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Bajaj JS, Choudhury A, Kumaran V, Wong F, Seto WK, Alvares-Da-Silva MR, Desalgn H, Hayes PC, Idilman R, Topazian M, Torre A, Xie Q, George J, Kamath PS. Geographic disparities in access to liver transplant for advanced cirrhosis: Time to ring the alarm! Am J Transplant 2024; 24:733-742. [PMID: 38387623 DOI: 10.1016/j.ajt.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
Decompensated cirrhosis and hepatocellular cancer are major risk factors for mortality worldwide. Liver transplantation (LT), both live-donor LT or deceased-donor LT, are lifesaving, but there are several barriers toward equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure. Rates of LT vary widely worldwide but are lowest in lower-income countries owing to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the Chronic Liver Disease Evolution and Registry for Events and Decompensation consortium defined these barriers toward LT as critical in determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and hepatocellular cancer care to prevent the need for LT. Live-donor LT is predominant across Asian countries, whereas deceased-donor LT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges toward equitable access but uniform definitions of acute-on-chronic liver failure, improving transplant expertise, enhancing availability of resources and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA.
| | - Ashok Choudhury
- Department of Hepatology, Institute for Liver and Biliary Sciences, New Delhi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Florence Wong
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wai Kay Seto
- Department of Medicine, School of Clinical Medicine, the University of Hong Kong, Hong Kong, China
| | - Mario Reis Alvares-Da-Silva
- Department of Hepatology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Hailemichael Desalgn
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Peter C Hayes
- Hepatology, Division of Health Sciences, Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Topazian
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Aldo Torre
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jacob George
- Storr Liver Centre, Westmead Millennium Institute, Westmead Hospital and University of Sydney, New South Wales, Australia
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Kaplan A, Ladin K, Junna S, Lindenberger E, Ufere NN. Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning. GASTRO HEP ADVANCES 2024; 3:634-645. [PMID: 38873184 PMCID: PMC11175167 DOI: 10.1016/j.gastha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology, Department of Surgery, Transplant Institute, Tufts University Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Boston, Massachusetts
| | - Shilpa Junna
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth Lindenberger
- Department of Geriatrics and Palliative Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N. Ufere
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Verma M, Desai AP. The role of patient-reported outcomes in a patient-centered care model for managing chronic liver diseases. Clin Liver Dis (Hoboken) 2024; 23:e0222. [PMID: 38881726 PMCID: PMC11177829 DOI: 10.1097/cld.0000000000000222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/15/2024] [Indexed: 06/18/2024] Open
Affiliation(s)
- Manisha Verma
- Department of Medicine, Jefferson Einstein Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Au J, Falloon C, Ravi A, Ha P, Le S. A Beta-Prototype Chatbot for Increasing Health Literacy of Patients With Decompensated Cirrhosis: Usability Study. JMIR Hum Factors 2023; 10:e42506. [PMID: 37581920 PMCID: PMC10466144 DOI: 10.2196/42506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/25/2023] [Accepted: 05/14/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Health literacy is low among patients with chronic liver disease (CLD) and associated with poor health outcomes and increased health care use. Lucy LiverBot, an artificial intelligence chatbot was created by a multidisciplinary team at Monash Health, Australia, to improve health literacy and self-efficacy in patients with decompensated CLD. OBJECTIVE The aim of this study was to explore users' experience with Lucy LiverBot using an unmoderated, in-person, qualitative test. METHODS Lucy LiverBot is a simple, low cost, and scalable digital intervention, which was at the beta prototype development phase at the time of usability testing. The concept and prototype development was realized in 2 phases: concept development and usability testing. We conducted a mixed methods study to assess usability of Lucy LiverBot as a tool for health literacy education among ambulatory and hospitalized patients with decompensated CLD at Monash Health. Patients were provided with free reign to interact with Lucy LiverBot on an iPad device under moderator observation. A 3-part survey (preuser, user, and postuser) was developed using the Unified Acceptance Theory Framework to capture the user experience. RESULTS There were 20 participants with a median age of 55.5 (IQR 46.0-60.5) years, 55% (n=11) of them were female, and 85% (n=17) of them were White. In total, 35% (n=7) of them reported having difficulty reading and understanding written medical information. Alcohol was the predominant etiology in 70% (n=14) of users. Participants actively engaged with Lucy LiverBot and identified it as a potential educational tool and device that could act as a social companion to improve well-being. In total, 25% (n=5) of them reported finding it difficult to learn about their health problems and 20% (n=4) of them found it difficult to find medical information they could trust. Qualitative interviews revealed the conversational nature of Lucy LiverBot was considered highly appealing with improvement in mental health and well-being reported as an unintended benefit of Lucy LiverBot. Patients who had been managing their liver cirrhosis for several years identified that they would be less likely to use Lucy LiverBot, but that it would have been more useful at the time of their diagnosis. Overall, Lucy LiverBot was perceived as a reliable and trustworthy source of information. CONCLUSIONS Lucy LiverBot was well received and may be used to improve health literacy and address barriers to health care provision in patients with decompensated CLD. The study revealed important feedback that has been used to further optimize Lucy LiverBot. Further acceptability and validation studies are being undertaken to investigate whether Lucy LiverBot can improve clinical outcomes and health related quality of life in patients with decompensated CLD.
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Affiliation(s)
- Jessica Au
- School of Clinical Sciences, Monash University, Clayton, Australia
| | - Caitlin Falloon
- School of Clinical Sciences, Monash University, Clayton, Australia
| | - Ayngaran Ravi
- School of Clinical Sciences, Monash University, Clayton, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Clayton, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Clayton, Australia
- Monash Digital Therapeutics and Innovation Laboratory, Monash University, Clayton, Australia
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Yeo YH, Samaan JS, Ng WH, Ting PS, Trivedi H, Vipani A, Ayoub W, Yang JD, Liran O, Spiegel B, Kuo A. Assessing the performance of ChatGPT in answering questions regarding cirrhosis and hepatocellular carcinoma. Clin Mol Hepatol 2023; 29:721-732. [PMID: 36946005 PMCID: PMC10366809 DOI: 10.3350/cmh.2023.0089] [Citation(s) in RCA: 133] [Impact Index Per Article: 133.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND/AIMS Patients with cirrhosis and hepatocellular carcinoma (HCC) require extensive and personalized care to improve outcomes. ChatGPT (Generative Pre-trained Transformer), a large language model, holds the potential to provide professional yet patient-friendly support. We aimed to examine the accuracy and reproducibility of ChatGPT in answering questions regarding knowledge, management, and emotional support for cirrhosis and HCC. METHODS ChatGPT's responses to 164 questions were independently graded by two transplant hepatologists and resolved by a third reviewer. The performance of ChatGPT was also assessed using two published questionnaires and 26 questions formulated from the quality measures of cirrhosis management. Finally, its emotional support capacity was tested. RESULTS We showed that ChatGPT regurgitated extensive knowledge of cirrhosis (79.1% correct) and HCC (74.0% correct), but only small proportions (47.3% in cirrhosis, 41.1% in HCC) were labeled as comprehensive. The performance was better in basic knowledge, lifestyle, and treatment than in the domains of diagnosis and preventive medicine. For the quality measures, the model answered 76.9% of questions correctly but failed to specify decision-making cut-offs and treatment durations. ChatGPT lacked knowledge of regional guidelines variations, such as HCC screening criteria. However, it provided practical and multifaceted advice to patients and caregivers regarding the next steps and adjusting to a new diagnosis. CONCLUSION We analyzed the areas of robustness and limitations of ChatGPT's responses on the management of cirrhosis and HCC and relevant emotional support. ChatGPT may have a role as an adjunct informational tool for patients and physicians to improve outcomes.
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Affiliation(s)
- Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jamil S. Samaan
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Wee Han Ng
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Hirsh Trivedi
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aarshi Vipani
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Walid Ayoub
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Omer Liran
- Department of Psychiatry and Behavioral Sciences, Cedars-Sinai, Los Angeles, CA, USA
- Division of Health Services Research, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Brennan Spiegel
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Health Services Research, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Alexander Kuo
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Younossi ZM, Wong G, Anstee QM, Henry L. The Global Burden of Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1978-1991. [PMID: 37121527 DOI: 10.1016/j.cgh.2023.04.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/09/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023]
Abstract
Chronic liver disease (CLD) and its associated complications (cirrhosis and liver cancer) cause significant mortality, morbidity, and economic burden. Published data from the World Health Organization and/or the Global Burden of Disease show that the burden of CLD is large and increasing, primarily owing to the increasing burden of nonalcoholic fatty liver disease and alcohol-related liver disease (ALD). Middle Eastern, Northern African, and Asian regions of the globe are most affected by hepatitis B and hepatitis C virus. Furthermore, Middle Eastern and North African regions also are affected by nonalcoholic fatty liver disease, and Eastern European, West African, and Central Asian regions are affected by ALD. In this context, the rate of increase for cirrhosis is highest in the Middle East, as well as in middle high and high sociodemographic index (SDI) regions. On the other hand, the highest SDI countries are experiencing increasing rates of hepatocellular carcinoma (HCC). Assessing HCC burden based on country and etiology shows that China, Korea, India, Japan, and Thailand have the highest hepatitis B virus-related HCC cases, while China, Japan, and the United States have the highest hepatitis C virus-related HCC cases. Additionally, the United States has the highest ALD-related HCC cases, while India, the United States, and Thailand have the highest nonalcoholic steatohepatitis-related HCC cases. Although the burden of CLD is increasing globally, regions of the world are impacted differently as a result of a number of sociodemographic factors.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia; Inova Medicine, Inova Health System, Falls Church, Virginia.
| | - Grace Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle National Institute Health and Care Research Biomedical Research Centre, Newcastle upon Tyne Hospitals National Health Service Trust, Newcastle upon Tyne, United Kingdom
| | - Linda Henry
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia; Inova Medicine, Inova Health System, Falls Church, Virginia; Center for Outcomes Research in Liver Disease, Washington, District of Columbia
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Valery PC, Stuart KA, Bernardes CM, Hartel G, Martin C, Gordon L, Powell EE. Higher levels of supportive care needs are linked to higher health service use and cost, poor quality of life, and high distress in patients with cirrhosis in Queensland, Australia. Hepatol Commun 2023; 7:e0066. [PMID: 36848120 PMCID: PMC9974077 DOI: 10.1097/hc9.0000000000000066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/19/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Australians with cirrhosis have significant practical and psychosocial needs. This longitudinal study examined the association between supportive care needs and health service use and costs, and patient outcomes from June 2017 to December 2018. METHODS The Supportive Needs Assessment tool for Cirrhosis (SNAC), quality of life (Chronic Liver Disease Questionnaire and Short Form 36), and distress (distress thermometer) were self-reported through an interview at recruitment (n=433). Clinical data were obtained from medical records and through linkage, and health service use and costs through linkage. Patients were grouped as by needs status. Rates of hospital admissions (per person days at risk) and costs were assessed by needs status [incidence rate ratios (IRR), Poisson regression]. Multivariable linear regression was used to assess the differences in SNAC scores by quality of life and distress. Multivariable models included Child-Pugh class, age, sex, recruitment hospital, living arrangements, place of residence, comorbidity burden, and primary liver disease etiology. RESULTS In adjusted analyses, compared with patients with low/no needs, patients with unmet needs had more cirrhosis-related admissions (adjusted IRR=2.11, 95% CI=1.48-3.13; p<0.001), admissions through the emergency department (IRR=2.99, 95% CI=1.80-4.97, p<0.001), and emergency presentations (IRR=3.57, 95% CI=1.41-9.02; p<0.001). Total hospitalization costs for cirrhosis admissions were higher for those with unmet needs ($431,242 per person days at risk) compared with those with met needs ($87,363 per person days at risk, adjusted cost ratio=3.52, 95%CI=3.49-3.54; p<0.001). In multivariable analysis, increasing overall mean SNAC scores (higher needs) were correlated with poorer quality of life and higher level of distress (p<0.001 for all comparisons). CONCLUSIONS Patients with cirrhosis and high unmet psychosocial needs and practical and physical needs have poor quality of life, high distress, and very high service use and costs, highlighting the importance of urgently addressing unmet needs.
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Affiliation(s)
- Patricia C. Valery
- Population Health Program, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Katherine A. Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Christina M. Bernardes
- Population Health Program, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Gunter Hartel
- Population Health Program, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Cathy Martin
- Social Work Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Louisa Gordon
- Population Health Program, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Elizabeth E. Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Powell EE, Stuart KA, Finnigan S, Hinson J, Bernardes CM, Hartel G, Valery PC. Low Prevalence of Use of Allied Health and Community Services for Patients with Cirrhosis in Australia: A Need for Greater Engagement. Patient Prefer Adherence 2023; 17:1117-1130. [PMID: 37102126 PMCID: PMC10124554 DOI: 10.2147/ppa.s405567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
Background Psychosocial, lifestyle and practical needs are not routinely attended to during outpatient hepatology management, and little is known about the type and effectiveness of support services accessed by patients with cirrhosis. We quantified the type and use of community and allied health services in patients with cirrhosis. Methods The study included 562 Australian adults with a diagnosis of cirrhosis. Health service use was assessed via questionnaire and via linkage to the Australian Medicare Benefits Schedule. Patient needs were assessed using the Supportive Needs Assessment tool for Cirrhosis (SNAC). Results Although most patients (85.9%) used at least one community/allied health service for support with their liver disease, many reported requiring additional help with psychosocial (67.4%), lifestyle (34.3%) or practical needs (21.9%) that were not met by available services, or patients did not access services. A multidisciplinary care plan or case conference (in the 12 months prior to recruitment) was accessed by 48% of patients, 56.2% reported the use of a general practitioner for support with cirrhosis, and a dietician was the allied health clinician most accessed by patients (45.9%). Despite the high prevalence of psychosocial needs, there was relatively limited use of mental health and social work services (14.1% of patients reported the use of a psychologist), confirmed by a low prevalence of use of mental health services (17.7%) in the linked data. Conclusion Patients with cirrhosis who have unmet complex physical and psychosocial needs require better strategies to increase their engagement with allied health and community services.
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Affiliation(s)
- Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Centre for Liver Disease Research, Faculty of Medicine, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Simon Finnigan
- Community and Oral Health, Metro North Health, Chermside, Queensland, Australia
| | - Jan Hinson
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, Banyo, Queensland, Australia
| | - Christina M Bernardes
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Gunter Hartel
- Statistics, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Patricia C Valery
- Centre for Liver Disease Research, Faculty of Medicine, the University of Queensland, Woolloongabba, Queensland, Australia
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Correspondence: Patricia C Valery, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, 4006, Australia, Tel +61 07 3362 0376, Email
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