Liver cirrhosis turns life into an unpredictable roller coaster: A qualitative interview study

A randomized controlled trial of a postdischarge nursing intervention for patients with decompensated cirrhosis

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.

Patient perceived quality of cirrhosis care- adjunctive nurse-based care versus standard medical care: a pragmatic multicentre randomised controlled study

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.

Collaborating with patients and caregivers to create web-based educational resources for people affected by cirrhosis

Objective

To describe the development of multimodal, web-based educational resources about cirrhosis alongside patients and caregivers.

Methods

We used an iterative process that was guided by the Strategy for Patient Oriented Research (SPOR) patient engagement framework in describing patient engagement activities to partner with a team of 16 patients and caregivers (Patient Advisory Team (PAT)). This process included five phases: a) Prioritize and gather content, b) design and build the website and videos, c) gather and integrate feedback, d) improve user accessibility, and e) assess usability and knowledge uptake for users.

Results

This 2-year process resulted in a 55-page website and 78 animated and live-action videos on cirrhosis complications, procedures, nutrition, and exercise. We implemented usability testing through pre-defined tasks and a think-aloud method from individuals with no previous exposure to the website to assess navigation, appearance, and content issues. Following usability testing, we have been gathering quantitative data from each unique page about relevance and ease of use, as well as qualitative data on the value of the content itself.

Conclusions

Collaboration between clinicians, patients, and caregivers is key to developing high-quality digital educational resources. Lessons from our process may help other organizations looking to address disease-specific knowledge gaps. Next steps with www.cirrhosiscare.ca will be continued iterative refinement and structured impact evaluation.

Innovation

This project used a patient-centered approach to develop a comprehensive online educational resource for patients with cirrhosis. By having patients with cirrhosis as a key part of our team, we ensured that the site met the needs of this unique population.

Knowledge needs in patients with Liver Disease: a qualitative study

BACKGROUND

Knowledge is essential for patients' disease management strategies and a critical component of healthcare. The importance of increasing patients level of knowledge has become more widely acknowledge in liver disease management in recent years, but further studies are needed to address patients experiences of unmet knowledge needs to develop appropriate patient education strategies. Therefore, the aim of this study was to explore knowledge needs in patients' with liver disease of different etiology and severity.

METHODS

A qualitative study was designed and an inductive method was chosen. Thirty-three patients with liver disease of different etiology and severity were interviewed using a semi-structured interview guide. Content analysis was used as an inspiration to describe and compare patients' needs for knowledge across disease etiology and severity. The reporting followed consolidated criteria for reporting qualitative research.

RESULTS

The analysis generated three categories and nine subcategories. In general, the patients described lack of knowledge related to their liver disease, which made it difficult for them to manage their disease. Patients wished to be more involved in care and treatment of the liver disease. However, patients' had difficulties to assess and understand the importance of the information they received from healthcare professionals. Due to lack of knowledge, patients' had a misconception of the liver disease. Patients' had variation in knowledge needs depending on liver disease etiology and severity.

CONCLUSION

Within liver disease management, knowledge of patients' experiences is vital to meet patients' knowledge needs and to develop appropriate patient education strategies. Therefore, it is important to ascertain a patient-centered approach to accommodate patients' individual knowledge needs, involve patients in care and treatment, and insure understanding to strengthen their self-management and give the patients the necessary skills to manage their disease and everyday life.

REGISTRATION NUMBER

Open Science Framework registration DOI https://doi.org/10.17605/OSF.IO/W28RC .

A new theory to promote self-management of symptom clusters and healthcare quality in patients with decompensated cirrhosis

Patients with decompensated cirrhosis, a symptomatic phase of cirrhosis, commonly experience multiple symptoms concurrently, referred to as symptom clusters. Effective self-management of symptoms is known to improve outcomes in various chronic diseases. However, a theory for self-management of symptom clusters in decompensated cirrhosis is lacking. In this study, we applied grounded theory research methodology to construct a new theory of self-management of symptom clusters in these patients. This qualitative study prospectively enrolled 20 patients with decompensated cirrhosis within 1 week after hospital admission. Data related to patients' experiences, needs, perspectives, and abilities related to their symptoms were collected via a semi-structured, in-depth interview and analyzed with Nvivo version 20 software. Grounded theory methodology with 3 coding steps (open, axial, and selective coding) was applied to generate a theory of self-management of symptom clusters. From the step-by-step coding process, 2 core categories or major themes were identified: patients' experiences with symptoms and coping with symptoms. The first major theme included symptom clustering, multidimensionality, recurrence, and specificity, while the second consisted of endogenous motivation, endogenous resistance, and external support needs. A new theory of self-management of symptom clusters was then constructed and delineated to enhance self-management among patients with decompensated cirrhosis. Using patient experience data, we developed a new theory of self-management of symptom clusters in patients with decompensated cirrhosis. Use of this theory has the potential to promote patient self-management and guide healthcare providers in planning optimal treatments and implementing timely interventions, ultimately improving in patient outcomes.

A Nurse-Led Outpatient Clinic for Patients With Decompensated Liver Cirrhosis: Staffing, Structure, and Patient Satisfaction

Patients with decompensated liver cirrhosis constitute a growing and vulnerable patient group with a particular need for easy outpatient access and close follow-up. By establishing a nurse-led clinic, we aimed to counter this need in a patient-centered manner within a multidisciplinary rehabilitating framework. This article presents the organization, staffing, and structure of this initiative as well as the patient population demographics and characteristics. Furthermore, patient satisfaction within the clinic was explored. Two complementary substudies are presented: a descriptive, registry-based journal audit, presenting data from the clinic's first years, 2017-2019, and a cross-sectional, descriptive survey, exploring patient satisfaction 2 years later. Different visit types with predefined content constitute an operable structure suitable for meeting patients' current needs. An increase in both the number of patients and visits from the first to second years indicates an existing need for nurse-led support. Data not only support the well-known characteristics of patients with cirrhosis but also add to a broader perspective with more nuances for this patient population. The survey shows an overall high score on satisfaction but also points out areas for improvement. The nurse-led clinic provides both structure and knowledge to facilitate patient-centered treatment and care for those suffering from liver cirrhosis.

The stigma of alcohol-related liver disease and its impact on healthcare

People with alcohol-related liver disease (ALD) experience stigma and discrimination. This review summarises the evidence on stigma in healthcare and its implications for people with ALD, drawing from the literature on the stigma associated with mental illness and, specifically, alcohol use disorder (AUD). Public stigma, self-stigma and structural stigma all contribute to failure to seek help or delays in seeking help, inferior healthcare, and negative health outcomes, which increase the overall burden of ALD. Stigma can be experienced, but also anticipated and avoided, with both scenarios negatively impacting on ALD healthcare. Blaming people with ALD for their condition is central to the stigma of ALD. Stigma affects ALD healthcare at all stages, from prevention, early detection and intervention, to allocation of scarce resources in liver transplantation. People with lived experience need to be empowered to lead action against the stigmatisation of patients with ALD. Promulgating a dynamic model of individual and social responsibility for AUD, a continuum model of harmful alcohol use, and establishing training on ALD-related stigma for healthcare professionals are strategies to address stigma. Integrating addiction and ALD services, providing stigma-free prevention, and overcoming the frequent separation of addiction services from general healthcare are necessary. Beyond healthcare, addressing social inequality, the social dimensions of ALD risk and outcomes, and ensuring equal access to services is necessary to improve outcomes for all people with ALD. More research is needed on the stigma of ALD in low- and middle-income countries and in countries with restrictive drinking norms. Interventions to reduce the stigma of ALD and facilitate early help-seeking need to be developed and evaluated.

The Main Thing is to be Alive-Exploring Patients' Experiences With Weight Gain After Liver Transplantation: A Qualitative Study

Weight gain after liver transplantation (LTx) contributes to new-onset obesity. We explored patients’ experiences with gaining weight after LTx. Individual interviews were guided by open-ended questions. We analyzed transcripts with the reflexive thematic analysis approach by Braun and Clarke. The 12 participants gained 11.5 kg weight (median) over a median of 23 months after LTx. The constitutive theme “The main thing is to be alive” was a recurrent insight, captured in three facets: “The arduous path back to living” was the emotional expression of the ups and downs during a life-threatening illness to finally being grateful for the new life. “A pleasurable new phase of life” was the legitimation, reflecting the appreciation of gaining weight and returning to a healthy appearance. “I am allowed to look like this now” was the consoling facet after a time of burden due to the increased weight and frustration of being unsuccessful in losing weight. Finally, the awareness of being a LTx survivor outplayed the burden of the excess weight. Early interventions are crucial because the comforting insight “I am allowed to look like this now” may hinder further engagement in weight loss activities. Our recommendations on education and self-management support may guide clinical practice.

Partnering with support persons and clinicians to improve the health care experiences of patients with cirrhosis

AIM

To explore the care experiences of Aboriginal and Torres Strait Islander Australians diagnosed with cirrhosis with a focus on support needed.

BACKGROUND

Cirrhosis disproportionately affects Indigenous Australians, and liver diseases contribute to the mortality gap between Indigenous and other Australian adults.

DESIGN

A qualitative study.

METHODS

Using yarning methods, Indigenous patients (n = 13) and support persons (n = 3) were interviewed by an Aboriginal researcher during April-July, 2020. Thematic analysis was used to identify common themes using an inductive approach.

RESULTS

Six themes emerged. (1) Experience of diagnosis. This theme included stories of delays in the system, self-awareness of signs and symptoms and relief of being diagnosed. (2) 'Shame, shame, shame'. Experiences of prejudices and discrimination from health professionals, the lack of understanding of cirrhosis among health professionals, and stories about alcohol cessation and counselling around alcohol cessation. (3) Health literacy. Participants' understanding of cirrhosis was variable. While the importance of knowledge was recognised, 'what works for someone might not work for others'. Several patients partnered with their support persons and clinicians to bridge the health literacy gap. (4) Sources of support included family and friends, transport facilities, health professionals and peers. (5) Positive and negative aspects of communication and patient consultation were discussed. (6) Psychosocial counselling to 'look after the caring side'. The need for more mental health care services was raised.

CONCLUSION

Barriers related to poor health literacy, stigma and lack of practical and emotional support, and issues with communication and patient consultation, may lead to inequitable access to cirrhosis care and treatment for Indigenous Australians.

RELEVANCE TO CLINICAL PRACTICE

Gaining knowledge of the experiences of Indigenous Australians with cirrhosis is important for providing patient-centred and culturally appropriate care. Liver specialist nurses have an important role in bridging the health literacy gap and in supporting Indigenous patients and families.

Liver cirrhosis turns life into an unpredictable roller coaster: A qualitative interview study

Aim

To explore how persons living with liver cirrhosis experience day‐to‐day life.

Background

Liver cirrhosis is the sixth most common cause of death among adults in Western countries. Persons with advanced liver cirrhosis report poor quality of life, in comparison with other chronic diseases. However, knowledge regarding day‐to‐day life during earlier stages of the disease is lacking. In other chronic diseases, the suffering process is well explored, while in liver cirrhosis, suffering is insufficiently investigated.

Design

An exploratory study, with a qualitative inductive interview approach.

Methods

A purposive maximum variation sample of 20 informants with liver cirrhosis aged 25–71, from two gastroenterology outpatient clinics in mid‐Sweden, were interviewed from September 2016 to October 2017. Interview data were analysed inductively with qualitative content analysis. Reporting followed the COREQ guidelines.

Results

The experiences of day‐to‐day life living with liver cirrhosis comprised four sub‐themes. Living with liver cirrhosis implied varying levels of deterioration, the most apparent being exhaustion or tiredness. The informants had to find ways of adapting to a new life situation. The insecurity of future health evoked existential reflections such as feeling emotionally and existentially distressed. Shame and guilt were reasons for feeling stigmatised. These sub‐themes emerged into one overarching theme of meaning: life turns into an unpredictable roller coaster. This is based on experiences of liver cirrhosis as an unpredictable disease with fluctuating symptoms, worries and disease progression.

Conclusion

Living with cirrhosis implies an unpredictable condition with a progressive, stigmatising disease. The fluctuating symptoms and deep concerns about future life pose an increased personal suffering.

Relevance to clinical practice

Within health care, knowledge of the person's experience is vital to enable and fulfil the person's healthcare needs. Clinical registered nurses need a person‐centred approach to strengthen their patients to cope with their new life situation.