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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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Meinders AM, Hobeika MJ. Starting the conversation about value in liver transplantation: Invited Commentary on "Is there value in volume? An assessment of liver transplant practices in the United States since the inception of MELD". Surgery 2022; 172:1263-1264. [PMID: 35842312 DOI: 10.1016/j.surg.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Andrea M Meinders
- Department of Surgery, J.C. Walter Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, TX. https://twitter.com/ameinders4
| | - Mark J Hobeika
- Department of Surgery, J.C. Walter Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, TX; Department of Surgery, Weill Cornell Medical College, New York, NY.
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Patel AA, Woodrell C, Ufere NN, Hansen L, Tandon P, Verma M, Lai J, Pinotti R, Rakoski M. Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach. Hepatol Commun 2021; 5:1469-1480. [PMID: 34510839 PMCID: PMC8435283 DOI: 10.1002/hep4.1743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/28/2021] [Accepted: 04/19/2021] [Indexed: 02/04/2023] Open
Abstract
Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions.
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Affiliation(s)
- Arpan A. Patel
- Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCAUSA
- Veterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- James J. Peters Veterans Affairs Medical CenterBronxNYUSA
| | - Nneka N. Ufere
- Gastrointestinal UnitDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Lissi Hansen
- School of NursingOregon Health Sciences UniversityPortlandORUSA
| | - Puneeta Tandon
- Department of MedicineCirrhosis Care ClinicEdmontonALCanada
- Liver Transplant UnitUniversity of AlbertaEdmontonALCanada
| | - Manisha Verma
- Department of Digestive Diseases and TransplantationEinstein Healthcare NetworkPhiladelphiaPAUSA
| | - Jennifer Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Rachel Pinotti
- Gustave L. and Janet W. Levy LibraryIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Mina Rakoski
- Division of Gastroenterology and HepatologyLoma Linda University HealthLoma LindaCAUSA
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