A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study

Abstract

Background Ascites is a common, painful, and serious complication of cirrhosis. Body weight is a reliable proxy for ascites volume; therefore, daily weight monitoring is recommended to optimize ascites management. Objective This study aims to evaluate the feasibility of a smartphone app in facilitating outpatient ascites management. Methods In this feasibility study, patients with cirrhotic ascites requiring active management were identified in both inpatient and outpatient settings. Patients were provided with a Bluetooth-connected scale, which transmitted weight data to a smartphone app and then via the internet to an electronic medical record (EMR). Weights were monitored every weekday. In the event of a weight change of ≥5 lbs in 1 week, patients were called and administered a short symptom questionnaire, and providers received an email alert. The primary outcomes of this study were the percentage of enrolled days during which weight data were successfully transmitted to an EMR and the percentage of weight alerts that prompted responses by the provider. Results In this study, 25 patients were enrolled: 12 (48%) were male, and the mean age was 58 (SD 13; range 35-81) years. A total of 18 (72%) inpatients were enrolled. Weight data were successfully transmitted to an EMR during 71.2% (697/979) of the study enrollment days, with technology issues reported on 16.5% (162/979) of the days. Of a total of 79 weight change alerts fired, 41 (52%) were triggered by weight loss and 38 (48%) were by weight gain. Providers responded in some fashion to 66 (84%) of the weight alerts and intervened in response to 45 (57%) of the alerts, for example, by contacting the patient, scheduling clinic or paracentesis appointments, modifying the diuretic dose, or requesting a laboratory workup. Providers responded equally to weight increase and decrease alerts (P=.87). The staff called patients a mean of 3.7 (SD 3.5) times per patient, and the number of phone calls correlated with technology issues (r=0.60; P=.002). A total of 60% (15/25) of the patients chose to extend their participation beyond 30 days. A total of 17 patient readmissions occurred during the study period, with only 4 (24%) related to ascites. Conclusions We demonstrated the feasibility of a smartphone app to facilitate the management of ascites and reported excellent rates of patient and provider engagement. This innovation could enable early therapeutic intervention, thereby decreasing the burden of morbidity and mortality among patients with cirrhosis.

A Telemonitoring Intervention for Cirrhotic Ascites Management Is Cost-Saving

“…Another intensive outpatient monitoring program with a day hospital followed 80 patients with cirrhotic ascites and reduced early readmission by onethird (11.3% vs. 29.5%) [5]. Finally, a 25-patient pilot study of a remote weight monitoring program from our group found an 11% readmission rate for ascites, though a much higher rate for all-cause readmission [7]. We predict that a telemonitoring program specifically for patients undergoing ascites management, without day hospital or other ancillary supports, would likely fall somewhere between the outcomes of these four programs: increasing outpatient care utilization by approximately 15% and decreasing inpatient care utilization by approximately 15%.…”

“…Two of the main reasons for readmission are failure to either arrange outpatient paracentesis for symptomatic ascites or recognize warning signs of over-diuresis [4]. Data are limited, however, supporting interventions that can reduce the burden of hospitalization for patients with ascites [5][6][7][8][9].…”

“…Weight telemonitoring may address the two key failures of outpatient ascites management by identifying rapidly increasing or decreasing weight. Single-center studies have generated optimism for weight telemonitoring programs in patients with cirrhotic ascites, but such programs have been limited to narrow populations [7,12].…”

Monitoring for Ascites in Cirrhosis Using Patient-Generated Health Data: No Longer a Remote Possibility

“…Ascites is a particularly common and costly cirrhosis complication that has been the target of several interventions aimed to reduce hospitalization frequency and length by improving timely access to paracentesis and redesigning acute models of care [4,5]. Though telemedicine and "automated hovering" interventions are particularly promising modalities that can improve access to care and inbetween visit monitoring, the evidence base for their clinical effectiveness and optimal implementation is still building for cirrhosis [6,7].In this issue of Digestive Diseases and Sciences, Bloom et al evaluated the costs and outcomes of a telemonitoring intervention for ascites in cirrhosis [8]. The authors developed a decision-analytic model that examined payerperspective costs of a standard-of-care compared with a telemonitoring intervention among 100 simulated patients at a tertiary care center over a 6-month horizon.…”

“…Ascites is a particularly common and costly cirrhosis complication that has been the target of several interventions aimed to reduce hospitalization frequency and length by improving timely access to paracentesis and redesigning acute models of care [4,5]. Though telemedicine and "automated hovering" interventions are particularly promising modalities that can improve access to care and inbetween visit monitoring, the evidence base for their clinical effectiveness and optimal implementation is still building for cirrhosis [6,7].…”