New focus for chronic liver disease care

Developing improved care models for decompensated liver disease is one of the major clinical challenges in gastroenterology and hepatology, and in a recent landmark study, published in Hepatology, researches from Flinders Medical Center and Flinders University provide evidence that improved models of care can benefit patients with decompensated cirrhosis.

Identifying improved care is of primary importance as the number of chronic liver failure cases at South Australia's public hospitals has increased more than three-fold in the past decade, while obesity-related liver disease is expected to become a modern epidemic by 2050. Nationally, more than 6 million Australians suffer from chronic liver disease, resulting in more than 7,000 deaths a year.

The study represents more than five years of work conducting a randomized controlled trial (RCT) led by Professor Alan Wigg from Flinders University's College of Medicine and Public Health and Flinders Medical Center. The RCT involved six Australian tertiary care hospitals across three states and represents one of the first investigator-initiated multicenter RCTs in Australian hepatology.

The primary aim of this randomized control trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions to hospitals. Secondary aims were to assess effects on quality-of-care and patient reported outcomes.

"Chronic disease management approaches appear to be a logical, evidence-based strategy and have been successfully applied in many non-liver settings," says Professor Wigg.

"We believe that CDM models for decompressed cirrhosis have great potential towards an improved standard of care in hepatology. However, we also need to accept that CDM models in decompensated cirrhosis may not be as effective as CDM in other chronic diseases due to the more complex and severe nature of this liver disorder."

The study's primary outcome showed that the liver-related emergency admissions rate was not significantly improved despite robust intervention, nor was any improvement in patient survival recorded.

However, the study did show several significant and clinically important benefits including reduced emergency admissions due to hepatic encephalopathy, one of the most frequent, preventable and expensive causes for admission in patients with decompensated cirrhosis. Improvements in quality of care and quality of life were also demonstrated in the CDM group.

The detailed work undertaken by the study also highlighted several significant shortcomings in the care of decompensated cirrhosis. While alcohol-related cirrhosis was the major cause of decompensated cirrhosis in about 70% of participants in the study, access for them to obtain high-quality alcohol addiction, mental health and supportive care services remained limited.

A lack of trained liver disease management nurses was also identified, with the few available trained liver nurses being employed part-time (three days per week) and required to manage up to 22 patients.