Improved models of care for decompensated liver disease may benefit patients but still remain a significant challenge and are falling behind other chronic disease management approaches in non-liver settings, Australian researchers say.
Led by Professor Alan Wigg from Flinders Medical Centre, Adelaide, the researchers said the number of chronic liver failure cases at South Australia’s public hospitals had increased more than three-fold in the past decade, while obesity-related liver disease was expected to become a modern epidemic by 2050.
Nationally, more than 7000 deaths related to chronic liver failure occur each year.
To investigate possible care models, they conducted a randomised controlled trial (RCT) involving five Australian tertiary care hospitals across three states, which represented one of the first investigator-initiated multicentre RCTs in Australian hepatology.
The researchers assessed the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions over two years, such as ascites and peripheral oedema, encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, alcohol misuse/hepatitis, progressive jaundice, diuretic-related complications or acute renal injury due to hepatorenal syndrome.
Secondary aims included assessments of quality-of-care and patient-reported outcomes.
Some 146 participants, mostly male and caucasian, were recruited (75 in the intervention and 71 in the usual care group) with a median model for end-stage liver disease (MELD) score of 19.
Cirrhosis was attributed to alcohol in more than two-thirds of patients, and ascites was the most frequent presenting complication, occurring in about 40% of patients at baseline.
The intervention included case management and care coordination by hepatology nurses using individualised, protocol-driven care plans, initial home visit and regular phone contact, rapid access to care pathways via direct telephone number of hepatology nurse and appointment reminders.
Findings published in Hepatology [link here] showed that the liver-related emergency admissions rate was not significantly improved, with a nonsignificant 11% reduction in rate in the intervention group (IRR 0.89), nor was there any improvement in patient survival (HR 1.14) between the liver nurse-coordinated CDM model and usual care.
However, there were some clinically important benefits including reduced emergency admissions due to hepatic encephalopathy – one of the most frequent, preventable and expensive causes for admission in patients with the condition – in the intervention group compared to the control group (HR 1.87).
“The mechanism of this intervention benefit is likely related to improved medication adherence and the management of participants with known encephalopathy, mediated by medication adherence aids (blister packs) and frequent nurse monitoring. Improved detection and early management of new-onset encephalopathy are other potential mechanisms,” the authors wrote.
Improvements in quality of care for performance of bone density, vitamin D testing and HCC surveillance adherence were also demonstrated. Quality of life was improved in the intervention group at three months, although differences relative to the control group were not significant.
“Chronic disease management approaches appear to be a logical, evidence-based strategy and have been successfully applied in many non-liver settings. We believe that CDM models for decompressed cirrhosis have great potential towards an improved standard of care in hepatology,” Professor Wigg said in a statement.
“However, we also need to accept that CDM models in decompensated cirrhosis may not be as effective as CDM in other chronic diseases due to the more complex and severe nature of this liver disorder.”
The researchers also identified shortcomings in the care of decompensated cirrhosis. While alcohol-related cirrhosis was the major cause of decompensated cirrhosis in about 70% of participants in the study, access for them to obtain high-quality alcohol addiction, mental health and supportive care services was limited.
A lack of trained liver disease management nurses was also identified, with the few available being employed part-time and required to manage up to 22 patients.