisation days (incidence rate ratio 1.6, 95% CI: 0.5-4.8). For secondary outcomes, one study found a statistically significant improvement in patient knowledge (mean difference (MD) 3.68, 95% CI: 2.11-5.25) while another study found an increase in model for end-stage liver disease scores (MD 2.8, 95% CI: 0.6-4.9) in the self-management group. No statistical difference was found for the other secondary outcomes (self-efficacy, psychological health outcomes, healthcare utilisation, mortality). Overall, the quality of the evidence was low. The content of self-management programmes varied across studies with little overlap. CONCLUSIONS The current literature indicates that there is no evidence of a benefit of self-management programmes for people with cirrhosis. RELEVANCE TO CLINICAL PRACTICE Practitioners should use self-management programmes with caution when delivering care to patients living with cirrhosis. Further research is required to determine what are the key features in a complex intervention like self-management. This review offers a preliminary framework for clinicians to develop a new self-management programme with key features of effective self-management interventions from established models.
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Affiliation(s)
- Samuel Boudreault
- Family Medicine Department, Laval University, Quebec, QC, Canada.,Laboratoire de recherche et d'innovation en médecine de première ligne (ARIMED), Saint-Charles-Borromée, QC, Canada
| | | | - Kevin Y Wu
- Faculty of Medicine, Laval University, Quebec, QC, Canada
| | - Annette Plüddemann
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
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32
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Ramachandran J, Woodman RJ, Muller KR, Wundke R, McCormick R, Kaambwa B, Wigg AJ. Validation of Knowledge Questionnaire for Patients With Liver Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:1867-1873.e1. [PMID: 31809918 DOI: 10.1016/j.cgh.2019.11.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS There is no validated questionnaire to assess disease knowledge and self-management in patients with liver cirrhosis. We developed and validated a Cirrhosis Knowledge Questionnaire (CKQ). METHODS We created a preliminary CKQ comprising 10 questions relevant to self-management of cirrhosis, based on publications and clinical experiences. The CKQ was given to a pilot sample of 17 patients with decompensated cirrhosis to assess its face validity. In consultation with experts, we developed a second version of CKQ, comprising 14 multiple choice questions, and administered it to 116 patients with cirrhosis participating in a Chronic Liver Failure Program. The dimensionality of the construct was assessed using exploratory factor analysis and internal consistency was assessed with Cronbach's alpha. Known-group validity of the resulting instrument was assessed by comparing the performance of the CKQ in 69 patients with decompensated cirrhosis (mean age, 62 ± 13 years; 109 responses), with (n = 42) vs without (n = 67) case management. RESULTS A 3-factor model with 7 questions related to variceal bleeding, ascites, and hepatic encephalopathy was considered the optimal dimensionality with excellent internal consistency (Cronbach's alpha = 0.82). The mean knowledge score was higher in patients with case management (5.6 ± 1.1) than in patients without case management (4.3 ± 2.1) (P = .002). CONCLUSIONS We developed and validated a questionnaire with 7 questions on ascites, variceal bleeding, and hepatic encephalopathy to assess knowledge and self-management in patients with liver cirrhosis. Studies are needed to confirm its dimensionality and assess association of scores with patient outcomes.
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Affiliation(s)
- Jeyamani Ramachandran
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
| | - Richard J Woodman
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Kate R Muller
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Wundke
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Rosemary McCormick
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Alan J Wigg
- Hepatology and Liver Transplant Unit, Flinders Medical Centre, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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33
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Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors. J Clin Gastroenterol 2020; 54:218-226. [PMID: 31913877 DOI: 10.1097/mcg.0000000000001313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.
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34
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Valery PC, Clark PJ, Pratt G, Bernardes CM, Hartel G, Toombs M, Irvine KM, Powell EE. Hospitalisation for cirrhosis in Australia: disparities in presentation and outcomes for Indigenous Australians. Int J Equity Health 2020; 19:27. [PMID: 32066438 PMCID: PMC7027067 DOI: 10.1186/s12939-020-1144-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/12/2020] [Indexed: 12/21/2022] Open
Abstract
Background Indigenous Australians experience greater health disadvantage and have a higher prevalence of many chronic health conditions. Liver diseases leading to cirrhosis are among the most common contributor to the mortality gap between Indigenous and other Australian adults. However, no comparative data exist assessing differences in presentation and patient outcomes between Indigenous and non-Indigenous Australians hospitalised with cirrhosis. Methods Using data from the Hospital Admitted Patient Data Collection and the Death Registry, this retrospective, population-based, cohort study including all people hospitalised for cirrhosis in the state of Queensland during 2008–2017 examined rate of readmission (Poisson regression), cumulative survival (Kaplan–Meier), and assessed the differences in survival (Multivariable Cox regression) by Indigenous status. Predictor variables included demographic, health service characteristics and clinical data. Results We studied 779 Indigenous and 10,642 non-Indigenous patients with cirrhosis. A higher proportion of Indigenous patients were younger than 50 years (346 [44%] vs. 2063 [19%] non-Indigenous patients), lived in most disadvantaged areas (395 [51%) vs. 2728 [26%]), had alcohol-related cirrhosis (547 [70%] vs. 5041 [47%]), had ascites (314 [40%] vs. 3555 [33%), and presented to hospital via the Emergency Department (510 [68%] vs. 4790 [47%]). Indigenous patients had 3.04 times the rate of non-cirrhosis readmissions (95%CI 2.98–3.10), 1.35 times the rate of cirrhosis-related readmissions (95%CI 1.29–1.41), and lower overall survival (17% vs. 27%; unadjusted hazard ratio (HR) = 1.16 95%CI 1.06–1.27), compared to non-Indigenous patients. Most of the survival deficit was explained by Emergency Department presentation (adj-HR = 1.03 95%CI 0.93–1.13), and alcohol-related aetiology (adj-HR = 1.08 95%CI 0.99–1.19). The remaining survival deficit was influenced by the other clinico-demographic and health service factors (final adj-HR = 1.08 95%CI 0.96–1.20). Conclusions There was evidence of differential presentation, higher rates of readmissions, and poorer survival for Indigenous Australians with cirrhosis, compared to other Australians. The increased prevalence of Emergency Department presentation among Indigenous patients suggests missed opportunities for early intervention to prevent progressive cirrhosis complications and hospital readmissions.
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Affiliation(s)
- Patricia C Valery
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia. .,Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Mater Hospitals, Brisbane, QLD, Australia
| | - Gregory Pratt
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Christina M Bernardes
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Maree Toombs
- Rural Clinical School, Faculty of Medicine, University of Queensland, Toowoomba, QLD, Australia
| | - Katharine M Irvine
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Mater Research, University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth E Powell
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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The Chronic Liver Disease Nurse Role in Australia: Describing 10 Years of a New Role in Cirrhosis Management. Gastroenterol Nurs 2020; 43:E9-E15. [PMID: 31904629 DOI: 10.1097/sga.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cirrhosis of the liver is increasing, with growing patient numbers in hospital outpatient departments, as well as increasing admissions due to decompensated liver disease. Decompensated cirrhosis of the liver is a common and debilitating illness causing disability, readmissions to hospital, and decreased quality of life, and can lead to liver cancer. The advent of the chronic liver disease nurse (CLDN) position in our hospital in 2009 was the first role in Australia dedicated to providing care to patients with cirrhosis. The role incorporates the care of patients with stable compensated disease, case management of patients with complications of decompensated disease, and hepatocellular carcinoma coordination. After a pilot randomized controlled trial and almost 10 years of service, this article describes the role of the CLDN and presents key performance indicators that will assist other centers considering introducing the role or elements of it into their service.
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Readmissions for Cirrhosis Within the Healthcare Readmissions Reduction Program: A Hidden Challenge. Am J Gastroenterol 2019; 114:1419-1420. [PMID: 31449155 DOI: 10.14309/ajg.0000000000000368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
With the passage of the Affordable Care Act, the Healthcare Readmissions Reduction Program (HRRP) was implemented, leading to significant reductions in readmissions for congestive heart failure, pneumonia, and myocardial infarction. Patients with cirrhosis have a complex and difficult to manage underlying disease process and are often left out of large policy decisions such as the HRRP although they represent a population at high risk for readmission and other negative outcomes. In this editorial, hospital readmissions in patients with cirrhosis are discussed in the context of the HRRP and evolving models of care.
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Abstract
INTRODUCTION Although the Hospital Readmissions Reduction Program (HRRP) has decreased readmissions in targeted conditions, outcomes in high-risk subgroups are unknown. This study analyzed the impact of cirrhosis as a comorbidity on readmissions in conditions subjected to the HRRP. METHODS Using a longitudinal analysis of the New York, Florida, and Washington State inpatient databases from 2009 to 2013, adult Medicare beneficiaries with a diagnosis-related group of targeted conditions by the HRRP-pneumonia, congestive heart failure (CHF), and myocardial infarction (MI)-were included. Exclusion criteria included inability to assess for readmission, previous liver transplant, or having a readmission not subject to penalty under the HRRP. A sensitivity analysis used the International Classification of Diseases, 9th Revision, Clinical Modification codes to identify pneumonia, CHF, and MI hospitalizations. The primary outcome was 30-day readmission, with secondary outcomes including 90-day readmission, trends, and cirrhosis-specific risk factors for readmission. RESULTS Of the 797,432 patients included, 8,964 (1.1%) had cirrhosis. Patients with cirrhosis had significantly higher 30-day readmissions overall (29.3% vs 23.8%, P < 0.001) and specifically for pneumonia and CHF, but not for MI. Thirty-day readmission rates significantly decreased in patients without cirrhosis (annual percent change -1.8%, P < 0.001), but not in patients with cirrhosis (P = 0.39). Similar findings were present for 90-day readmissions. A sensitivity analysis confirmed these findings. On multivariable analysis, cirrhosis was associated with significantly higher 30-day readmissions (odds ratio 1.13, P < 0.001). DISCUSSION When cirrhosis is comorbid in patients with conditions subjected to the HRRP, readmissions are higher and have not improved. Focused efforts are needed to improve outcomes in cirrhosis and other high-risk comorbidities within the HRRP cohort.
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Rao BB, Sobotka A, Lopez R, Romero-Marrero C, Carey W. Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients. World J Hepatol 2019; 11:646-655. [PMID: 31528247 PMCID: PMC6717714 DOI: 10.4254/wjh.v11.i8.646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/12/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intervention to improve outcomes in cirrhotic patients (CP) after hospital discharge often focus on 30 d readmission rate (RR). However, recent studies suggest dissociation between RR and survival. At our center, CP are now offered outpatient telephonic transitional care (OTTC) by a care coordinator for 30 d after hospital discharge.
AIM To determine the effect of OTTC on survival in CP.
METHODS In this cohort study from a tertiary center, CP who received OTTC formed the intervention group. They were compared with a control group discharged during the same period. Mortality and RR were compared between the groups.
RESULTS After OTTC introduction, 194 CP were discharged. After applying exclusion criteria, 169 CP (51% male, mean age 58 years ± 12 years) were included. OTTC group comprised 76 patients and was compared with 93 controls. Baseline disease and index admission related characteristics were not significantly different between the groups. The intervention group showed significantly higher 6 mo survival compared to controls (84.2% vs 68.8%; P = 0.03), while RR at 1, 3, and 6 mo were comparable. On multivariable analysis, the intervention group showed lower odds for mortality compared to the controls (hazard ratio: 0.4; 95% confidence interval: 0.2-0.82; P = 0.012), while higher model for end-stage liver disease scores were associated with higher mortality (hazard ratio: 1.05; 95% confidence interval: 1.01-1.1; P = 0.024).
CONCLUSION CP provided OTTC had higher 6 mo survival compared to controls without a difference in RR. Use of RR to gauge quality of care provided during hospitalization or subsequent transitional care programs should be revisited.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Anastasia Sobotka
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Rocio Lopez
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Carlos Romero-Marrero
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - William Carey
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
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Ramachandran J, Hossain M, Hrycek C, Tse E, Muller KR, Woodman RJ, Kaambwa B, Wigg AJ. Coordinated care for patients with cirrhosis: fewer liver-related emergency admissions and improved survival. Med J Aust 2019; 209:301-305. [PMID: 30257622 DOI: 10.5694/mja17.01164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare the incidence of liver-related emergency admissions and survival of patients after hospitalisation for decompensated cirrhosis at two major hospitals, one applying a coordinated chronic disease management model (U1), the other standard care (U2); to examine predictors of mortality for these patients. DESIGN Retrospective observational cohort study. SETTING Two major tertiary hospitals in an Australian capital city. PARTICIPANTS Patients admitted with a diagnosis of decompensated cirrhosis during October 2013 - October 2014, identified on the basis of International Classification of Diseases (ICD-10) codes. MAIN OUTCOME MEASURES Incident rates of liver-related emergency admissions; survival (to 3 years). RESULTS Sixty-nine patients from U1 and 54 from U2 were eligible for inclusion; the median follow-up time was 530 days (range, 21-1105 days). The incidence of liver-related emergency admissions was lower for U1 (mean, 1.14 admissions per person-year; 95% CI, 0.95-1.36) than for U2 (mean, 1.55 admissions per person-year; 95% CI, 1.28-1.85; adjusted incidence rate ratio [U1 v U2], 0.52; 95% CI, 0.28-0.98; P = 0.042). The adjusted probabilities of transplantation-free survival at 3 years were 67.7% (U1) and 37.2% (U2) (P = 0.009). Independent predictors of reduced transplantation-free free survival were Charlson comorbidity index score (per point: hazard ratio [HR], 1.27; 95% CI, 1.05-1.54, P = 0.014), liver-related emergency admissions within 90 days of discharge (HR, 3.60; 95% CI, 1.87-6.92; P < 0.001), and unit (U2 v U1: HR, 2.54, 95% CI, 1.26-5.09; P = 0.009). CONCLUSIONS A coordinated care model for managing patients with decompensated cirrhosis was associated with improved survival and fewer liver-related emergency admissions than standard care.
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Affiliation(s)
| | | | | | | | | | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, SA
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Aye L, Volk M. First Do No Harm: Medication-Related Problems Among Patients With Cirrhosis. Hepatol Commun 2019; 3:603-604. [PMID: 31061948 PMCID: PMC6492472 DOI: 10.1002/hep4.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/24/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- Lydia Aye
- Division of Gastroenterology and Transplantation Institute Loma Linda University Health Loma Linda CA
| | - Michael Volk
- Division of Gastroenterology and Transplantation Institute Loma Linda University Health Loma Linda CA
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Volk ML, Mellinger J, Bansal MB, Gellad ZF, McClellan M, Kanwal F. A Roadmap for Value-Based Payment Models Among Patients With Cirrhosis. Hepatology 2019; 69:1300-1305. [PMID: 30226642 DOI: 10.1002/hep.30277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023]
Abstract
Healthcare reimbursement is shifting from fee-for-service to fee-for-value. Cirrhosis, which costs the U.S. healthcare system as much as heart failure, is a prime target for value-based care. This article describes models in which physician groups or health systems are paid for improving quality and lowering costs for a given population of patients with cirrhosis. If done correctly, we believe that such frameworks, once adopted, could help reduce burnout by freeing physicians of the burden of checking boxes in the electronic medical record so that they can devote their energies to managing populations. Conclusion: Value-based payment models for cirrhosis have the potential to benefit patients, physicians, and healthcare insurers.
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Affiliation(s)
- Michael L Volk
- Division of Gastroenterology and Transplant Institute, Loma Linda University, Loma Linda, CA
| | - Jessica Mellinger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Hospital System, Ann Arbor, MI
| | - Meena B Bansal
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | | | | | - Fasiha Kanwal
- Houston VA Health Services Research Center of Excellence, Houston, TX.,Health Services Research and Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Department of Medicine, Baylor College of Medicine, Houston, TX
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Singal AG, Tiro JA, Murphy CC, Marrero JA, McCallister K, Fullington H, Mejias C, Waljee AK, Bishop WP, Santini NO, Halm EA. Mailed Outreach Invitations Significantly Improve HCC Surveillance Rates in Patients With Cirrhosis: A Randomized Clinical Trial. Hepatology 2019; 69:121-130. [PMID: 30070379 PMCID: PMC6324997 DOI: 10.1002/hep.30129] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/31/2018] [Indexed: 12/25/2022]
Abstract
Hepatocellular carcinoma (HCC) surveillance is associated with early tumor detection and improved survival in patients with cirrhosis; however, effectiveness is limited by underuse. We compared the effectiveness of mailed outreach and patient navigation strategies to increase HCC surveillance in a racially diverse cohort of patients with cirrhosis. We conducted a pragmatic randomized clinical trial comparing mailed outreach for screening ultrasound (n = 600), mailed outreach plus patient navigation (n = 600), or usual care with visit-based screening (n = 600) among 1800 patients with cirrhosis at a large safety-net health system from December 2014 to March 2017. Patients who did not respond to outreach invitations within 2 weeks received reminder telephone calls. Patient navigation included an assessment of barriers to surveillance and encouragement of surveillance participation. The primary outcome was HCC surveillance (abdominal imaging every 6 months) over an 18-month period. All 1800 patients were included in intention-to-screen analyses. HCC surveillance was performed in 23.3% of outreach/navigation patients, 17.8% of outreach-alone patients, and 7.3% of usual care patients. HCC surveillance was 16.0% (95% confidence interval [CI]: 12.0%-20.0%) and 10.5% (95% CI: 6.8%-14.2%) higher in outreach groups than usual care (P < 0.001 for both) and 5.5% (95% CI: 0.9%-10.1%) higher for outreach/navigation than outreach alone (P = 0.02). Both interventions increased HCC surveillance across predefined patient subgroups. The proportion of HCC patients detected at an early stage did not differ between groups; however, a higher proportion of patients with screen-detected HCC across groups had early-stage tumors than those with HCC detected incidentally or symptomatically (83.3% versus 30.8%, P = 0.003). Conclusion: Mailed outreach invitations and navigation significantly increased HCC surveillance versus usual care in patients with cirrhosis.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Jasmin A. Tiro
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Caitlin C. Murphy
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Jorge A. Marrero
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | | | - Hannah Fullington
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Caroline Mejias
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Wendy Pechero Bishop
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Noel O. Santini
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
| | - Ethan A. Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX
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Thomson MJ, Lok AS, Tapper EB. Optimizing medication management for patients with cirrhosis: Evidence-based strategies and their outcomes. Liver Int 2018; 38:1882-1890. [PMID: 29845749 PMCID: PMC6202194 DOI: 10.1111/liv.13892] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/22/2018] [Indexed: 12/13/2022]
Abstract
Cirrhosis is a morbid condition associated with frequent hospitalizations and high mortality. Management of cirrhosis requires complex medication regimens to treat underlying liver disease, complications of cirrhosis and comorbid conditions. This review examines the complexities of medication management in cirrhosis, barriers to optimal medication use, and potential interventions to streamline medication regimens and avoid medication errors. A literature review was performed by searching PUBMED through December 2017 and article reference lists to identify articles relevant to medication management, complications, adherence, and interventions to improve medication use in cirrhosis. The structural barriers in cirrhosis include sheer medication complexity related to the number of medications and potential for cognitive impairment in this population, faulty medication reconciliation and limited adherence. Tested interventions have included patient self-education, provider driven patient education, intensive case management including medication blister packs and smartphone applications. Initiatives are needed to improve patient, caregiver and provider education on appropriate use of medications in patients with cirrhosis. A multidisciplinary team should be established to coordinate care with close monitoring, address patient and caregiver concerns, and to provide timely access to outpatient evaluation of urgent/complex issues. Future studies evaluating the clinical outcomes and cost effectiveness of interventions are needed.
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Affiliation(s)
- Mary J Thomson
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Hospital, Ann Arbor, MI, USA
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Hjorth M, Sjöberg D, Svanberg A, Kaminsky E, Langenskiöld S, Rorsman F. Nurse-led clinic for patients with liver cirrhosis-effects on health-related quality of life: study protocol of a pragmatic multicentre randomised controlled trial. BMJ Open 2018; 8:e023064. [PMID: 30337316 PMCID: PMC6196856 DOI: 10.1136/bmjopen-2018-023064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver cirrhosis affects health-related quality of life (HRQoL) even in its early stages. Morbidity is especially high when the disease decompensates and self-care actions become essential. Nurse involvement in secondary prevention in other chronic diseases has contributed to better symptom control, less need of inpatient care and improved HRQoL. In order to evaluate the impact of nurse involvement in the follow-up of patients with liver cirrhosis, we decided to compare structured nurse-led clinics, inspired by Dorothea Orem's nursing theory and motivational strategies, with a group of patients receiving standard care. The primary outcome is HRQoL and the secondary outcomes are quality of care, visits to outpatient clinics or hospitals, disease progress and health literacy. METHODS AND ANALYSIS This is a pragmatic, multicentre randomised controlled study conducted at six Swedish hepatology departments. Eligible patients are adults with diagnosed cirrhosis of the liver (n=500). Participants are randomised into either an intervention with nurse-led follow-up group or into a standard of care group. Recruitment started in November 2016 and is expected to proceed until 2020. Primary outcomes are physical and mental HRQoL measured by RAND-36 at enrolment, after 1 and 2 years. ETHICS AND DISSEMINATION The study is ethically approved by the Regional Ethical Review Board in Uppsala. The results shall be disseminated in international conferences and peer-reviewed articles. TRIAL REGISTRATION NUMBER NCT02957253; Pre-results.
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Affiliation(s)
- Maria Hjorth
- Center of Clinical Reaerch in Dalarna, Falun, Sweden
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
| | | | - Anncarin Svanberg
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
- Dalarna University, Falun, Sweden
| | - Elenor Kaminsky
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
| | - Sophie Langenskiöld
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
| | - Fredrik Rorsman
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
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Tey KR, Mohan P, Liu X, Desai AP. Closing the Quality Chasm in Cirrhosis. Clin Liver Dis (Hoboken) 2018; 12:45-49. [PMID: 30988910 PMCID: PMC6385903 DOI: 10.1002/cld.725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/10/2018] [Accepted: 04/21/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | - Xibei Liu
- Department of MedicineUniversity of ArizonaTucsonAZ
| | - Archita P. Desai
- Division of Gastroenterology, Thomas D. Boyer Liver Research Institute, Department of MedicineUniversity of ArizonaTucsonAZ
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Orman ES, Ghabril M, Emmett TW, Chalasani N. Hospital Readmissions in Patients with Cirrhosis: A Systematic Review. J Hosp Med 2018; 13:490-495. [PMID: 29694458 PMCID: PMC6202277 DOI: 10.12788/jhm.2967] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/29/2018] [Accepted: 02/09/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hospital readmission is a significant problem for patients with complex chronic illnesses such as liver cirrhosis. PURPOSE We aimed to describe the range of readmission risk in patients with cirrhosis and the impact of the model for end-stage liver disease (MELD) score. DATA SOURCES We conducted a systematic review of studies identified in Ovid MEDLINE, PubMed, EMBASE, CINAHL, the Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov from 2000 to May 2017. STUDY SELECTION We examined studies that reported early readmissions (up to 90 days) in patients with cirrhosis. Studies were excluded if they did not examine the association between readmission and at least 1 variable or intervention. DATA EXTRACTION Two reviewers independently extracted data on study design, setting, population, interventions, comparisons, and detailed information on readmissions. DATA SYNTHESIS Of the 1363 records reviewed, 26 studies met the inclusion and exclusion criteria. Of these studies, 21 were retrospective, and there was significant variation in the inclusion and exclusion criteria. The pooled estimate of 30-day readmissions was 26%(95% confidence interval [CI], 22%-30%). Few studies examined readmission preventability or the relationship between readmissions and social determinants of health. Reasons for readmission were highly variable. An increased MELD score was associated with readmissions in most studies. Readmission was associated with increased mortality. CONCLUSION Hospital readmissions frequently occur in patients with cirrhosis and are associated with liver disease severity. The impact of functional and social factors on readmissions is unclear.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
- Address for correspondence: Eric S. Orman, MD, MSCR, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202; Telephone: (317) 278-1630; Fax: (317) 278-6870;
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas W. Emmett
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
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Quality measurement and improvement in liver transplantation. J Hepatol 2018; 68:1300-1310. [PMID: 29559346 DOI: 10.1016/j.jhep.2018.02.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
Abstract
There is growing interest in the quality of health care delivery in liver transplantation. Multiple stakeholders, including patients, transplant providers and their hospitals, payers, and regulatory bodies have an interest in measuring and monitoring quality in the liver transplant process, and understanding differences in quality across centres. This article aims to provide an overview of quality measurement and regulatory issues in liver transplantation performed within the United States. We review how broader definitions of health care quality should be applied to liver transplant care models. We outline the status quo including the current regulatory agencies, public reporting mechanisms, and requirements around quality assurance and performance improvement (QAPI) activities. Additionally, we further discuss unintended consequences and opportunities for growth in quality measurement. Quality measurement and the integration of quality improvement strategies into liver transplant programmes hold significant promise, but multiple challenges to successful implementation must be addressed to optimise value.
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Wigg AJ, Chin JK, Muller KR, Ramachandran J, Woodman RJ, Kaambwa B. Cost-effectiveness of a chronic disease management model for cirrhosis: Analysis of a randomized controlled trial. J Gastroenterol Hepatol 2018; 33:1634-1640. [PMID: 29462834 DOI: 10.1111/jgh.14127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/26/2018] [Accepted: 02/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS In this follow-up study to a randomized controlled trial of a chronic disease management (CDM) model in cirrhosis, our aim was to assess the relative cost-effectiveness of this model compared with usual care during the 12-month study period, using incremental costs per death avoided as the primary outcome. METHODS Mean differences in hospitalization costs, deaths avoided, and change in Chronic Liver Disease Questionnaire (CLDQ) total scores were presented with 95% non-parametric bootstrapped confidence intervals. Results were also presented using a cost-effectiveness plane (CEP) and cost-effectiveness acceptability curve. RESULTS The CDM intervention was more expensive, by 18 521 AUD per participant, but more effective (% of deaths at 12 months: 10% vs 15% and 0.67 units increase per patient in CLDQ total scores). The resultant incremental cost-effectiveness ratios were 370 425 AUD per death avoided (95% confidence interval: -14 564 AUD to 2 059 373 AUD) and 27 547 AUD per unit improvement in the CLDQ total score (95% CI: 7455 AUD to 143 874 AUD). The CEPs demonstrated some uncertainty around cost-effectiveness. The cost-effectiveness acceptability curves demonstrated that at willingness to pay values of 400 000 AUD per additional death avoided and 40 000 AUD per unit improvement in the CLDQ, there was at least a 70% probability of CDM being more cost-effective than usual care. At 24 months, CDM was much more effective (12% less deaths but now also cheaper by 985 AUD per patient). CONCLUSIONS The analysis of data from a randomized controlled trial suggests that the CDM intervention used is likely to be cost-effective, relative to usual care, due to fewer patient deaths.
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Affiliation(s)
- Alan J Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Jong K Chin
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kate R Muller
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Richard J Woodman
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- Health Economics Unit, School of Medicine, Flinders University, Adelaide, South Australia, Australia
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Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England. Lancet Gastroenterol Hepatol 2018; 3:95-103. [DOI: 10.1016/s2468-1253(17)30362-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 01/02/2023]
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