A chronic disease management model of care for decompensated chronic liver disease delivered in a non-transplant center.

Abstract

Background and Aim: Chronic liver disease (CLD) is associated with significant morbidity, mortality, and health care resource utilization. There is evidence to support a chronic disease management (CDM) model of care for CLD, but all studies to date have been conducted in liver transplant centers. We aimed to evaluate the cost-effectiveness of a coordinated, multidisciplinary, ambulatory care service for patients with decompensated CLD at a Victorian tertiary health care service. Method(s): We conducted a prospective cohort study of adult patients with decompensated CLD who attended a multidisciplinary liver clinic from May 2019 to May 2020. Patients received regular consultations with a hepatologist, pharmacist, and dietitian, coordinated by a liver clinical nurse consultant. Paper-based and electronic patient education tools and Bluetooth body composition scales were used to improve patient monitoring and self-efficacy. Clinical data were collected from the electronic medical record system, and costing data were obtained from the finance department. The primary endpoint was total cost of liver-related hospital admissions 3 months before, compared with 3 months after, the index clinic appointment. Secondary outcomes evaluated were changes in liver disease severity and mortality. Result(s): Forty-seven patients (median age, 58 years [IQR, 47-69]; 47% male) with decompensated CLD received CDM. The median baseline Charlson Comorbidity Index score was 5 (IQR, 4-7). Liver disease etiologies were alcohol (43%), non-alcoholic fatty liver disease (15%), and concomitant hepatitis C and alcohol (13%). Sixty-six percent of patients were referred following an acute hospital admission, with ascites the most common complication of CLD (60%). Compared with before CDM, there was a statistically significant reduction in unplanned admissions due to ascites (28 vs 15, P = 0.01) but no difference in admissions for other liver-related diagnoses (Fig. 1). The total cost of liver-related hospital admissions was A$764 065 versus A$469 565 in the 3-month follow-up. There was a statistically significant increase in the proportion of patients with Child-Pugh A class disease after CDM (1 vs 9, P = 0.02) but no change in median Model for End-Stage Liver Disease score (17 vs 18, P = 0.32). Four patients were referred for liver transplantation assessment. Three deaths (two non-liver-related) were observed during the 3-month follow-up. Conclusion(s): A coordinated, multidisciplinary model of care for patients with decompensated cirrhosis showed a significant reduction in ascites-related hospital admissions, reduced direct costs from hospitalizations, and an increase in recompensated Child-Pugh A class. Our study demonstrates the feasibility and early clinical benefits associated with a CDM model of care implemented at a non-transplant center.