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Ufere NN. Increasing Healthcare System Empathy for Patients with Advanced Liver Disease: My Top 10 Lessons in Palliative Hepatology. Dig Dis Sci 2024; 69:1929-1933. [PMID: 38704486 DOI: 10.1007/s10620-024-08406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Nneka N Ufere
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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2
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Kalo E, Baig A, Gregg E, George J, Read S, Ma WS, Ahlenstiel G. A novel, nurse-led 'one stop' clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival. BMC Gastroenterol 2023; 23:356. [PMID: 37845625 PMCID: PMC10578021 DOI: 10.1186/s12876-023-02986-y] [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: 07/10/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE Delivering effective secondary preventive and integrated care has the potential to break the revolving-door phenomenon of frequent readmissions in patients with advanced chronic liver disease. To address this, we launched the Care Coordination of Liver Disease (CCoLD) pilot, a novel nurse-led cirrhosis clinic in Western Sydney. METHODS AND ANALYSIS Following an index presentation to Blacktown or Mount Druitt hospitals (BMDH), patients (n = 89, matched by age, sex, and MELD-NA) were consecutively either followed up by the CCoLD clinical nurse consultant (intervention cohort) or received standard care (control cohort). Controlled evaluation of the impact of the nurse-led clinic was carried out for a 3-month period including readmission rates, survival, and cost effectiveness. RESULTS The inaugural nurse-led clinic led to improvement in patient-level outcomes including a reduction in unplanned liver-related readmissions (2.08% for intervention cohort vs 12.2% for control cohort, p < 0.01), and mortality at 30 days (0% for intervention cohort vs 7.3% for control cohort, p = 0.03). Similar trends were observed at 90 days from index discharge. No deaths were observed in the intervention cohort as compared to the control cohort at 90 days (0% versus 7.3%, p = 0.03), while unplanned liver-related readmissions were 10.41% for the intervention cohort vs 19.5% for the control cohort (p = 0.115). Moreover, time to readmission was significantly longer in the intervention cohort, resulting in an overall cost-effective intervention. CONCLUSION These findings highlight the significant impact of optimised care-coordination. A nurse-led clinic can deliver patient-centred, goal-directed, and cost-effective secondary prevention and care. A multicentre randomised trial for wider evaluation of these findings is warranted.
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Affiliation(s)
- Eric Kalo
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Asma Baig
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Emily Gregg
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Jacob George
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
- Westmead Hospital, Western Sydney Local Health District, Westmead, NSW, 2145, Australia
| | - Scott Read
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
| | - Wai-See Ma
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Golo Ahlenstiel
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia.
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia.
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia.
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3
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Tapper EB, Saleh ZM, Lizza S, Chen X, Nikirk S, Serper M. CAREGIVER Randomized Trial of Two Mindfulness Methods to Improve the Burden and Distress of Caring for Persons with Cirrhosis. Dig Dis Sci 2023; 68:3625-3633. [PMID: 37498415 PMCID: PMC10833499 DOI: 10.1007/s10620-023-08042-9] [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: 02/10/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Patient caregivers experience burden and distress that negatively impacts health-related quality of life (HRQOL). Mindfulness may alleviate caregiver burden but randomized trials of mindfulness activities on caregiver burden and distress are lacking. METHODS Caregivers for patients with advanced liver disease were recruited from the Universities of Michigan and Pennsylvania (12/2019-12/2021) and followed for 8 weeks. Participants were randomized 1:1:1 to: written emotional disclosure for 4 weeks, resilience training for 4 weeks, or control (no active intervention). All completed assessments at baseline, week 4 and 8. The primary outcome was change in the Zarit Caregiver Burden Index-12 (ZBI) at week 8. Secondary outcomes included changes at week 4 and 8 in the ZBI, distress thermometer (DT), HRQOL visual analog scale (VAS), and caregiver captivity index (CCI). RESULTS Eighty seven caregivers were enrolled, 59(72%) completed the study. In unadjusted analyses at week 4, the burden measured by ZBI was not significantly different between arms, increasing by 0.6 ± 5.7 and 2.5 ± 5.2 points, for the written emotional disclosure and resilience training study arms, respectively, and by 2.9 ± 6.1 points in the control arm. At week 8, the non-significant ZBI change was - 1.0 ± 8.9, 2.8 ± 6.1, and 1.5 ± 7.4 for written emotional disclosure, resilience training, at week 8, respectively. The DT and VAS worsened in all arms, however, it worsened the least in the written emotional disclosure arm. In analyses adjusted for differences in baseline characteristics, the ZBI declined by - 4.21 ± 2.03(p = 0.04) in the emotional disclosure arm at week 4. This decrease was attenuated week 8, - 1.13 ± 2.6(p = 0.67). There were no significant differences in secondary outcomes save for resilience training reducing the CCI at week 4 by 1.36 ± 0.67(p = 0.04). CONCLUSION Written emotional disclosure may reduce caregiver burden in the short term among caregivers for patients with cirrhosis. REGISTRATION NCT04205396.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
- 3912 Taubman, SPC 5362, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Zachary M Saleh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Sofia Lizza
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Xi Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Nikirk
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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4
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Ismond KP, Spiers JA, Tandon P. Identifying opportunities for hepatic encephalopathy self-management: A mixed methods systematic review and synthesis. CANADIAN LIVER JOURNAL 2023; 6:215-233. [PMID: 37503524 PMCID: PMC10370725 DOI: 10.3138/canlivj-2022-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/20/2022] [Indexed: 07/29/2023]
Abstract
Background Hepatic encephalopathy (HE) in cirrhosis is an extremely challenging complication for patients and care partners. To identify potentially modifiable factors to enhance HE self-management strategies, we conducted a synthesis of quantitative and qualitative research about real-world HE behaviours, knowledge, and experiences. Methods Using the EPPI-Centre's mixed methods synthesis procedure, a systematic literature search in five databases was completed; methods of selected articles underwent critical appraisal followed by descriptive analysis and coded line-by-line of content. Through refutational translation, the findings from the quantitative and qualitative syntheses were juxtaposed to highlight congruencies, incongruencies, or gaps. These findings informed generation of cross-analytical themes that were transformed into action statements. Results The quantitative narrative review of synthesis (n = 17) generated four themes (patients had low awareness of HE and low treatment adherence rates, physicians had a non-uniform approach to non-pharmaceutical therapies). Meta-aggregation of qualitative data from six articles yielded three themes (patients and care partners had low levels of HE awareness, were unfamiliar with HE self-management, and were adherent to treatments). Comparison of findings revealed three congruencies, two gaps, and one incongruency. The combined synthesis yielded two self-management themes: universal patient-oriented cirrhosis HE education and ensuring each health care encounter systematically addresses HE to guarantee health care is continuously modified to meet their needs. Conclusions By drawing on elements of Bloom's Taxonomy and distributed knowledge networks, deliberate patient-oriented HE messaging at all health care encounters is greatly needed to improve health outcomes and reduce care burdens related to HE.
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Affiliation(s)
- Kathleen P Ismond
- Division of Gastroenterology, Liver Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jude A Spiers
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Liver Unit, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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5
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Pompili E, Baldassarre M, Zaccherini G, Tufoni M, Iannone G, Pratelli D, Palmese F, Vizioli L, Faggiano C, Bedogni G, Domenicali M, Caraceni P. Low haemoglobin level predicts early hospital readmission in patients with cirrhosis and acute decompensation. JHEP Rep 2023; 5:100698. [PMID: 37025944 PMCID: PMC10070139 DOI: 10.1016/j.jhepr.2023.100698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background & Aims Patients with decompensated cirrhosis present frequent hospitalisations with a relevant clinical and socio-economic impact. This study aims to characterise unscheduled readmissions up to 1-year follow-up and identify predictors of 30-day readmission after an index hospitalisation for acute decompensation (AD). Methods We performed a secondary analysis of a prospectively collected cohort of patients admitted for AD. Laboratory and clinical data at admission and at discharge were collected. Timing and causes of unscheduled readmissions and mortality were recorded up to 1 year. Results A total of 329 patients with AD were included in the analysis. Acute-on-chronic liver failure was diagnosed in 19% of patients at admission or developed in an additional 9% of patients during the index hospitalisation. During the 1-year follow-up, 182 patients (55%) were rehospitalised and 98 (30%) more than once. The most frequent causes of readmission were hepatic encephalopathy (36%), ascites (22%), and infection (21%). Cumulative incidence of readmission was 20% at 30 days, 39% at 90 days, and 63% at 1 year. Fifty-four patients were readmitted for emergent liver-related causes within 30 days. Early readmission was associated with a higher 1-year mortality (47 vs. 32%, p = 0.037). Multivariable Cox regression analysis showed that haemoglobin (Hb) ≤8.7 g/dl (hazard ratio 2.63 [95% CI 1.38-5.02], p = 0.003) and model for end-stage liver disease-sodium score (MELD-Na) >16 at discharge (hazard ratio 2.23 [95% CI 1.27-3.93], p = 0.005), were independent predictors of early readmission. In patients with MELD-Na >16 at discharge, the presence of Hb ≤8.7 g/dl doubles the risk of early rehospitalisation (44% vs. 22%, p = 0.02). Conclusion Besides MELD-Na, a low Hb level (Hb ≤8.7 g/dl) at discharge emerged as a new risk factor for early readmission, contributing to identification of patients who require closer surveillance after discharge. Impact and Implications Patients with decompensated cirrhosis face frequent hospitalisations. In the present study, type and causes of readmissions were analysed during 1-year follow-up in patients discharged after the index hospitalisation for an acute decompensation of the disease. Early (30-day) liver-related readmission was associated with higher 1-year mortality. The model for end-stage liver disease-sodium score and low haemoglobin at discharge were identified as independent risk factors for early readmissions. Haemoglobin emerged as a new easy-to-use parameter associated with early readmission warranting further investigation.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Centre for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Manuel Tufoni
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Dario Pratelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Francesco Palmese
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Luca Vizioli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Chiara Faggiano
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Bedogni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit addressed to Frailty and Aging, “Santa Maria delle Croci” Ravenna Hospital, AUSL Romagna, Ravenna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Department of Primary Health Care, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Corresponding authors. Addresses: Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. Tel.: +39-051-214-2919; fax: +39-051-214-2930.
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6
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Brown C, Aksan N, Muir AJ. Consider hospice in end-stage liver disease prognostic scale to open discussions regarding six-month mortality. JGH Open 2023; 7:278-285. [PMID: 37125249 PMCID: PMC10134759 DOI: 10.1002/jgh3.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/29/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Background and Aim Hospice is underutilized in the management of patients with end-stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6-month mortality to more comprehensively facilitate hospice referral. Methods Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end-stage liver disease prognostic scale (HELP) scale (70% sample, N = 13 516) followed with replication in a 30% (N = 5792) internal validation sample. Results Only the predictor groups of Complexities and Laboratory studies met the c-statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale = (functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × -3) + (albumin × -3) + (MELD-Na ≥ 21 × 20). HELP scale had a strong predictive value for six-month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample. Conclusion HELP scale is a novel prognostic score utilizing the strength of model of end-stage liver disease-sodium (MELD-Na), along with clinical factors, for a more nuanced assessment of six-month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.
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Affiliation(s)
- Cristal Brown
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Nazan Aksan
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Andrew Joseph Muir
- Duke University School of MedicineDuke Clinical Research InstituteDurhamNorth CarolinaUSA
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7
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Abasseri M, Hoque S, Slavica Kochovska BA, Caldwell K, Sheahan L, Zekry A. Barriers to palliative care in hepatocellular carcinoma: A review of the literature. J Gastroenterol Hepatol 2023. [PMID: 36634200 DOI: 10.1111/jgh.16107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023]
Abstract
Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.
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Affiliation(s)
- Mostafa Abasseri
- School of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Shakira Hoque
- Gastroenterology and Hepatology Department, St George Hospital, Sydney, New South Wales, Australia
| | - B A Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia.,IMPACCT, Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Kim Caldwell
- Palliative Medicine, Calvary Hospital Kogarah, Kogarah, New South Wales, Australia
| | - Linda Sheahan
- Clinical Ethics Service, South Eastern Sydney Local Health District, Randwick, New South Wales, Australia.,Sydney Health Ethics, The University of Sydney, Camperdown, New South Wales, Australia.,UNSW Medicine & Health, St George and Sutherland Clinical Campus.,Palliative Medicine Department, St George Hospital, Sydney, New South Wales, Australia
| | - Amany Zekry
- School of Medicine and Health, UNSW, Sydney, New South Wales, Australia.,Gastroenterology and Hepatology Department, St George Hospital, Sydney, New South Wales, Australia.,UNSW Medicine & Health, St George and Sutherland Clinical Campus
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8
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Ufere NN, Satapathy N, Philpotts L, Lai JC, Serper M. Financial burden in adults with chronic liver disease: A scoping review. Liver Transpl 2022; 28:1920-1935. [PMID: 35644920 PMCID: PMC9669101 DOI: 10.1002/lt.26514] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/21/2022] [Accepted: 05/04/2022] [Indexed: 01/19/2023]
Abstract
The economic burden of chronic liver disease is rising; however, the financial impact of chronic liver disease on patients and families has been underexplored. We performed a scoping review to identify studies examining financial burden (patient/family health care expenditures), financial distress (material, behavioral, and psychological consequences of financial burden), and financial toxicity (adverse health outcomes of financial distress) experienced by patients with chronic liver disease and their families. We searched MEDLINE, Embase, Cochrane Library, and the Web of Science online databases for articles published since the introduction of the Model for End-Stage Liver Disease score for liver transplantation allocation in February 2002 until July 2021. Final searches were conducted between June and July 2021. Studies were included if they examined the prevalence or impact of financial burden or distress among patients with chronic liver disease and/or their caregivers. A total of 19 observational studies met inclusion criteria involving 24,549 patients and 276 caregivers across 5 countries. High rates of financial burden and distress were reported within the study populations, particularly among patients with hepatic encephalopathy, hepatocellular carcinoma, and liver transplantation recipients. Financial burden and distress were associated with increased pre- and posttransplantation health care utilization and poor health-related quality of life as well as caregiver burden, depression, and anxiety. None of the included studies evaluated interventions to alleviate financial burden and distress. Observational evidence supports the finding that financial burden and distress are underrecognized but highly prevalent among patients with chronic liver disease and their caregivers and are associated with poor health outcomes. There is a critical need for interventions to mitigate financial burden and distress and reduce financial toxicity in chronic liver disease care.
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Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Lisa Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine
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9
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Saleh ZM, Salim NE, Nikirk S, Serper M, Tapper EB. The emotional burden of caregiving for patients with cirrhosis. Hepatol Commun 2022; 6:2827-2835. [PMID: 35791893 PMCID: PMC9512483 DOI: 10.1002/hep4.2030] [Citation(s) in RCA: 4] [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: 03/31/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 12/17/2022] Open
Abstract
Caregivers for patients with cirrhosis face immense physical and psychological strain that negatively impact quality of life and ability to care for oneself. The aim is to explore the caregiver experience for patients with cirrhosis, identify prominent stressors, and understand the multidimensional contributors to caregiver burden, to help tailor effective interventions. The caregivers of 25 patients with decompensated cirrhosis underwent semistructured in‐person interviews and completed written exercises targeting emotional disclosure or resilience training that were analyzed for dominant emotions and themes. Burden was quantified using the Zarit Burden Interview‐12 (ZBI, range 0–48), Distress Thermometer (0–10), and Caregiver Captivity Index (0–4). Quality of life was assessed with a visual analog scale (0–100). Median ZBI was moderate (14 [10–19]), as was distress (5 [2–7]), and captivity (2 [1–4]). Quality of life was fair (80 [70–85]). Dominant emotions included anxiety, guilt, fear, frustration, captivity, and resentment. Prominent themes included lack of time for self‐care, hierarchy of caregiver role, support from versus frustration with medical professionals, social support, spirituality and religion, and disease‐related restrictions. Hepatic encephalopathy, and need to follow strict nutrition and diet recommendations, are frequent sources of disease‐related caregiver burden. The health care system confers some degree of burden, especially when doubts arise regarding physician competence. Conclusion: Caregiver burden is significant. The impact of interventions to alleviate caregiver burden should be explored, so that their appreciated efforts do not have such detrimental effects on their quality of life.
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Affiliation(s)
- Zachary M. Saleh
- Department of Internal Medicine University of Michigan Health System Ann Arbor Michigan USA
| | - Najat E. Salim
- Division of Gastroenterology and Hepatology University of Michigan Ann Arbor Michigan USA
| | - Samantha Nikirk
- Division of Gastroenterology and Hepatology University of Michigan Ann Arbor Michigan USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology University of Michigan Ann Arbor Michigan USA
- Gastroenterology Section VA Ann Arbor Healthcare System Ann Arbor Michigan USA
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10
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Ufere NN, Hinson J, Finnigan S, Powell EE, Donlan J, Martin C, Clark P, Valery PC. The Impact of Social Workers in Cirrhosis Care: a Systematic Review. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:160-176. [PMID: 35676928 PMCID: PMC9167183 DOI: 10.1007/s11938-022-00381-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 01/23/2023]
Abstract
Purpose of review To report social workers' involvement in supporting patients with cirrhosis. Recent findings Six intervention studies (three published in the past 3 years) highlighed the potential role of social worker-led interventions to improve the outcomes of patients with cirrhosis. In studies of patients with alcohol-related liver disease (n = 4), social workers conducted psychosocial assessments, screened for substance use disorder and psychological distress, coordinated referrals to addiction services, and provided relapse prevention therapy. In studies including transplant recipients or candidates (n = 2), social workers focused on psychosocial interventions. In two studies (n = 1 patient with alcohol-related liver disease; n = 1 transplant recipients), social workers provided practical support (e.g., housing, transportation). Most articles provided limited information about the intervention and the role of the social worker, making comparisons of the studies difficult. Summary More high-quality evidence is needed to formally assess the impact of social workers in improving the outcomes of patients with cirrhosis. Supplementary Information The online version contains supplementary material available at 10.1007/s11938-022-00381-2.
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Affiliation(s)
- Nneka N Ufere
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - Jan Hinson
- Faculty of Health Sciences, School of Allied Health, Social Work Discipline, Australian Catholic University, Brisbane Campus (McAuley), 1100 Nudgee Road, Banyo, QLD 4014 Australia
| | - Simon Finnigan
- Centre for Functioning and Health Research, Metro South Health, Level 3, Buranda Village, Buranda, QLD 4102 Australia.,Department of Social Work, Princess Alexandra Hospital, 199 Ipswish Road, Woolloongabba, QLD 4102 Australia.,UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029 Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, 199 Ipswish Road, Woolloongabba, QLD 4102 Australia
| | - John Donlan
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA
| | - Cathy Martin
- Queensland Liver Transplant Service, Princess Alexandra Hospital, 199 Ipswish Road, Woolloongabba, QLD 4102 Australia
| | - Phil Clark
- Faculty of Health Sciences, School of Allied Health, Social Work Discipline, Australian Catholic University, Brisbane Campus (McAuley), 1100 Nudgee Road, Banyo, QLD 4014 Australia
| | - Patricia C Valery
- Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD 4006 Australia
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11
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Freitas RD, Oliveira LCD, Mendes GLQ, Lima FLT, Chaves GV. Barreiras para o encaminhamento para o cuidado paliativo exclusivo: a percepção do oncologista. SAÚDE EM DEBATE 2022. [DOI: 10.1590/0103-1104202213306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Pacientes com câncer avançado demandam cuidados paliativos. Nosso objetivo foi o de avaliar as barreiras ao encaminhamento ao cuidado paliativo na percepção de oncologistas. Desenvolvemos um estudo com oncologistas de uma instituição de referência nacional, questionando-os quanto a aspectos da sua formação acadêmica, à compreensão dos significados de cuidados paliativos, bem como limites e benefícios do encaminhamento de pacientes a uma unidade de cuidados paliativos exclusivos. A análise qualitativa foi realizada por meio da técnica de análise de conteúdo de Bardin. Participaram 19 oncologistas, que, apesar de definirem o cuidado paliativo com características multidisciplinares, voltado para doença avançada, com o objetivo de melhorar a qualidade de vida, relataram dificuldades no encaminhamento relacionadas ao próprio profissional, expectativas dos pacientes ou familiares, obstinação terapêutica e características institucionais. A criação de um ‘time consultor’ nas unidades de cuidados usuais foi a principal estratégia relatada como potencial facilitadora para essa transição de cuidados. Concluímos que a deliberação do cuidado paliativo exclusivo para pacientes com câncer avançado é uma tarefa difícil, que perpassa diferentes barreiras. A dicotomia existente entre ‘tratamento’ e ‘paliação’ na modalidade do cuidado paliativo exclusivo deve ser repensada, contrapondo a ideia do cuidado paliativo ofertado a partir do diagnóstico.
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Affiliation(s)
- Renata de Freitas
- Instituto Nacional de Câncer José Alencar Gomes da Silva (Inca), Brasil
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12
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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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13
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Ohikere K, Veracruz N, Wong RJ. Cognitive Impairment and Cirrhosis in Older Patients: A Systematic Review. Gerontol Geriatr Med 2022; 8:23337214221122520. [PMID: 36105374 PMCID: PMC9465583 DOI: 10.1177/23337214221122520] [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: 04/13/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 11/15/2022] Open
Abstract
Prevalence of cirrhosis and hepatic encephalopathy (HE) in older patients receiving care in long-term care settings is unknown. This systematic review aimed to identify potential factors associated with HE and cognitive impairment in older patients with cirrhosis. A PubMed search of English-language articles published between January 1, 2000, and November 3, 2021, was conducted to identify studies in adults with cirrhosis relevant to cognitive impairment and/or HE (e.g., fall, frailty, and sarcopenia). Of 2,879 English-language publications, 24 were included. In patients with cirrhosis, falls were increased in the presence of HE and were associated with increased injury risk. Frailty was associated with HE development and cognitive impairment in patients with cirrhosis. Further, cognitive impairment and frailty were predictive of HE-related hospitalizations. Sarcopenia increased the risk of developing HE. Furthermore, specific medications increased the risk of developing HE. Risk reduction and management of patients with HE are critical to prevent negative outcomes.
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Affiliation(s)
- Kabiru Ohikere
- San Francisco Department of Public Health, San Francisco, CA, USA
| | | | - Robert J Wong
- Stanford University School of Medicine and Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
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14
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Hepatic Encephalopathy-Related Hospitalizations in Cirrhosis: Transition of Care and Closing the Revolving Door. Dig Dis Sci 2022; 67:1994-2004. [PMID: 34169435 PMCID: PMC9167177 DOI: 10.1007/s10620-021-07075-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/24/2021] [Indexed: 12/09/2022]
Abstract
Cirrhosis is associated with substantial morbidity and mortality. Development of complications of cirrhosis, including hepatic encephalopathy (HE), portends poorer outcomes. HE is associated with hospital readmission, impaired patient and caregiver quality of life, risk of falls, and mortality. Guidelines recommend lactulose as first-line therapy for HE and rifaximin in combination with lactulose for reducing the risk of HE recurrence. Improving post-discharge outcomes, including readmissions, is an important aspect in the management of patients with HE. Approaches focused on improving management and prevention of HE, including properly titrating lactulose dosing, overcoming medication-related nonadherence, and incorporating rifaximin as therapy to reduce the risk of recurrence, as well as incorporating supportive care initiatives, may ease the transition from hospital to home. Strategies to decrease readmission rates include using hospital navigators, who can offer patient/caregiver education, post-discharge planning, and medication review; and involving pharmacists in post-discharge planning. Similarly, telemedicine offers providers the opportunity to monitor patients with HE remotely and improves outcomes. Providers offering transitional care management may be reimbursed when establishing contact with patients within 2 days post-discharge and conducting an outpatient visit within 7 days or 14 days. Several approaches have been shown to improve outcomes broadly in patients post-discharge and may also be effective for improving outcomes specifically in patients hospitalized with cirrhosis and HE, thus closing the revolving door on rehospitalizations in this population.
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Ufere NN. Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease. CURRENT HEPATOLOGY REPORTS 2021; 20:77-84. [PMID: 35083111 PMCID: PMC8788995 DOI: 10.1007/s11901-021-00565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE OF REVIEW Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care. RECENT FINDINGS Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population. SUMMARY Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.
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Affiliation(s)
- Nneka N. Ufere
- Liver Center, Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Das D, Ali M, Hussain IA, Ingram JTN, Johnstone RS, Lopes JJ, Wadee T, Chakraborty N. What do we know about patients' perspectives and expectations relating to palliative and end-of-life care in advanced liver disease? A systematic review of qualitative literature using ENTREQ guidelines. BMJ Support Palliat Care 2021:bmjspcare-2021-003057. [PMID: 34233896 DOI: 10.1136/bmjspcare-2021-003057] [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: 03/17/2021] [Accepted: 06/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Liver disease, a major cause of death worldwide, affects younger people compared with other major causes of death. Palliative and end-of-life care for these patients are often overlooked. Guidelines are emerging on what good end-of-life care in liver disease should look like, but there is a dearth of research into patients' perspectives even though they are most affected by these guidelines. AIM To explore current knowledge and understanding of patients' lived experiences, perspectives and expectations in relation to palliative and end-of-life care in advanced liver disease. DESIGN Systematic review with thematic synthesis complying to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. SETTING AND PARTICIPANTS Database searches (Ovid Medline, 1946-2021 and Web of Science, 1970-2021) to identify qualitative studies exploring patients' perspectives of palliative and end-of-life care in advanced liver disease. FINDINGS Only eight articles met all criteria. Themes demonstrated repeated hospital admissions towards the end of life, lack of coordinated care in community and barriers in discussion about palliative care in end-stage liver disease due to lack of confidence among professionals and a negative view about palliative care among patients and carers. Emotional, financial and disability-related needs of patients and their carers are often neglected. CONCLUSION There is a dearth of studies exploring patients' perspectives about care in advanced liver disease relating to palliative and end-of-life care. Lack of coordinated community support and honest conversations around palliative care leads to reduced quality of life. More primary research from diverse population is needed to improve palliative care and end-of-life care in end-stage liver disease.
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Affiliation(s)
- Debasish Das
- Department of Digestive Diseases, Kettering General Hospital, Kettering, UK
- Medical School, University of Leicester, Leicester, UK
| | - Mafas Ali
- Medical School, University of Leicester, Leicester, UK
| | | | | | | | | | - Tasneem Wadee
- Medical School, University of Leicester, Leicester, UK
| | - Nandini Chakraborty
- PIER Team, Leicestershire Partnership NHS Trust, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
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