Telemedicine in Hepatology: Current Applications and Future Directions

Decreased Completion of Ordered Laboratories and Imaging in Telehealth Compared With In-person Hepatology Encounters

OBJECTIVE

To evaluate order completion after telehealth compared with in-person encounters.

BACKGROUND

Completion of ordered testing, including laboratories and imaging, is an important aspect of successful outpatient care of patients with liver disease. Whether the completion of orders from telehealth encounters differs from in-person visits is unknown.

MATERIALS AND METHODS

Completion of ordered laboratories and imaging from hepatology encounters at our center from 2021 to 2022 were evaluated and compared between video telehealth and in-person visits. Laboratory completion was evaluated at 14 days, 30 days, and 90 days, and imaging completion was assessed at 1 year.

RESULTS

Telehealth encounters were significantly less likely to have laboratories completed at all evaluated time points (14 d: 40.7% vs 90.9%; 30 d: 50.9% vs 92.2%; 90 d: 63.9% vs 94.3%, P< 0.001 for all). Among telehealth encounters, encounters in patients more remote from the center were less likely to have laboratories completed. Imaging ordered at telehealth encounters was also less likely to be completed within 1 year (62.5% vs 70.1%, P< 0.001), including liver ultrasounds (59.1% vs 67.6%, P= 0.001), which persisted when limited to encounters for cirrhosis (55.8% vs 66.4%, P= 0.01).

CONCLUSIONS

Telehealth encounters were significantly less likely to have ordered laboratories and imaging completed compared with in-person visits, which has important clinical implications for effective outpatient care of patients with liver disease. Further research is needed to better understand the barriers to order completion for telehealth visits and ways to optimize this to improve the effectiveness of this visit modality.

Review article: Telecare in gastroenterology-Within the COVID-19 pandemic and beyond

BACKGROUND

Telehealth is a growing model of care, greatly accelerated with the demands of the COVID-19 pandemic. Telecare is a synchronous audio-visual or audio-only format of health delivery.

AIMS

To evaluate the existing literature on telecare within adult gastroenterology subspecialties to determine if outcomes are comparable to traditional in-person consultations and to highlight the Pokapū Network, a local initiative in the Lakes Region of New Zealand, amongst these international findings.

METHODS

We completed an OVID MEDLINE search using the terms gastroenterology, endoscopy, digestive system, inflammatory bowel disease, functional, hepatology, liver, telemedicine, telehealth, videoconferencing, remote consultation, video clinic and telephone clinic.

RESULTS

Patients showed positive attitudes towards telecare and, in several reports, would elect to have telecare consults in the future. Telecare reduces travel time and out-of-pocket costs for patients and the need for patients to take time off work. Generally, patients engaging with telecare show equivalent health outcomes to patients engaging with traditional models of care. Patients from ethnic minority groups or lower socio-economic backgrounds, or who are older, are less likely to complete a 'successful' telecare consult.

CONCLUSION

Telecare is a useful model of care to allow gastroenterology centres to function within the context of COVID-19 isolation and beyond. It has significant benefits for patients who face geographical and financial barriers to accessing healthcare. Telecare models such as the Pokapū Network hold promise in reducing inequities for gastroenterology patients. Such models must be introduced with consideration of digital disparities that exist amongst patients to avoid worsening the digital divide.

Telemonitoring of the Continuum of Care of Hepatitis C During the COVID-19 Pandemic in Brazil

Introduction: To accomplish elimination of hepatitis C virus (HCV) by 2030, as proposed by the World Health Organization, the Brazilian Ministry of Health outlined the Hepatitis C Elimination Plan, which provides coverage of all critical steps in the continuum of care (CoC) of hepatitis C. As expected, the advent of COVID-19 pandemic has disrupted the CoC of hepatitis C worldwide. The Brazilian Liver Institute launched a remote patient monitoring (RPM) program to assist the general population at risk in HCV testing and to provide linkage and retention to care for HCV-positive subjects. The RPM program was also designed to relink HCV-positive patients lost to follow-up during the COVID-19 pandemic due to their limited access to the health care system. Methods: The HCV telemonitoring number was highly advertised in Brazilian media. The RPM program was conducted by dedicated health care personnel trained to follow a predefined script designed to provide awareness, ensure consistent information for educational purposes, and recruit eligible participants to be tested for HCV. Results: From August 2020 to December 2021, 3,738 subjects entered in contact with RPM. There were 26,884 interactions (mean 7.2 interactions per participant), mostly by WhatsApp (78%). Twenty out of those 221 subjects (9%) who tested were HCV positive. Those subjects altogether with 128 other patients with HCV, tested elsewhere, were followed in the HCV CoC. Up to now, 94% of them were linked to care, 24% are undergoing treatment and 8% achieved sustained virological response (SVR). Conclusions: Our preliminary results showed that HCV CoC telemonitoring was a feasible and useful strategy to follow HCV at-risk subjects through all cascade of care until SVR during the COVID-19 health care disruption. It could be used beyond the defervescence of SARS-CoV-2 pandemic to ensure linkage to care of those HCV-positive patients.

Noninvasive transcutaneous bilirubin measurement in adults using skin diffuse reflectance

Accurate measurement of bilirubin concentration in adults is crucial for the diagnosis and management of liver and biliary tract diseases. Traditional methods relying on central laboratory testing pose challenges such as invasiveness, patient discomfort, and time consumption. Non-invasive alternatives have been explored, but their applicability to adult populations remains uncertain. This study aimed to develop and validate a portable non-invasive optical system based on spatially resolved diffuse reflectance spectroscopy (DRS) specifically tailored for adult transcutaneous bilirubin measurement. Forty-two adult patients with various underlying conditions were included in the study. Comparisons between transcutaneous bilirubin values measured by the DRS system and total serum bilirubin concentrations obtained through blood tests revealed strong correlations, particularly at the neck (r = 0.872) and the medial side of the right upper arm (r = 0.940). Bland-Altman analyses demonstrated substantial agreement between the transcutaneous bilirubin values and total serum bilirubin concentrations. The results highlight the potential of the non-invasive DRS system as a convenient and reliable tool for monitoring bilirubin values in adults.

Barriers that prevent adults living with HBV infection from participating in clinical research: experience from South Africa

High profile international goals have been set for the elimination of hepatitis B virus (HBV) infection as a public health threat by the year 2030. Developing and expanding equitable, accessible translational HBV research programmes that represent real-world populations are therefore an urgent priority for clinical and academic communities. We present experiences and insights by an expert interdisciplinary group focusing on barriers that impede adults living with HBV infection from participating in clinical studies. Our viewpoint describes barriers we have identified through working in a variety of settings across South Africa, including lack of education and awareness, experiences of stigma and discrimination, challenges for governance and data management, and a burden of complex morbidity. Through identifying these challenges, we propose solutions and interventions, highlight new approaches, and provide a framework for future research.

Challenges in liver transplantation in the context of a major pandemic

Coronavirus disease-2019 (COVID-19) has led to a temporary suspension of liver transplant activity across the world and the remodeling of care for patients on the waiting list and transplant recipients with the increasing use of remote consultations. Emerging evidence shows that patients with more advanced liver disease are at increased risk of severe COVID-19 and death, whereas transplant recipients have similar risk with the general population which is mainly driven by age and metabolic comorbidities. Tacrolimus immunosuppression might have a protective role in the post-transplant population. Vaccines that have become rapidly available seem to be safe in liver patients, but the antibody response in transplant patients is likely suboptimal. Most transplant centers were gradually able to resume activity soon after the onset of the pandemic and after modifying their pathways to optimize safety for patients and workforce. Preliminary evidence regarding utilizing grafts from positive donors and/or transplanting recently recovered or infected recipients under certain circumstances is encouraging and may allow offering life-saving transplant to patients at the greatest need. This review summarizes the currently available data on liver transplantation in the context of a major pandemic and discusses areas of uncertainty and future challenges. Lessons learnt from the COVID-19 pandemic might provide invaluable guidance for future pandemics.

A historical review of jaundice: May the golden oriole live forever

Content available: Audio Recording.

Current Applications of Telemedicine in Gastroenterology

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures.