Introducing EL‐FIT (Exercise and Liver FITness): A Smartphone App to Prehabilitate and Monitor Liver Transplant Candidates

Abstract

Preserved physical function is key for successful liver transplantation (LT); however, prehabilitation strategies are underdeveloped. We created a smartphone application (app), EL-FIT (Exercise and Liver FITness), to facilitate exercise training in end-stage liver disease (ESLD). In this feasibility study, we tested EL-FIT app usage and the accuracy of physical activity data transfer and obtained feedback from initial users. A total of 28 participants used the EL-FIT app and wore a physical activity tracker for 38 ± 12 days (age, 60 ± 8 years; 57% males; Model for End-Stage Liver Disease-sodium, 19 ± 5). There was fidelity in data transfer from the tracker to the EL-FIT app. Participants were sedentary (1957 [interquartile range, 873-4643] steps/day) at baseline. Level of training assigned by the EL-FIT app agreed with that from a physical therapist in 89% of cases. Participants interacted with all app features (videos, perceived exertion, and gamification/motivational features). We rearranged training data to generate heart rate-validated steps as a marker of performance and showed that 35% of the participants had significant increases in their physical performance. Participants emphasized their interest in having choices to better engage in exercise, and they appreciated the sense of community the EL-FIT app generated. We showed that patients with ESLD are able to use and interact with the EL-FIT app. This novel smartphone app has the potential of becoming an invaluable tool for home-based prehabilitation in LT candidates.

Strategies to Improve Delivery of Cirrhosis Care

“…Likewise, there is growing evidence that mobile phone text-messaging and other technology-based remote monitoring systems can improve care across a number of chronic diseases [10,11]. Smartphone applications (apps) such as the EncephalApp_Stroop app have been demonstrated to be effective and reliable in the diagnosis of minimal and covert encephalopathy [12,13] Caregiver education -improved encephalopathy care [5] Mailed patient reminders -increased HCC surveillance [6] Virtual visits -improved survival [7••] Mobile text-messaging -improved medication adherence [10] Smartphone applications -improved encephalopathy management [12][13][14] -acceptable to patients with ascites [15] Wearables -improved encephalopathy monitoring [16] -improved physical performance [17] Inpatient Hospitalist/GI co-management service -trend towards improved survival and decreased readmission [18] Automatic specialty consultation -improved quality indicators (but not readmission) [19] Palliative care consultation -decreased readmission [21•] Education interventions -decreased readmission and longer "time to tap" for patients with ascites [25,26] -decreased encephalopathy [20] Medical record checklist -decreased readmission [23] Order sets -decreased readmission [22][23][24] Transitional Care Early follow-up -improved survival [29] Telephonic transitional care -improved survival [30] Day encephalopathy-related admissions [14]. Similarly, an application-based ascites management intervention, which included a scale and Bluetooth connection between the app and the electronic health record, found that the app was acceptable to patients and providers and resulted in frequent, weight-based diuretic adjustments [15].…”

“…Similarly, an application-based ascites management intervention, which included a scale and Bluetooth connection between the app and the electronic health record, found that the app was acceptable to patients and providers and resulted in frequent, weight-based diuretic adjustments [15]. Wearable technologies are currently being trialed for monitoring encephalopathy [16] and addressing frailty [17]. Thus, outpatient care delivery evidence has supported tech-based approaches and engaging expanding upon who is engaged in the cirrhosis care team.…”

Individualized treatment options for patients with non-cirrhotic and cirrhotic liver disease

“…An even more recently published prospective study reported that financial incentives resulted in more patients achieving their target of > 7000 steps per day, which, however, did not translate into less weight gain[ 134 ]. Another study using a smartphone app found that 35% of participants significantly increased their physical performance, but did not report whether this translated into an outcome benefit[ 135 ]. Thus, despite positive impacts on surrogate parameters, little to no high-quality evidence is available on whether exercise directly affects overall survival or liver related outcome after transplantation.…”

Frailty in Liver Transplantation: A Comprehensive Review

“…The authors noted that the participants emphasized their interest in having choices for exercise engagement and appreciation of the sense of community the EL-FIT app generated. [58] Further data collection with an evaluation of the impact on frailty is ongoing, and real-world use at other institutions will be valuable.…”