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Yakovchenko V, Morgan TR, Miech EJ, Neely B, Lamorte C, Gibson S, Beste LA, McCurdy H, Scott D, Gonzalez R, Park A, Powell BJ, Bajaj JS, Dominitz JA, Chartier M, Ross D, Chinman MJ, Rogal SS. Core implementation strategies for improving cirrhosis care in the Veterans Health Administration. Hepatology 2022; 76:404-417. [PMID: 35124820 PMCID: PMC9288973 DOI: 10.1002/hep.32395] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. APPROACH AND RESULTS VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. CONCLUSIONS In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.
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Affiliation(s)
- Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Timothy R. Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA,Division of Gastroenterology, Department of Medicine, University of California, Irvine, CA
| | - Edward J. Miech
- Department of Veterans Affairs, Roudebush VA Medical Center, HSR&D Center for Health Information & Communication, VA PRIS-M QUERI, Indianapolis, IN,Regenstrief Institute, Indianapolis, IN
| | - Brittney Neely
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lauren A. Beste
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA,General Medicine Service, VA Puget Sound Health Care System, Seattle, WA
| | | | - Dawn Scott
- Department of Medicine, Central Texas Veterans Healthcare System, Temple, TX
| | - Rachel Gonzalez
- Department of Veterans Affairs, Sierra Pacific Veterans Integrated Service Network, Pharmacy Benefits Management, Mather, CA
| | - Angela Park
- Office of Healthcare Transformation, Department of Veterans Affairs, Washington, DC
| | - Byron J. Powell
- Brown School, Washington University in St. Louis, St. Louis, MO
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA,Division of Gastroenterology, Central Virginia Veterans Affairs Healthcare System, Richmond, VA
| | - Jason A. Dominitz
- Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA,Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - David Ross
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - Matthew J. Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,RAND Corporation, Pittsburgh, PA
| | - Shari S. Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Wu T, Simonetto DA, Halamka JD, Shah VH. The digital transformation of hepatology: The patient is logged in. Hepatology 2022; 75:724-739. [PMID: 35028960 PMCID: PMC9531185 DOI: 10.1002/hep.32329] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Tiffany Wu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John D. Halamka
- Mayo Clinic Platform, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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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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Halalau A, Imam Z, Karabon P, Mankuzhy N, Shaheen A, Tu J, Carpenter C. External validation of a clinical risk score to predict hospital admission and in-hospital mortality in COVID-19 patients. Ann Med 2021; 53:78-86. [PMID: 32997542 PMCID: PMC7877986 DOI: 10.1080/07853890.2020.1828616] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/20/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Identification of patients with novel coronavirus disease 2019 (COVID-19) requiring hospital admission or at high-risk of in-hospital mortality is essential to guide patient triage and to provide timely treatment for higher risk hospitalized patients. METHODS A retrospective multi-centre (8 hospital) cohort at Beaumont Health, Michigan, USA, reporting on COVID-19 patients diagnosed between 1 March and 1 April 2020 was used for score validation. The COVID-19 Risk of Complications Score was automatically computed by the EHR. Multivariate logistic regression models were built to predict hospital admission and in-hospital mortality using individual variables constituting the score. Validation was performed using both discrimination and calibration. RESULTS Compared to Green scores, Yellow Scores (OR: 5.72) and Red Scores (OR: 19.1) had significantly higher odds of admission (both p < .0001). Similarly, Yellow Scores (OR: 4.73) and Red Scores (OR: 13.3) had significantly higher odds of in-hospital mortality than Green Scores (both p < .0001). The cross-validated C-Statistics for the external validation cohort showed good discrimination for both hospital admission (C = 0.79 (95% CI: 0.77-0.81)) and in-hospital mortality (C = 0.75 (95% CI: 0.71-0.78)). CONCLUSIONS The COVID-19 Risk of Complications Score predicts the need for hospital admission and in-hospital mortality patients with COVID-19. Key points: Can an electronic health record generated risk score predict the risk of hospital admission and in-hospital mortality in patients diagnosed with coronavirus disease 2019 (COVID-19)? In both validation cohorts of 2,025 and 1,290 COVID-19, the cross-validated C-Statistics showed good discrimination for both hospital admission (C = 0.79 (95% CI: 0.77-0.81)) and in-hospital mortality (C = 0.75 (95% CI: 0.71-0.78)), respectively. The COVID-19 Risk of Complications Score may help predict the need for hospital admission if a patient contracts SARS-CoV-2 infection and in-hospital mortality for a hospitalized patient with COVID-19.
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Affiliation(s)
- Alexandra Halalau
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Zaid Imam
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nikhil Mankuzhy
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Aciel Shaheen
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
| | - John Tu
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Clinical Informatics, Beaumont Health, Southfield, MI, USA
| | - Christopher Carpenter
- Internal Medicine Department, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Section of Infectious Disease, Beaumont Health, Royal Oak, MI, USA
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Louissaint J, Foster C, Harding-Theobald E, Lok AS, Tapper EB. Social Support Does Not Modify the Risk of Readmission for Patients with Decompensated Cirrhosis. Dig Dis Sci 2021; 66:1855-1861. [PMID: 32578043 PMCID: PMC7755706 DOI: 10.1007/s10620-020-06421-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with decompensated cirrhosis are at high risk of frequent hospitalizations. Whether the level of perceived social support impacts this risk is unknown. We sought to determine the relationship between social support and burden of hospitalization in patients with decompensated cirrhosis. METHODS A total of 73 patients, all with decompensated cirrhosis and an index cirrhosis-related admission between 7/1/2017 and 7/1/2019, completed the modified medical outcomes study social support (mMOS-SS) survey. We retrospectively assessed the relationship between mMOS-SS scores and probability of readmission 90-days after the index admission. Additionally, we prospectively analyzed the association between mMOS-SS scores at enrollment and risk of 90-day hospitalization. RESULTS At enrollment, 50.7% were female, median age 61 years, and median mMOS-SS score was 87.5. Median model for end-stage liver disease sodium (MELD-Na) at the time of the index admission was 15 and was 13 at the time of enrollment. The mMOS-SS score did not modify the rate of readmission 90 days after the index admission date (adjusted HR 1.01, 95%CI 0.98-1.03) nor was it associated with the rate of admission 90 days after enrollment prospectively (adjusted HR 0.99, 95%CI 0.96-1.02). The MELD-Na score at enrollment was the only significant predictor of hospitalization during prospective follow-up (adjusted HR 1.18, 95%CI 1.09-1.27). CONCLUSIONS Social support, as measured by the mMOS-SS survey, in patients with decompensated cirrhosis was high. However, this did not modify the risk of cirrhosis-related hospitalizations. Future investigation to define the specific components of social support that could modify readmission risk is needed.
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Affiliation(s)
- Jeremy Louissaint
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Chelsey Foster
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Emily Harding-Theobald
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman, SPC 5362 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Abstract
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.
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Louissaint J, Lok AS, Fortune BE, Tapper EB. Acceptance and use of a smartphone application in cirrhosis. Liver Int 2020; 40:1556-1563. [PMID: 32343467 DOI: 10.1111/liv.14494] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 02/13/2023]
Abstract
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.
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Affiliation(s)
- Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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