How to improve preventive health care in patients with cirrhosis

INTRODUCTION

Cirrhosis poses unique challenges for patients due to the many associated complications, leading to a significant reduction in quality of life and a median survival time of 2 years in the decompensated state.¹ Patients with cirrhosis suffer from recurrent symptoms such as ascites, HE, and variceal bleeding, all of which not only significantly impact the quality of life but also result in a significant impact on health care utilization.^2,3 The American Association for the Study of Liver Diseases has developed a set of evidence-based quality measures for people living with cirrhosis in an attempt to standardize the management of patients living with cirrhosis.⁴

Screening for common complications of cirrhosis should be performed during each patient visit and should include a review of patient medications for potential hepatotoxicity or dose adjustments. Counseling regarding alcohol abstinence, immunizations, as well as treatment of any identifiable causes of cirrhosis should be reassessed at each visit as well. Preventive care can be related to cirrhosis-related complications as well as liver disease–specific complications and is detailed in Table 1.

TABLE 1.

Examples of common preventive measures in cirrhosis

Complication	Preventative measures
Portal hypertension  • Ascites  • SBP  • Varices  • HE  • HCC  • Vitamin deficiency  • Immunizations  • Medication hepatotoxicity  • Alcohol avoidance  • Family planning	Diagnostic paracentesis at first diagnosis of ascites Diagnostic paracentesis at each hospital admission Low-salt diet counseling Diuretics management Albumin repletion with large-volume paracentesis (>5 L removed) Primary prophylaxis for high-risk patients with low protein ascites Secondary prophylaxis with antibiotics lifelong Primary prophylaxis for patients with clinically significant portal hypertension (carvedilol preferred over nonselective beta-blockers) Secondary prophylaxis with beta-blockers and banding Screening at each visit Starting lactulose and/or rifaximin for overt HE Discussion regarding safety of driving Imaging and AFP every 6 mo Measuring fat-soluble vitamins yearly As per CDC guidelines, Hepatitis A and Hepatitis B vaccinations Review of medications at each visit Review of alcohol intake at each visit and address appropriately Discussion of family planning, safe contraception options, and pregnancy risks at each visit
Liver transplant evaluation	Once MELD is over 15 HCC within Milan criteria MELD exception conditions (eg, hepatopulmonary syndrome) Recurrent complications
PSC  • Risk of metabolic bone disease  • Risk of cholangiocarcinoma  • Risk of colorectal cancer with inflammatory bowel disease	Bone mineral density every 2 y Imaging with MRI/MRCP Colonoscopy every 1–2 y
PBC  • Risk of hypothyroidism	Yearly TSH
Viral hepatitis  • Risk of transmission if untreated	Discussion about vaccinations and household precautions
Genetic liver disease	Discussion regarding the need for family testing
Metabolic syndrome–associated steatotic liver disease	Discussions regarding weight loss options and referral to weight loss clinic Management of metabolic syndrome

Abbreviations: AFP, alpha fetoprotein; CDC, centers for disease control; HCC, hepatocellular carcinoma; HE, hepatic encephalopathy; MELD, model for end-stage liver disease; MRI, magnetic resonance imaging; MRCP, magnetic resonance cholangiopancreatography; PBC, primary biliary cholangitis; PSC, primary sclerosing cholangitis; SBP, spontaneous bacterial peritonitis; TSH, thyroid stimulating hormone.

In light of the burden on both patients and the health care system, exploring innovative solutions in preventive cirrhosis care is imperative. This article provides a review of the application of digital health tools in preventive health care for patients grappling with cirrhosis (Figure 1).

FIGURE 1.

Digital health tools in CLD preventive care. Abbreviations: CLD, chronic liver disease; DHT, digital health tools.

TELEMEDICINE IN THE CARE OF PATIENTS WITH CIRRHOSIS

The COVID-19 pandemic provided a much-needed catalyst for the expansion of telemedicine (TM) services for all people living with cirrhosis rather than focusing on patients with inadequate access to medical services.⁵ Several studies reported successful TM use with high rates of satisfaction among patients with chronic liver disease (CLD) and cirrhosis in Canada, the United States, and Europe.^6–8 TM visits to coordinate liver cancer surveillance were shown to be noninferior to standard consultation in an Australian study; however, US Veteran Affairs–based experience showed that in-person visits were more likely to lead to surveillance completion.⁶

A large observational study of Veterans Affairs population with CLD enrolled in Specialty Access Network‐Extension of Community Healthcare Outcome (the SCAN‐ECHO) study showed decreased risk of mortality in 518 patients compared to 62,237 controls with no visits (HR of 0.54 [95% CI: 0.36–0.81, p = 0.003]).⁹ TM has also made its way into the transplant referral process; a recent systematic review of TM interventions in patients with CLD identified 8 studies reporting on TM-related liver transplantation referrals, evaluations, and listings demonstrating both decreased time from referral to evaluation and listing.¹⁰

The benefits of TM are apparent; it can improve and optimize access to medical care for disadvantaged patient populations, reduce patient travel, and expedite care for patients with CLD. The limitations include (a) difficulty in navigating TM for older adults due to media device literacy, (b)access to the internet, and (c) uncertainty regarding insurance reimbursement for the services provided. Future areas of investigation include the feasibility of integrating TM as a part of routine care for patients with cirrhosis without increasing disparities in access to medical care (Figure 2).

FIGURE 2.

Telemedicine use in patient with cirrhosis.

ARTIFICIAL INTELLIGENCE AND EHR DATA FOR PREVENTIVE HEALTH CARE INTERVENTIONS

Artificial intelligence (AI) and digital technologies are changing the landscape of health care. In conjunction with the growing health care systems, health care providers are increasingly being inundated with large amounts of data daily. Although electronic health record systems provide an avenue for organizing many data streams into a singular interface, the significant volume of data present can be difficult to manage efficiently and effectively. To combat this data overload, clinical decision support tools that ingest these data for guided interpretation are necessary to facilitate the implementation of highly effective targeted interventions toward improving population health and preventive care management for patients (Figure 3).

FIGURE 3.

Utilization of Electronic Health Record Data for Digital Health Technologies.

AI provides an opportunity for optimizing pattern recognition within big data sets, and its integration into clinical decision support tools can be a promising strategy for efficient targeted interventions. When these tools are integrated into clinical workflows for providers, AI-augmented clinical decision support tools can allow for balancing the large volume of health care data with focused care delivery. In a study of an AI-augmented workflow designed for targeted Hepatitis C screening in Israel, study investigators used data from within their large health system to train a machine-learning algorithm to detect patients at the highest risk for being HCV carriers.¹¹ Prospective assessment of this algorithm to guide targeted outreach to 477 patients deemed to be high-risk led to the diagnosis of HCV in 38 patients. When compared to standard screening strategies guided by United States Preventive Task Force recommendations during the same period, the number needed to screen for detection was drastically reduced from 1029 to 10 when using the algorithm. This study highlights the power of leveraging AI to enhance clinical efficiencies and provide care to those patients who need it the most.

PATIENT-FACING DIGITAL INTERVENTIONS

Patient-facing digital interventions are another key component of using technology to improve cirrhosis care and quality of life. In addition to the technologies designed to optimize clinician workflow, patient-facing technologies deliver information or interventions directly to individuals with cirrhosis and their caregivers. Current interventions can be broadly categorized as educational and monitoring interventions.

Educational interventions include educational interventions for weight management in patients with metabolic dysfunction–associated steatotic liver disease.¹² Monitoring has included interactive voice call systems or smartphone applications to assess symptoms.^13,14 This monitoring can be accomplished through patients or caregivers inputting responses to prompts, or through smartphone or wearable technology to assess for physical changes such as weight changes, oxygen saturation, or encephalopathy indicators.^15,16 Bloom et al reported on the successful use of Bluetooth-based scales for weight and ascites management showing cost-effectiveness in the management of patients with cirrhosis and ascites. A wealth of literature exists on HE-related admissions including using apps like Patient Buddy App and Encephalapp by Stroop App, the latter being currently available for commercial use.¹⁷ A recently published review has recently summarized evidence surrounding the use of mobile apps in patients with cirrhosis.¹⁸

With the widespread availability of technologies that can monitor physical characteristics, such as smartwatches and smartphones, clinicians can use these opportunities to optimize care.¹⁹ Importantly, we must ensure these opportunities are applied equitably to reduce the implications of lower socioeconomic status or health care literacy on the ability to access these interventions and patients have indicated a willingness to engage with these technologies.^20,21

CONCLUSIONS

In summary, the advent of digital health tools for both patients and providers can facilitate the management of preventive care for patients with cirrhosis. Although the integration of these technologies in routine practice is variable, several studies have highlighted the promise, potential, and acceptability for continued utilization of these tools. Additional work is needed to assess not only the portability of these solutions across clinical environments but also their feasibility of integration at scale as well.