Improving cirrhosis care: The potential for telemedicine and mobile health technologies

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prophylaxis of hepatic encephalopathy: current and future drug targets

Hepatic encephalopathy is described by a broad spectrum of neurological and psychiatric aberrations resulting due to advanced liver dysfunction. It is a neurological disorder due to hepatic insufficiency and/or portosystemic shunts. Its clinical presentation includes neuropsychiatric dysfunction ranging from subclinical changes to comatose state. It is a sign of poor prognosis in cirrhotics with a high 1-year mortality. Each episode of hepatic encephalopathy leads to high hospitalization rate, poor prognosis and raised burden of healthcare. Primary prophylaxis is prevention of initial occurrence and secondary prophylaxis is prevention of reappearance of hepatic encephalopathy in subjects who had prior history. Early detection and management of triggers is very important in the treatment of hepatic encephalopathy. The initial choice of treatment is still lactulose, as it is effective in minimal, overt, and recurrent hepatic encephalopathy. Rifaximin is equally effective as lactulose in managing hepatic encephalopathy and is better tolerated. Branch chain amino acids are beneficial in subjects who are protein intolerant. L-ornithine L-aspartate and probiotics are also useful in the management of hepatic encephalopathy. Rifaximin along with lactulose is effective in managing overt and recurrent hepatic encephalopathy. Large portosystemic shunts embolization and liver transplant is efficacious in certain group of patients. Nutritional therapy and fecal microbiota transplantation are newer therapies for hepatic encephalopathy but the evidences are limited, more research is required to prove their efficacy. Involvement of hospital pharmacists, telemedicine, and providing education are also beneficial in managing hepatic encephalopathy.

Leveraging telemedicine in gastroenterology and hepatology: a narrative review

Background and Objective

Over the years, telemedicine has played a prominent role in delivering healthcare to patients. Due to its flexibility and many benefits, telemedicine confers physicians the ability to guide and promote medical care remotely. The advent of the coronavirus disease 2019 (COVID-19) pandemic has changed the landscape of medicine and has accelerated the usage of digital and remote healthcare systems for clinical care. Herein, we provide an overview of telemedicine, its applications in managing inflammatory bowel disease (IBD), celiac disease (CD), and liver diseases, its advantages and limitations, and its use in educating the next generation of gastroenterologists.

Methods

We conducted a review of scientific articles published in PubMed and Google Scholar. Articles were selected based on the search terms included in the search strategy summary. The language of the articles was restricted to English only.

Key Content and Findings

We report that telemedicine has the potential to streamline and improve patient care in gastroenterology (GI) and hepatology while also limiting health care expenses. Additionally, we noted the importance of tele-education for training the next generation of physicians who intend on practicing in rural settings. Furthermore, we identified barriers to telemedicine care that exacerbate health inequities and potential solutions to achieving digital health equity. Lastly, we briefly discuss the role of artificial intelligence (AI) in remote patient monitoring.

Conclusions

Although telemedicine has existed for many decades, over the past decade there have been many advancements in telemedicine applications in GI and hepatology. Despite its broad benefits, further research needs to be done to alleviate barriers to telemedicine care.

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Telehealth interventions in patients with chronic liver diseases: A systematic review

BACKGROUND AND AIM

Telehealth interventions may improve access to care, disease-specific, and quality outcomes in chronic liver diseases (CLDs). We aimed to systematically evaluate outcomes of telehealth interventions in CLDs.

MATERIALS AND METHODS

We used key terms and searched PubMed/EMBASE from inception to January 10, 2022. Two authors independently screened abstracts. Disagreements were resolved by a third reviewer. We included any type of CLD, including posttransplant patients, and extracted outcomes as defined by authors for each etiology of CLD (sustained virological response in HCV or weight loss in NAFLD). Meta-analysis was not performed because of the heterogeneity of data. Quality assessment was performed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for clinical trials.

RESULTS

Of 4250 studies screened, 43 met the inclusion criteria. Of these, 28 reported HCV treatment outcomes. All studies showed no statistically significant differences between sustained virological response rates in TH groups compared with control groups or historic cohorts. Eight studies evaluating liver transplant-related processes and outcomes demonstrated improved rates of transplant evaluation and referrals and decreased short-term readmission rates. Three randomized controlled trials and 1 observational study on NAFLD showed improved weight loss outcomes. One retrospective study showed reduced mortality risk in CLD patients with at least 1 TH encounter.

CONCLUSIONS

TH interventions in patients with CLDs consistently show equivalent or improved clinical outcomes compared with traditional encounters. TH in CLDs can bridge the gap in access while maintaining the quality of care for underserved populations.

Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis

BACKGROUND

We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis (DC).

AIM

To study prospective interventions to reduce early readmissions in DC at our tertiary center.

METHODS

Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention (INT) or standard of care (SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.

RESULTS

Calculated sample size was not achieved due to coronavirus disease 2019; 240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm (P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy (HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT (21%) vs SOC arm (45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up (n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).

CONCLUSION

Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.

A novel smartphone scleral-image based tool for assessing jaundice in decompensated cirrhosis patients

BACKGROUND AND AIM

Serum bilirubin is an established marker of liver disease. Reliable tools for non-invasive assessment of jaundice in cirrhosis patients, at risk of clinical decompensation, are highly desirable. While smartphone-based imaging has been described in neonatal jaundice, it has not been investigated in advanced cirrhosis patients.

METHODS

We included 46 hospitalized patients with acute cirrhosis decompensation and jaundice. Scleral images using an Android smartphone were taken to derive "Scleral Color Values (SCV)," which were matched with same day serum bilirubin measurements. In 29 patients, repeat SCV and bilirubin measurements were performed over time. We analyzed the relationship of SCV and its dynamics with serum bilirubin, clinical scores, and patient outcomes.

RESULTS

Of 46 patients, 26 (57%) had alcoholic hepatitis as the decompensation precipitant. Seven patients died during admission; a further 12 following hospital discharge. SCV had an excellent linear correlation with serum bilirubin (rho = 0.90, P < 0.001); changes in SCV and serum bilirubin across different time points, were also closely associated (rho = 0.77, P < 0.001). SCV correlated significantly with CLIF Consortium Acute Decompensation score (rho = 0.38, P < 0.001) and grade of Acute-on-Chronic Liver Failure (rho = 0.42, P = 0.039). SCV was higher in patients who died, however, not significantly (86.1 [IQR 83.0-89.7] vs 82.3 [IQR 78.5-83.3], P = 0.22). The associations of SCV with clinical parameters mirrored those of serum bilirubin.

CONCLUSION

Smartphone-based assessment of jaundice shows excellent concordance with serum bilirubin and is associated with clinical parameters in acute cirrhosis decompensation. This approach offers promise for remote assessment of cirrhosis patients at-risk of decompensation, post hospital discharge.

Evaluation of CirrhoCare® - a digital health solution for home management of individuals with cirrhosis

BACKGROUND & AIMS

Individuals with cirrhosis discharged from hospital following acute decompensation are at high risk of new complications. This study aimed to assess the feasibility and potential clinical benefits of remote management of individuals with acutely decompensated cirrhosis using CirrhoCare®.

METHODS

Individuals with cirrhosis with acute decompensation were followed up with CirrhoCare® and compared with contemporaneous matched controls, managed with standard follow-up. Commercially available monitoring devices were linked to the smartphone CirrhoCare® app, for daily recording of heart rate, blood pressure, weight, % body water, cognitive function (CyberLiver Animal Recognition Test [CL-ART] app), self-reported well-being, and intake of food, fluid, and alcohol. The app had 2-way patient-physician communication. Independent external adjudicators assessed the appropriateness of CirrhoCare®-based decisions.

RESULTS

Twenty individuals with cirrhosis were recruited to CirrhoCare® (mean age 59 ± 10 years, 14 male, alcohol-related cirrhosis [80%], mean model for end-stage liver disease-sodium [MELD-Na] score 16.1 ± 4.2) and were not statistically different to 20 contemporaneous controls. Follow-up was 10.1 ± 2.4 weeks. Fifteen individuals showed good engagement (≥4 readings/week), 2 moderate (2-3/week), and 3 poor (<2/week). In a usability questionnaire, the median score was ≥9 for all questions. Five CirrhoCare®-managed individuals had 8 readmissions over a median of 5 (IQR 3.5-11) days, and none required hospitalisation for >14 days. Sixteen other CirrhoCare®-guided patient contacts were made, leading to clinical interventions that prevented further progression. Appropriateness was confirmed by adjudicators. Controls had 13 readmissions in 8 individuals, lasting a median of 7 (IQR 3-15) days with 4 admissions of >14 days. They had 6 unplanned paracenteses compared with 1 in the CirrhoCare® group.

CONCLUSIONS

This study demonstrates that CirrhoCare® is feasible for community management of individuals with decompensated cirrhosis with good engagement and clinically relevant alerts to new decompensating events. CirrhoCare®-managed individuals have fewer and shorter readmissions justifying larger controlled clinical trials.

IMPACT AND IMPLICATIONS

As the burden of cirrhosis grows worldwide, increasing demands are being placed on limited healthcare resources, necessitating the adoption of more sustainable care models that allow for at-home patient management. The CirrhoCare® management system was developed to fill this care gap, deploying a novel combination of hardware, apps, and algorithms, to monitor and intervene in individuals at risk of new decompensation. This study highlights the possibility of reducing hospital readmissions for cirrhosis by optimising specialist community care, reducing the need for interventions such as paracentesis, while providing a more sustainable care pathway that is acceptable to patients. However, given the pilot and non-randomised nature of this study, the outcomes require further validation in a larger randomised controlled trial, to assess both clinical effectiveness and cost-effectiveness. Moreover, the data generated will also facilitate data modelling and further research to refine the CirrhoCare® algorithms to increase their detection sensitivity and utility.

The digital transformation of hepatology: The patient is logged in

The rise in innovative digital health technologies has led a paradigm shift in health care toward personalized, patient-centric medicine that is reaching beyond traditional brick-and-mortar facilities into patients' homes and everyday lives. Digital solutions can monitor and detect early changes in physiological data, predict disease progression and health-related outcomes based on individual risk factors, and manage disease intervention with a range of accessible telemedicine and mobile health options. In this review, we discuss the unique transformation underway in the care of patients with liver disease, specifically examining the digital transformation of diagnostics, prediction and clinical decision-making, and management. Additionally, we discuss the general considerations needed to confirm validity and oversight of new technologies, usability and acceptability of digital solutions, and equity and inclusivity of vulnerable populations.

The Evolution and Future of Telehealth for Gastroenterology and Hepatology

Content available: Author Audio Recording.

Hepatic Encephalopathy-Related Hospitalizations in Cirrhosis: Transition of Care and Closing the Revolving Door

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.

Telemedicine based remote monitoring after liver transplantation: Feasible in a select group and a more stringent control of immunosuppression

Telemedicine gained interest in liver transplant patients but focused until now on the early post‐operative period. This prospective cohort study assessed feasibility, safety, and clinical beneficial effects of a telemedicine based remote monitoring program (TRMP) for the chronic follow‐up of adult liver transplant recipients. Between November 2017 and August 2019, a total of 87 of the 115 selected patients (76%) started the TRMP. Over the 2 years study period, none of the patients switched to standard follow‐up: 39/87 (45%) continued to do this autonomously and 48/87 (55%) stopped to report their data personally but communicated their lab values to the nurse. The other 28/115 (11%) patients who did not accept the TRMP continued the standard follow‐up. There was no difference in educational level between the three groups. Remote monitoring did not result in an increase in liver graft rejection and need of hospitalization. TRMP was associated with a higher number of tacrolimus level determinations and tacrolimus blood level concentrations could be kept lower. In conclusion, our results show that in patients with a stable clinical condition there is a high willingness to participate in TRMP and that this approach is safe. Remote monitoring allowed a stringent follow‐up of tacrolimus levels.

Understanding Preferences Toward Virtual Care: A Pre-COVID Mixed Methods Study Exploring the Perspectives of Patients with Chronic Liver Disease

Background: Traditionally, outpatient visits for those with chronic liver disease (CLD) have been delivered in-person with the patient traveling to a centralized location to see the health care provider. The use of virtual care in health care delivery has been gaining popularity across a variety of patient populations, especially within the COVID-19 context. Performed before COVID-19, the aim of the present study was to explore the perspectives of patients with CLD toward the use of virtual care with their liver specialists. Methods: A cross-sectional, mixed methods study was used to conduct this work. Results: A total of 101 patients with CLD participated in this study. Participants had a mean age of 54.5 years (range 19-87 years). Quantitative analysis revealed that 86% were willing to attend a virtual visit with their liver specialist in the future. There was a significant relationship between both age and income level and acceptance of virtual care. The themes emerging from the qualitative analysis included: (1) past experiences attending in-person visits, (2) perspectives on the use of virtual visits, and (3) perceived challenges of virtual visits. Conclusions: Although there are many potential benefits of virtual care to both the patient and the health care system, there are instances (older age, low income level) when in-person care may be preferred by patients. A tailored approach that is mindful of the individual patient's health status, ease of access to technology, and preferences must be considered when offering virtual care. These findings are of particular relevance during COVID-19, an era that has forced us into the virtual space.

Strategies to Improve Delivery of Cirrhosis Care

Purpose of review

This review provides an overview of the current state of research around improving healthcare delivery for patients with cirrhosis in the outpatient, inpatient, and transitional care settings.

Recent findings

Recent studies have broadly employed changes to the model of care delivery, team composition, and technology to improve cirrhosis care. In the outpatient setting, approaches have included engaging caregivers, patient navigators, and non-physicians and using virtual care, smartphone applications, and wearables. Inpatient care approaches have focused on the role of interdisciplinary teams, education interventions, and changes to the medical record system, while post-discharge interventions have included day hospitals and care coordinator interventions. This review also describes the Veterans Health Administration’s novel, population-level approach to delivery of cirrhosis care, and addressed how the pandemic has impacted the delivery of cirrhosis care.

Summary

Comprehensive, evidence-based approaches to delivering high-quality cirrhosis care continue to evolve to meet the needs of a growing population in an ever-changing healthcare environment.

Telemedicine in the COVID-19 era for Liver Transplant Recipients: an Italian lockdown area experience

BACKGROUND

Data on COVID-19 in Liver Transplant (LT) recipients are scanty, but one can hypothesize that they are more susceptible to infection due to chronic immunosuppression. Telemedicine could be an alternative to the routine clinical care in this difficult period. We aimed to investigate in a cohort of LT recipients the access to remote consultation and the attitude towards Telemedicine using an internet-based survey.

MATERIAL AND METHODS

We invited LT recipients from the Liver Transplant Follow-up Center of the University Hospital of Salerno to access remote consultation. A subgroup of them also participated in a self-administered, internet-based survey evaluating demographics; LT data and immunosuppressive therapy; comorbidities; attitudes towards COVID-19 infection; their perceptions of the need for health care, and their approach to telemedicine.

RESULTS

Seventy-four/one hundred and fifty-three (48.3%) LT recipients were unable to access remote consultation. They showed a significantly higher mean age and a higher percentage of low school degree compared to those who accessed it (p=0.03 and p=0.001, respectively). Among the remaining LT recipients, 50/79 (63.3%) responded to the survey; mean time from liver transplantation was 12±7 years; 94% of the sample reported at least one comorbidity; 44% of LT recipients declared to be "very much/much" worried because of COVID-19 infection, and 64% considered themselves more vulnerable than the general population. Forty percent of responders refused the routine follow-up visit, and 62% were very interested in using Telemedicine.

CONCLUSION

LT recipients were anxious because of COVID-19 infection and considered themselves more vulnerable than the general population, refusing the routine clinical visit. For continuing services during the COVID-19 era, new strategies are needed and telemedicine shows promise.

Telemedicine Chronic Viral Hepatitis C Treatment during the Lockdown Period in Romania: A Pilot Study

The COVID-19 pandemic is currently delaying the process of chronic hepatitis C (HCV) eradication, since most of the chronic diseases are neglected. Thus, there is a need for alternative programs for HCV therapy implementation and disease monitoring. Our aim was to provide a multidisciplinary approach, so that HCV-infected patients from distant locations may benefit from HCV antivirals during the COVID-19 outbreak and within the lockdown period in Romania. Previously diagnosed HCV patients willing to participate in this telemedicine pilot study were included. Patient characteristics and medical adherence were assessed and compared to the year preceding the pandemic. We proposed a multidisciplinary approach by using a telemedicine program for HCV therapy monitoring. Patients also received a satisfaction questionnaire after delivering the sustained virologic response (SVR) result. A total of 41 patients agreed to participate in this study. The medication adherence was 100% for patients included in the telemedicine group, with a statistically significant difference from the medication adherence of the patients treated in 2019. The satisfaction item score was 4.92 out of 5 and our results (r = −0.94, p < 0.0001) suggested that older patients embraced the telemedicine program less, but with the same success in terms of SVR (100%) and medication adherence (100%). Our pilot study offers the first example of a telemedicine program in Romania for HCV therapeutic management. During the lockdown period, telemedicine has served as a reliable tool and novel alternative for conventional monitoring of patients treated with direct antiviral agents and should be further considered even following the pandemic.

Impact of mobile health and medical applications on clinical practice in gastroenterology

Mobile health apps (MHAs) and medical apps (MAs) are becoming increasingly popular as digital interventions in a wide range of health-related applications in almost all sectors of healthcare. The surge in demand for digital medical solutions has been accelerated by the need for new diagnostic and therapeutic methods in the current coronavirus disease 2019 pandemic. This also applies to clinical practice in gastroenterology, which has, in many respects, undergone a recent digital transformation with numerous consequences that will impact patients and health care professionals in the near future. MHAs and MAs are considered to have great potential, especially for chronic diseases, as they can support the self-management of patients in many ways. Despite the great potential associated with the application of MHAs and MAs in gastroenterology and health care in general, there are numerous challenges to be met in the future, including both the ethical and legal aspects of applying this technology. The aim of this article is to provide an overview of the current status of MHA and MA use in the field of gastroenterology, describe the future perspectives in this field and point out some of the challenges that need to be addressed.

Acceptance and use of a smartphone application in cirrhosis

BACKGROUND AND AIMS

The development of cirrhosis-related smartphone applications for remote monitoring is increasing. Whether patients with cirrhosis will welcome such new technology, however, is uncertain.

METHODS

We prospectively enrolled patients with cirrhosis (N = 102) to determine predictors of acceptance and utilization of a smartphone application for cirrhosis management using a 12-item Technology Acceptance Model (TAM) survey. Patients were then shown the EncephalApp© and evaluated for their willingness to download and use the application.

RESULTS

Patients had a median age of 61.3 years and 63.7% had a history of hepatic decompensation. Intention to use the hypothetical application was associated with perceived usefulness (β: 0.4, 95% CI: 0.3-0.5) and the presence of a caregiver (β: 1.1, 95% CI: 0.2-2.0). Of the eligible participants, 71% agreed to download the EncephalApp© and the decision was influenced by computer anxiety, behavioural intent, caregiver presence and disease state factors. Actual usage was 32% and not associated with baseline characteristics or the technology acceptance model.

CONCLUSIONS

Patient acceptance of smartphone applications for the management of cirrhosis is high and related to their attitudes towards technology and the presence of a caregiver. However, usage was low. Future research must employ behavioural interventions to optimize uptake and utilization of remote monitoring technology.