Toward the Effective Co-management of Patients with Cirrhosis by Primary Care Providers and Specialists.

Dig Dis Sci DOI 10.1007/s10620-015-3704-y EDITORIAL Toward the Effective Co-management of Patients with Cirrhosis by Primary Care Providers and Specialists Rena K. Fox 1 Received: 30 April 2015 / Accepted: 6 May 2015 O Springer Science+Business Media New York 2015 The US population suffers from such a progressively high prevalence of many chronic diseases that it is now esti- mated that over half of all US adults suffer from one or more chronic medical conditions [1]. Cirrhosis is not only one of the most common chronic diseases, its prevalence is rising along with the overall mortality from liver disease, due mostly to preceding hepatitis C virus (HCV) infection, the aging of the hepatitis C-infected baby boomer cohort [2], continually high rates of alcohol abuse, chronic hep- atitis B virus (HBV), and the epidemic of obesity and diabetes mellitus to which an estimated 20–40 % of the US population with nonalcoholic fatty liver disease (NAFLD) is attributed [3]. These chronic liver diseases, typically indolent and slowly progressive for decades, are similar to many other common chronic conditions that are largely asymptomatic in their initial phases, such as hypertension and kidney disease. If progression to cirrhosis is reached, the ultimate risk of decompensation and death is very high: It is estimated that 58 % of compensated cirrhosis patients will decompensate within 10 years at a rate of 12 % per year and that the median survival for decompensated pa- tients is 2 years [4]. Currently, in the US, cirrhosis is the twelfth most common cause of death, with the increase in the incidence rate for hepatocellular carcinoma second among any malignancy [5]. Although cirrhosis is a disease of the liver, multiple other organs systems are affected such as the renal, central nervous, cutaneous, gastrointestinal, endocrine, and & Rena K. Fox rena.fox@ucsf.edu Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, 1545 Divisadero St., Ste 307, San Francisco, CA 94143, USA immune, necessitating a ‘‘whole-patient’’ approach to comprehensive medical care. With a high frequency of underlying drug and alcohol abuse, patients with cirrhosis also face challenges of addiction, depression and a need for mental health care; furthermore, similar to oncology pa- tients, many patients with cirrhosis may warrant palliative care when their condition progresses to a terminal state. Vaccinations, Mayo End-Stage Liver Disease (MELD) score tracking, hepatocellular carcinoma (HCC) and eso- phageal varices screening, weight loss and obesity man- agement, fat soluble vitamin replacement, ascites surveillance, diuresis monitoring, spontaneous bacterial peritonitis (SBP) prophylaxis, and preparation for potential liver transplant consideration are only some of the other routine aspects of managing cirrhosis patients. To be the sole providers for this ideal all-inclusive care for cirrhosis patients, primary care physicians would need to have adequate time, training, support, and coordination, similar to the care for patients with other disease states with vast multisystem components, such as diabetes mellitus. In the diabetic model, generalists have been traditionally trained to manage most if not all aspects of routine care, such that demonstrating standards and achievements in diabetic management is frequently viewed as a marker of overall quality-of-care [6]. Published guidelines, electronic clinical reminders, and even support from payers are in place to support generalists accomplishing all the needs of patients with diabetes. Unfortunately, these systems are not paralleled for supporting generalists caring for patients with cirrhosis. Very few practice guidelines have been published in print or online that address all of the com- ponents of cirrhosis management. Clinical practice guide- lines exist for the specific treatment of HBV and HCV, alcoholic liver disease, and NAFLD [7–10]—but it is much harder to find guidelines that are designed for either