Patient-centred care for cirrhosis: a key role for chronic disease management

Early diagnosis and coordinated care are critical for achieving the best outcomes for patients with liver disease

Chronic liver disease affects more than 6 million Australians, and it is estimated that more than 70 000 have cirrhosis.1 The most common causes are non-alcoholic fatty liver disease, alcohol-related chronic liver disease, and chronic hepatitis B and C. People with cirrhosis are at risk of liver decompensation and liver cancer. More than 7000 Australians die from liver-related causes each year, and another 300 people receive liver transplants.2 Primary liver cancer is the second most rapidly increasing cause of cancer death in Australia.3

Decompensated cirrhosis is characterised by clinical events that include ascites, spontaneous bacterial peritonitis, variceal bleeding, encephalopathy, and hepato-renal syndrome. Patients with decompensated cirrhosis have a poor prognosis; the one-year survival rate for those requiring hospitalisation is 55%.4 The management of decompensated cirrhosis remains a significant clinical challenge that involves frequent hospitalisations, and rates of re-admission within 30 days of initial discharge are about 30%.5

Chronic disease management is a patient-centred approach to health care delivery that emphasises proactive, longitudinal quality care between visits, rather than traditional episodic, symptom-driven care.6 Chronic disease management has been shown to improve patient outcomes and to reduce the costs of managing patients with diseases such as heart failure.7 Quality of care indicators have been identified for people with decompensated cirrhosis,8,9 adherence to which is associated with improved outcomes, including lower re-admission rates and reduced mortality.

In this issue of the MJA, Ramachandran and colleagues10 report the results of a retrospective study in which they compared the rates of liver-related emergency admissions and survival for patients hospitalised for decompensated cirrhosis at two major metropolitan hospitals, one of which had implemented chronic disease management for patients with liver disease. This comprehensive liver failure program was a nurse-led model of care with support from specialist hepatologists. The model included checklists for improving adherence to clinical guidelines, post-discharge phone contact and home visits, self-management support with enhanced patient and carer education, and development of action plans for early intervention and the management of ascites and hepatic encephalopathy. Patients enrolled in the program had fewer liver-related emergency admissions and better survival than those receiving standard care, but more elective liver-related admissions, suggesting that early diagnosis and intervention reduced the need for emergency treatment. Despite the methodological limitations of the study, the data suggest that a nurse-led chronic disease management model improves clinical outcomes for patients with decompensated cirrhosis. The authors have recently shown that this approach is also likely to be cost-effective.11

The complexity of the patient population in the study by Ramachandran and colleagues and the need for chronic disease management underscore the importance of early diagnosis and treatment of liver disease for preventing cirrhosis and its complications. Chronic liver disease is often clinically silent. It should be suspected in all adults with suggestive investigation results (eg, abnormal transaminase levels, prolonged prothrombin time or low albumin level, thrombocytopenia), or a medical history that indicates they may be at risk (eg, metabolic syndrome, diabetes, excessive alcohol consumption, risk factors for viral hepatitis infection). Risk of progression to cirrhosis can be reduced by taking metabolic risk factors into account, reducing alcohol consumption, or treating chronic viral hepatitis.

The introduction of direct-acting antiviral therapy for curing hepatitis C — therapy that can be prescribed by general practitioners — has laid the foundation for eliminating hepatitis C as a public health threat in Australia. Patients with cirrhosis should be referred to specialists for risk factor management and disease-specific interventions with the goal of reducing the risk of decompensation and liver cancer. Patients with cirrhosis should be enrolled in surveillance programs for liver cancer, screened for complications (including portal hypertension, osteoporosis, encephalopathy, and sarcopenia), and vaccinated against influenza, pneumococcus, and hepatitis A and B.

In conclusion, patients with decompensated cirrhosis have complex care needs and poor long term survival. Chronic disease management of decompensated cirrhosis by teams of specialist hepatology nurses and hepatologists can reduce the numbers of emergency presentations and mortality for patients. This model of care warrants prospective evaluation in larger patient groups that may support its broader implementation and the allocation of resources for workforce development.