Telemedicine Approaches for Patients with Cirrhosis, Including Vulnerable Populations: A Narrative Review

Abstract

Background:

The COVID-19 pandemic accelerated the adoption of telemedicine in health care. However, telemedicine in cirrhosis care remains underexplored. In particular, patients with alcohol use disorder (AUD) and hepatitis C virus (HCV) may be overrepresented among vulnerable populations, but have limited access to telemedicine.

Method:

We performed a literature review on telemedicine approaches for patients with cirrhosis as well as patients with AUD and HCV with or without cirrhosis. Peer-reviewed studies involving direct patient-physician interactions were searched on PubMed and Google Scholar. Keywords used included cirrhosis, AUD, HCV, and telemedicine. Abstracts were screened. Full texts were reviewed.

Results:

Among patients with cirrhosis, videoconferencing at satellite sites shortened the time from liver transplant referral to evaluation and listing. Telephone calls were less effective, especially for those with decompensated cirrhosis. Among patients with AUD, videoconferencing at satellite sites was effective, with patients being five times more likely to be prescribed medications. Treatment programs involving videoconferencing and telephone calls demonstrated retention rates above 50%. Among patients with HCV, videoconferencing was effective, with high (>90%) sustained virological response rates. Across all approaches, concerns raised included audiovisual quality, patient privacy, and licensing restrictions.

Conclusion:

Videoconferencing at satellite sites is most promising if audiovisual quality and other barriers are optimized. Telemedicine may not be appropriate for management of decompensated cirrhosis.

Lay Summary

The COVID-19 pandemic accelerated the adoption of telemedicine in health care. However, telemedicine remains underexplored among patients with cirrhosis (scarring of the liver). In particular, patients with alcohol use disorder (AUD) and hepatitis C virus (HCV) may be overrepresented among vulnerable populations, but have limited access to telemedicine. We performed a literature review on telemedicine approaches for patients with cirrhosis as well as patients with AUD and HCV with or without cirrhosis. Among patients with cirrhosis, videoconferencing at satellite sites shortened the time from liver transplant referral to evaluation and listing. Telephone calls were less effective, especially for patients who were decompensating. Among patients with AUD, videoconferencing at satellite sites was effective, with patients being five times more likely to be prescribed medications. Treatment programs involving videoconferencing and telephone calls demonstrated retention rates above 50%. Among patients with HCV, videoconferencing was effective, with high (>90%) response rates. Across all approaches, concerns raised included audiovisual quality, patient privacy, and licensing restrictions. In conclusion, videoconferencing at satellite sites is most promising if audiovisual quality and other barriers are optimized. Telemedicine may not be appropriate for managing decompensated cirrhosis.

Abbreviations

• AUD = alcohol use disorder

• ECHO = Extension for Community Healthcare Outcomes

• HCV = hepatitis C

Introduction

The COVID-19 pandemic dramatically changed how health care is delivered in North America. With physical distancing required and citizens told to shelter in place, medical visits rapidly pivoted from in-person visits to widespread use of telemedicine (1, 2, 3). This included the use of telephone visits and video calls directed to the patient, in contrast with previous use of satellite sites that required patients to travel to communication hubs (1, 2, 3).

Telemedicine, as defined by “two-way, real-time interactive communication between the patient and the physician at a distant site,” has demonstrated numerous advantages, particularly when care needs to be delivered over large geographic areas (4). It increases medical accessibility, especially for rural inhabitants and individuals with disabilities (5,6). There is increased patient satisfaction due to improved convenience and efficiency (5,6). Caregiver burnout is reduced (7). From a system perspective, telemedicine has been shown to decrease health care costs and wait times (5,6). However, the adoption of telemedicine to facilitate direct technological interactions between patients and providers, with no intermediary such as a satellite site, has only really been widespread since the pandemic pushed physician compensation models to permit these types of encounters.

Arora et al. transformed HCV treatment by leveraging videoconferencing technology to train primary care providers in managing complex diseases, leading to the successful development of the Extension for Community Healthcare Outcomes (ECHO) model (8). However, there are limited data on the use of telemedicine for liver disease treatment in scenarios in which patients interact directly with hepatologists, rather than through provider training programs.

As we return to pre-pandemic routines, health authorities must now re-evaluate the role of telemedicine within the standard medical model of health care delivery. There are multiple barriers to the continued adoption of telemedicine, including reimbursement, medical liability, patient privacy and confidentiality, and fraud. In addition, certain patients struggle with accessing telemedicine due to socioeconomic determinants of health, such as social isolation and poverty. However, we believe that telemedicine is likely to continue due to patient preference.

We therefore performed a review of the literature on the efficacy of different telemedicine approaches (e.g. telephone calls, videoconferencing software) in patients with cirrhosis. Cirrhosis is not a monolithic entity. Certain etiologies of liver disease (e.g., AUD, HCV) are more common among vulnerable populations, who may have difficulty accessing telemedicine. We therefore also reviewed the use of telemedicine in patients with AUD and HCV with or without cirrhosis as there are no data in cirrhotic patients with only AUD or HCV. Based on our findings, we seek to propose a model on how to deliver high-quality, safe patient care via telemedicine to all patients with cirrhosis, including vulnerable populations.

Method

We used PubMed and Google Scholar to search peer-reviewed studies written in English. We searched the following terms and their synonyms as keywords: cirrhosis, alcohol use disorder, hepatitis C, and telemedicine. Search terms were used in combination. Titles and abstracts of search results were screened for relevant publications. Full text reviews were then conducted to select appropriate papers. Reference lists of included studies were reviewed for additional studies. Papers assessing efficacy of smartphone applications and websites without direct assistance from health care providers were excluded (e.g., an app that tracks the amount of alcohol use). Key findings from included studies on different telemedicine approaches for patients with cirrhosis, AUD, and HCV were summarized in tables. Information reported included year of publication, country, study design, inclusion and/or exclusion criteria, intervention used, and outcomes.

Efficacy of Different Telemedicine Approaches for Patients with Cirrhosis

Table 1 shows the different telemedicine approaches that have been used for patients with cirrhosis of all etiologies. They were divided into use of videoconferencing software at a satellite site and use of telephone calls. There were no studies using videoconferencing software to connect patients in their homes directly with a hepatologist. Instead, study patients who used videoconferencing were required to travel to a local center, where specialized nurses and/or technicians would take vitals and assist with the technology.

Table 1:

Telemedicine approaches in patients with cirrhosis

Authors	Country	Study Design	Inclusion and Exclusion Criteria	Intervention and Comparison Groups	Outcomes
Satellite site
John et al., 2020 (9)	United States	Retrospective study (n = 465 from 60 Veteran Affairs medical centres in 29 states)	Inclusion: referred for liver transplant evaluation from 2005 to 2017	– Intervention: virtual evaluations with a transplant hepatologist at local medical centres. Nurses or technologists assisted with technology. – Videoconferencing software used: N/A. – Comparison group: in-person evaluations with a transplant hepatologist.	– Patients seen virtually were evaluated 57.8 days faster for transplantation than those seen in person. – Virtual evaluations were associated with a shorter transplant waitlist time by 110 days. – Times from referral to transplant evaluation and listing were shorter for those seen virtually, especially for those with lower MELD-Na scores.
Serper et al., 2020 (10)	United States	Case series (n = 67 between a community gastroenterology clinic and a single tertiary center)	Inclusion: hospitalized for decompensated cirrhosis; referred by gastroenterologist for a second opinion; offered a telemedicine appointment	– Intervention: virtual visits with hepatologists at patient's local gastroenterologist's clinic. Medical assistants assisted with technology. – Videoconferencing software: VidyoConnect (Vidyo, Inc., Hackensack, NJ), Health Insurance Portability and Accountability Act compliant and encrypted. – Comparison group: none.	– 46% of patients had decompensated cirrhosis. – 85% of patients referred received a teleconsultation. – More than half of visits resulted in an intervention (e.g., medication changes, transplant referral). Patients were satisfied with the teleconsultation service with a mean Net Promoter Score of 92. – 11% of patients were not satisfied with the audiovisual quality and the communication between referring physicians and hepatologists. – Referring physicians had strongly positive survey responses.
Telephone
Bensted et al., 2021 (11)	Australia	Survey (n = 302)	Inclusion: adult age, received telephone visit between March and September 2020 at St. George Hospital or Sutherland Hospital Gastroenterology Clinics Exclusion: decompensated cirrhosis; received hepatocellular carcinoma treatment; a recent inflammatory bowel disease flare	– Intervention: telephone visits with a gastroenterologist – Comparison: none	– 35 patients had cirrhosis. 97.1% of them reported that their telephone visits were “very good” or “good.” – 17.1% of patients with cirrhosis experienced worsening symptoms including ascites, hepatic encephalopathy, and jaundice. 25% of them believed that care was not easily accessible.

Satellite sites were used to evaluate patients for liver transplant eligibility and provide follow-up care for hospitalized cirrhotic patients and/or hepatology consultations. For liver transplant evaluation, there appeared to be significantly improved access to care (9). For patients who were seen virtually versus in-person, time from liver transplant referral to evaluation was significantly shorter (21.7 days vs. 79.5 days, p < 0.0001), as was time from liver transplant referral to listing (138.8 days vs. 249 days, p < 0.01) (9). However, this did not translate into a reduction in time to transplantation or pre-transplant mortality (9). This is likely because the difference in time was greatest for patients with low Na-MELD scores (Na-MELD < 20) (9). For example, time from referral to listing in patients with a Na-MELD < 15 was 150 days for patients seen virtually versus 311 days for patients seen in person (9). For patients with a Na-MELD > 25, the time from referral to listing was 58.8 days versus 52.5 days, respectively (9). Serper et al. reported a case series on the use of community-based gastroenterologists’ offices to connect with a hepatologist, with the help of on-site medical assistants (10). It appeared to be feasible, with only 6% (n = 4) of patients unable or unwilling to complete the appointment. It appeared to be effective, with 45% (n = 26) of visits resulting in medical changes, and 18% (n = 10) leading to referral for liver transplant, although there was no comparator group. Survey responses exceeded typical satisfaction levels seen in health care settings, although 11% (n = 4) thought there could be improvements in the audiovisual quality, and 11% (n = 4) desired better communication between the provider and referring physician. Referring physicians also found the service provided to be ‘valuable,’ ‘helpful,’ ‘convenient,’ and ‘efficient.’ Unfortunately, this pilot program could not be extended as providers could not obtain reimbursement, but instead had to be compensated on a one-time basis via a research grant. In addition, due to state-specific licensing regulations, care could not be automatically extended across state lines. Many jurisdictions require providers to be licensed in the state where patients are physically located, that is, where the care is considered to have occurred. This highlights some of the important barriers to the expansion of telemedicine.

Telephone calls appeared to be less effective for telemedicine. At the start of the pandemic, an Australian teaching hospital converted their gastroenterology clinics to telephone calls (11). A sub-analysis of the hepatology clinic identified 35 patients (24.3%) with cirrhosis. In a survey, 97.1% of patients with cirrhosis reported that the care they received via telephone visits were ‘very good’ or ‘good.’ However, 8 patients (17.1%) experienced worsening symptoms including ascites, hepatic encephalopathy, and jaundice over time. Among those patients who decompensated, 25% (n = 2) reported that the care was not easily accessible by telephone. This highlights that telemedicine may not be appropriate for all patients depending on their disease severity.

Efficacy of Different Telemedicine Approaches for Patients with Alcohol Use Disorder and Hepatitis C Virus

A major concern is that vulnerable groups without access to computers and the Internet may be unable to benefit from telemedicine. We therefore elected to look at telemedicine approaches for patients with diagnoses traditionally associated with lower socioeconomic status and social barriers to health care (e.g., AUD and HCV). Because no data exist for patients with alcohol-related cirrhosis and HCV cirrhosis, we reviewed patients with AUD and HCV alone, with or without documented liver disease.

Telemedicine and AUD

Table 2 shows the different telemedicine approaches that have been used for patients with AUD. We found no studies with physicians directly contacting patients through telephone or videoconferencing software. Instead, patients were enrolled in alcohol treatment programs that incorporated the capacity to connect directly with physicians using either videoconferencing software or telephone calls. In addition, one study used primary care providers’ offices as satellite sites for patients to connect with addiction medicine specialists. We did not include studies in which patients were connected with nurses or psychologists only for management of AUD.

Table 2:

Telemedicine approaches for patients with AUD

Authors	Country	Study Design	Inclusion and Exclusion Criteria	Intervention and Comparison Groups	Outcomes
Videoconference and phone call
Mitchell et al., 2019 (12)	United States	Prospective cohort study (n = 77)	Inclusion: at least 21 years of age, alcohol use disorder, able to pay $99 to access telemedicine service	– Intervention: an AUD treatment program via a smartphone application that offered physician visits, support from recovery coaches, and monitoring of medication adherence and blood alcohol content levels. Visits were conducted via telephone and videoconferencing. – Videoconferencing software used: N/A. – Comparison group: none.	– Retention rate was 55% at 90 days. – Among patients who continued to be engaged with the service at 90 days, their average blood alcohol content decreased by 50%.
Ghodsian et al., 2018 (13)	United States	Case report (n = 4)	Inclusion: mild-moderate opioid/alcohol/benzodiazepine/hypnotic/anxiolytic use disorders; stable living conditions; available social supports; access to the Internet; stable mental/medical health; motivation for substance use treatment; history of withdrawal symptoms	– Intervention: 7–11 day telemedicine detoxification treatment. – Initial visit—addiction medicine physician via videoconferencing. – Physicians prescribed detoxification medications. – Physicians contacted patients by telephone 1–4 times per day to monitor withdrawal symptoms, vitals, and medical and psychiatric issues and adjust detoxification medications. – Videoconferencing software used: compliant with Ryan Haight Act that prevents illegal distribution of controlled substances via the Internet. – Comparison group: none.	– Patients were satisfied with the convenience of the virtual service. – Patients only experienced mild withdrawal symptoms and did not have any complications.
Satellite site
Leibowitz et al., 2020 (14)	United States	Pilot feasibility prospective study (n = 566) Patients with a video consult with an addiction medicine specialist (n = 32)	Inclusion: AUD; issues with alcohol use; barriers to starting treatment through existing services	– Intervention: Patients were seen via videoconferencing by an addiction medicine physician at their primary care provider's (PCP) clinic.	– 52 virtual visit requests were made. 32 virtual visits were completed. 20 visits requested were not completed because the addiction medicine specialist was unavailable, the PCP did not follow the workflow, or there was poor internet connection. – 3 virtual visits were completed via telephone because of technical problems. For 57% of virtual visits completed, the quality was affected by technological issues. – 34.4% of patients who received a virtual visit were prescribed AUD medications compared with 6.4% of patients without a virtual visit.
		Patients without a video consult with an addiction medicine specialist (n = 534)		– Physicians performed clinical assessments, provided motivational enhancement and psychoeducation about treatment options, and scheduled follow-up appointments as needed – Provided guidance to primary care providers about pharmacotherapy, prescribed medications, and ordered lab work – Kaiser Permanente Northern California HIPAA-compliant video visit web and mobile apps were used – Comparison group: patients who did not receive a virtual visit with an addiction medicine physician

In the study by Mitchell et al., patients were enrolled in a comprehensive treatment program using a smartphone application as an interface (12). The app could be accessed for virtual visits with physicians via telephone and videoconferencing as well as for support from recovery coaches via telephone, videoconferencing, and text message. Through virtual visits, physicians were able to prescribe anti-craving medications, monitor labs, and assess compliance. However, local health care providers performed physical examinations, and findings were communicated to treating physicians. The retention rate was 55% at 90 days. Among patients who continued to be engaged with the service at 90 days, their average blood alcohol content decreased by 50% from 0.091 to 0.045. Self-reported alcohol use was not documented.

Another virtual service focused on detoxification treatment. In a case study by Ghodosian et al., four low-income patients completed a 7-to-11-day detoxification treatment via videoconferencing and telephone (13). Patients were given blood pressure monitors to take their vitals at home, while addiction medicine specialists would call patients up to four times per day to monitor their symptoms and prescribe or adjust detoxification medications as needed (e.g., oxazepam). All patients successfully completed treatment with no medical or psychiatric complications and only mild withdrawal symptoms.

A study by Leibowitz et al., used videoconferencing technology to allow patients immediate access to addiction medicine specialists via their primary care physician's (PCP) offices (14). In this study, 91 PCPs, who served over 100,000 patients 18 years of age and older at 9 clinics, were trained on AUD and its health impacts, introductory information on AUD pharmacotherapy, and how to access video consultations with an addiction medicine specialist. A total of 586 patients with an AUD diagnosis were seen by their PCP. Of those patients, PCPs requested 52 video consultations with specialists. However, due to technical issues and a lack of availability of specialist personnel, only 32 consults were completed. Video call quality was quite poor, with 57% of consults affected by issues such as video and audio lag to the degree that 3 consults occurred via telephone call as a result. Perhaps due to the aforementioned issues, only five PCPs requested more than one consult for more than one patient. However, if patients were able to connect with an addiction medicine specialist, they were more likely to be prescribed AUD medications (34.4% vs. 6.4% of patients). The majority of PCPs (94%) indicated that they would use the service again if specialist availability and technical quality were improved.

Telemedicine and HCV

Table 3 shows the different telemedicine approaches that have been used for patients with HCV. Two studies used videoconferencing only. Two studies used videoconferencing at satellite sites (PCP's office and prison setting). One study used telephone calls only. One study used a combination of videoconferencing and telephone calls.

Table 3:

Telemedicine approaches for patients with HCV

Authors	Country	Study Design	Inclusion and Exclusion Criteria	Intervention and Comparison Groups	Outcomes
Videoconference
Doica et al., 2021 (15)	Romania	Pilot study (n = 41)	– Inclusion: received direct antiviral agent regimens from March 15 to May 15, 2020; prior diagnosis of HCV infection and followed by general practitioner. – % of patients with cirrhosis: N/A. – % of patients with genotype 3 HCV: N/A. – % of patients with HCV of other genotypes: N/A.	– Intervention: three visits with hepatologists via videoconferencing. Included initial assessments, education about indications and side effects of direct antiviral agents, and determination of patient adherence and compliance. – Comparison: in-person visits with hepatologists. – Videoconferencing software used: n/a, freely available video applications. – HCV treatment: dasabuvir with ombitasvir, paritaprevir, or ritonavir; ledipasvir with sofosbuvir.	– All patients in the intervention group were adherent to their medications vs. 94.7% in the comparison group (p = 0.0328). – All patients in the intervention group achieved sustained virological response (SVR). – Patients were satisfied with the care. Average score on the Telemedicine Satisfaction Questionnaire is 4.92 out of 5. – 89% of patients in the intervention group used their mobile phones. – 4.8% of visits were rescheduled due to poor Internet connection.
Nazareth et al., 2013 (16)	Australia	Prospective cohort study (n = 53)	– Inclusion: rural and remote adult with HCV; not pregnant; not trying to become pregnant; not breastfeeding; willing to use two forms of contraception. – % of patients with cirrhosis: 20% in intervention group (Hepascore greater or equal to 0.8). – % of patients with genotype 3 HCV: 36%. – % of patients with HCV of other genotypes: 64%.	– Intervention: visits with nurse practitioners via videoconferencing. Visits involved consultation, follow-up, HCV therapy initiation, and patient education. – Comparison: in-person visits. – Videoconferencing software used: N/A, bandwidth of 384 kbit/s ISDN or 1 Mbit/s IP. – HCV treatment: pegylated interferon and ribavirin.	– 50 patients were started on HCV therapy; 35 patients completed treatment. – Patients in the intervention group with genotype 1 infection had a higher SVR rate than the comparison group (73% vs. 51%, p-value >0.05). – Patients in the intervention group with genotype 2 and 3 had a similar SVR rate (70% vs. 68%). – 35 patients in the intervention group completed a questionnaire and were satisfied with the care.
Satellite site
Rossaro et al., 2013 (17)	United States	Retrospective cohort study (n = 80)	– Inclusion: 18–75 years of age, HCV infection diagnosed via PCR; had not received prior HCV treatment; referred to HCV specialist by general practitioner. – % of patients with cirrhosis: 27.5% (intervention group) and 45% (comparison group). – % of patients with genotype 3 HCV: 17.5% (intervention group) and 25% (comparison group). – % of patients with HCV of other genotypes: 82.5% (intervention group) and 75% (comparison group).	– Intervention: visits with hepatologists via videoconferencing at their PCP's clinics. The visits involved discussions about disease severity, treatment indications and contraindications, treatment benefits and side effects, risk of HCV transmission, monitoring, and follow-ups. PCPs performed physical examinations. – Videoconferencing software used: N/A. – Comparison: in-person visits. – HCV treatment: pegylated interferon and ribavirin.	– SVR rates were similar between groups (55% vs. 43%, p = 0.36). – The intervention group had a higher treatment completion rate (78% vs. 53%, p = 0.03). – The intervention group received 10 times more visits than the comparison group (19.6 vs. 0.07, p <0.0001). – Treatment discontinuation rate was higher in the intervention group because of depression (10% vs. 2.5%).
Halder et al., 2021 (18)	Australia	Prospective study (n = 332)	Inclusion: incarcerated; chronic HCV infection; referred from prisons within Western Australian East Metropolitan Health Service area; baseline investigations completed with recent Hepascore – % of patients with cirrhosis: 10% with Child Pugh A – % of patients with genotype 3 HCV: 52% – % of patients with HCV of other genotypes: 48%	– Intervention: video call with hepatologist, prison nurses, hepatology nurses, and telehealth coordinators. – Videoconferencing software used: Health Direct that allows for secure, encrypted video communications. – Comparison: none. – HCV treatment: sofosbuvir with velpatasvir, ledipasvir, daclatasvir, or velpatasvir and voxilaprevir; glecaprevir with pibrentasvir; elbasvir with grazoprevir.	– 332 patients were started on HCV therapy within 30 months. – 221 patients had SVR data; 91% of them achieved SVR. – 23 patients had cirrhosis and SVR data; 96% of them achieved SVR. – 29% of patients were lost to follow-up as they were released from prison. – The telemedicine clinic increased the number of prisoners seen per year from 10 to 137.
Phone call
Chen et al., 2014 (19)	Taiwan	Prospective study (n = 298)	– Inclusion: adult age; interferon treatment; minimum 2,000 copies of HCV RNA per millilitre of serum by PCR; elevated alanine aminotransferase above upper limit of normal 6 months prior; liver biopsy showing chronic HCV. – % of patients with cirrhosis: N/A. – % of patients with genotype 3 HCV: 14.2% (intervention group) and 13.3% (comparison group). – % of patients with HCV of other genotypes: 85.8% (intervention group) and 86.7% (comparison group).	– Intervention: 4 nurses and a physician provided telephone visits. Patients had the option to call health care professionals anytime. – Comparison: in-person visits with public health nurses at an outpatient clinic. – HCV treatment: pegylated interferon and ribavirin.	– SVR rates in the telemedicine and comparison groups were similar (68.9% vs. 66%). – 28.6% and 26% of patients in the telemedicine and comparison groups, respectively, experienced flulike symptoms. – Dropout rate was less in the intervention group (5.4% vs. 12%). – The telemedicine program cost less than the in-person program (112,500USD vs. 232,632USD).
Videoconference and phone call
Sivakumar et al., 2022 (20)	United States	Retrospective study (n = 31)	– Inclusion: opioid use disorder; actively injecting drugs; had insurance; referred for HCV testing. – % of patients with cirrhosis: 0%. – % of patients with genotype 3 HCV: N/A. – % of patients with HCV of other genotypes: N/A.	– Intervention: A clinician reviewed laboratory results with patients via telephone, ensured patients did not have contraindications to HCV treatment, and formulated a treatment plan. Patients had the option to receive counseling via telephone or videoconferencing. – HCV treatment: glecaprevir with pibrentasvir; sofosbuvir with velpatisvir.	– Of the 66 patients, 35 had chronic HCV infection; 31 patients were started on HCV treatment. – SVR rate was 93.5% among those who received treatment. – SVR rate was 83.3% among the 12 patients who were unstably housed.
Unspecified telemedicine intervention
Syed et al., 2021 (21)	United States	Prospective study (n = 870)	– Inclusion: patients in the Virginia Department of Corrections; positive HCV RNA; compensated liver disease – Exclusion: end-stage liver disease; hepatocellular carcinoma; comorbidities; less than 9 months sentence remaining; recent tattoos; recent alcohol or drug use. – % of patients with cirrhosis: 62% had cirrhosis, 18% had bridging fibrosis, median FIB 4 score = 2.15. – % of patients with genotype 3 HCV: N/A. – % of patients with HCV of other genotypes: N/A.	– Intervention: telemedicine visits that assessed compliance, tolerance, adverse effects, duration of treatment, and response to treatment. – HCV treatment: sofosbuvir with velpatasvir; glecaprevir with pibrentasvir; ledipasvir with sofosbuvir; elbasvir with grazoprevir; among patients with cirrhosis, ribavirin was used with ledipasvir and sofosbuvir or with sofosbuvir and velpatasvir.	– SVR rate was 97%. – Compliance was almost 100%.
Talal et al., 2019 (22)	United States	Prospective cohort study (n = 62)	– Inclusion: enrolled in an opioid substitution therapy for at least 3 months; had medical insurance. – % of patients with cirrhosis: 34.5%. – % of patients with genotype 3 HCV: N/A. – % of patients with HCV of other genotypes: N/A.	– Intervention: biweekly virtual sessions via videoconferencing with a hepatologist and an advanced practitioner as the telepresenter. – A regulatory compliant system was used. – HCV treatment: sofosbuvir with velpatasvir/ledipasvir/ribavirin; ombitasvir with paritaprevir, dasabuvir, and ribavirin; elbasvir with grazoprevir.	– 45 patients received HCV treatment; 93.3% were eradicated of HCV. – 17 patients were not treated. 3 discontinued from the program due to relocation or incarceration; 2 were lost to follow-up; 2 were nonadherent to treatment; 10 had issues with medical insurance. – Positive predictor of treatment included marriage and mental health diagnosis except for depression. Negative predictors of treatment included divorced, separated, and widowed.

In the study by Doica et al., which used videoconferencing only, 100% of patients were compliant to their medications and achieved sustained virological response (SVR) (15). This is in comparison with 94.7% of patients who were seen in person and compliant to their medications (p = 0.0328). Forty-one patients with HCV received video visits with hepatologists who performed an initial assessment, education about HCV treatment, and assessment of patient compliance. The quality of video visits was overall good. Only 4.8% of video visits were affected by an unstable Internet connection and had to be rescheduled. Patients were also satisfied with the care that they received, giving an average score of 4.92 of 5 on the Telemedicine Satisfaction Questionnaire. Another study by Nazareth et al. showed an SVR rate of only 72% but included 15 of 50 patients who did not complete treatment by the time of analysis (16). Interestingly, 21 patients in the telemedicine group required in-person visits in addition to video visits—indicating that telemedicine was not considered adequate for almost half of the study population. Some issues raised by patients included poor audio quality and privacy concerns.

Two studies reviewed the management of HCV patients using telemedicine at satellite sites. Rossaro et al. included 40 patients who presented to their PCP's clinic, where physical examinations were performed (17). Patients also saw a hepatologist via video conferencing. Patients were treated with pegylated interferon and ribavirin. The SVR rate did not significantly differ between the telemedicine group and the in-person group (55% vs. 43% respectively, p = 0.36). However, a larger proportion of patients in the telemedicine group completed treatment compared with the in-person group (78% vs. 53%, respectively, p = 0.03). This is likely due to patients undergoing direct observed therapy and receiving 10 times more visits than the in-person group (19.6 vs. 0.07, respectively, p < 0.0001) to maximize treatment adherence, provide psychological support, and monitor and treat side effects. Another satellite site used is the prison setting, as studied by Halder et al. (18). A telemedicine clinic serving four prisons facilitated videoconferencing consultations between hepatologists and patients with HCV. The SVR rate was 91%. Initiation of the telemedicine clinic significantly improved access to care, increasing the number of prisoners seen annually from 10 to 137.

Another modality used was telephone calls only. In the study by Chen et al., four nurses and a physician provided telephone visits to 148 patients (19). Patients were treated with pegylated interferon and ribavirin. The SVR rate was similar to that of the in-person group (68.9% vs. 66%, respectively). However, a smaller proportion of patients in the telemedicine group discontinued treatment compared with the in-person group (5.4% vs. 12%, p < 0.05). Patients in the telemedicine group had the option to call health care professionals anytime and receive a faster response to potential adverse effects. Moreover, telemedicine was more cost-effective at half the cost of in-person care (USD112,500 vs. USD232,632).

One study by Sivakumar et al. utilized telephone calls or videoconferencing to provide HCV treatment to 35 patients who inject drugs (20). Two patients were lost to follow-up, and two patients became incarcerated. Among the 31 patients who initiated HCV treatment, 93.5% achieved SVR. The SVR rate was still 83.3% in 12 patients who had unstable housing.

Two final studies did not specify the exact method of telemedicine used. Syed et al. evaluated 870 patients who were referred from 25 correction facilities to a telemedicine clinic (21). The SVR rate was 97% irrespective of patient characteristics, HCV treatment regimen, and HCV genotype. A 100% compliance rate was observed as treatment was supervised by 24-hour nursing staff at all facilities. In the study by Talal et al., 62 patients enrolled in an opioid substitution therapy (OST) program were seen virtually by a hepatologist (22). In this study, 45 patients were initiated on HCV treatment, and 42 patients achieved SVR (93.3%).

Discussion and Conclusion

Historically, telemedicine has been used in hepatology to either (1) train primary care providers in managing liver disease, such as a hepatitis C, or (2) facilitate interactions between patients and providers (but usually through an intermediary such as a satellite site). With direct patient interactions using videoconferencing software becoming the norm across Canada, we performed a narrative review to see if there are data justifying its widespread use in hepatology—particularly with its complex patient population and potentially reduced access to technology. We attempted to limit our review to papers with direct interactions between patients and health care providers, although we did include papers in which patients still travelled to satellite centers to access the technology and facilitate the teleconferencing.

Overall, our review demonstrated the primary advantage of telemedicine is lowering barriers to care, particularly for individuals in remote areas or with limited ability. This is an important aspect to improve the management of patients with liver disease. It improves access to specialist evaluations, thus facilitating access to subspecialty care usually reserved for larger urban centers (e.g., liver transplant assessments). The quality of care also seemed to be excellent, with the majority of patients and referring providers expressing satisfaction with the quality of care received via telemedicine. Retention and compliance rates were promising among patients who were seen virtually. Videoconferencing at satellite sites appears to be most effective among the different telemedicine modalities. This is most likely because patients can receive support with technology and still receive physical examinations at satellite sites. Moreover, telemedicine has been shown to increase medical accessibility among vulnerable populations, including patients with AUD, patients with HCV, and patients who are unstably housed and incarcerated. Brief alcohol interventions are underutilized among patients with non-cirrhotic and non–alcohol-associated chronic liver disease (23). Based on our review, videoconferencing and telephone calls with addiction medicine specialists are promising in delivering treatment to patients with AUD. Similar telemedicine designs can be utilized to increase patient-provider communication, promote alcohol cessation, and fill in the treatment gap for the aforementioned patient population. Additionally, consultation with a hepatologist among patients with AUD decreases the rates of alcohol relapse and hazardous alcohol use (24). More patients with AUD can possibly be reached via videoconferencing and telephone calls given its convenience to prevent or slow the progression of alcohol-associated liver disease.

On the other hand, it is unclear whether telemedicine can be used to effectively manage patients with advanced liver disease, namely decompensated cirrhosis. Although the studies included were small and observational, based on our review, it suggests that telemedicine may not be as effective for patients with decompensated cirrhosis as they worsened and experienced complications such as hepatic encephalopathy and ascites. More studies are needed among patients with decompensated cirrhosis to better understand whether telemedicine is appropriate and safe for this patient population. Moreover, telemedicine remains limited by logistical barriers, such as the lack of in-person support for technology use, unless patients travel to a satellite site. In addition, regulatory challenges, such as state-specific licensing requirements and reimbursement issues, continue to limit the widespread expansion of telemedicine across different jurisdictions. However, it appears that many studies were able to successfully meet the requirement of using a regulatory compliant videoconferencing system.

The success of the ECHO model in enhancing specialist-provider communication and improving treatment for patients with HCV across large geographic areas exemplifies the potential of telemedicine in optimizing management of chronic liver disease. However, there is a significant lack of data examining this clinical care model for direct patient-provider interactions and in specific populations of patients with liver disease, including alcohol-related cirrhosis. This underscores the need for further studies in this area as well as careful consideration of socioeconomic factors that may hinder access to care. Ensuring equitable access to telemedicine for vulnerable populations is crucial to avoid exacerbating health disparities.

In conclusion, while telemedicine holds significant promise in the management of cirrhosis and other liver diseases, particularly for underserved populations, its success depends on overcoming barriers related to technology access, disease severity, patient confidentiality, and regulatory frameworks. Continued innovation, research, and policy development are essential to harness its full potential in delivering high-quality, accessible, and equitable care for all patients with cirrhosis.

Funding Statement

There was no funding received for this work.

Contributions:

Conceptualization: MTK Yau, C Tsien; Methodology: MTK Yau, C Tsien; Formal Analysis: MTK Yau, C Tsien; Investigation: MTK Yau, C Tsien; Writing - Original Draft: MTK Yau, C Tsien; Writing - Review and Editing: MTK Yau, C Tsien; Supervision: C Tsien.

Ethics Approval:

N/A

Informed Consent:

N/A

Registry and the Registration No. of the Study/Trial:

N/A

Data Accessibility:

N/A

Funding:

There was no funding received for this work.

Disclosures:

The authors have no conflicts of interest to disclose.

Peer Review:

This manuscript was peer reviewed.

Animal Studies:

N/A