Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study

Abstract

Background: Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians’ perceptions of factors that optimize or impede cirrhosis care. Methods: We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. Results: Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the “specialty care access network extension for community health care outcomes” program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. Conclusions: We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.

A novel, nurse-led ‘one stop’ clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival

“…Patients in nurse-led clinic are also more inclined towards accepting advice on alcohol substance misuse [ 26 ]. In addition, the education of patients and their caregivers, and telemedicine have shown encouraging results to reduce readmissions [ 27 – 29 ].…”

How to improve preventive health care in patients with cirrhosis

“…[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][7][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 inperson 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]).…”