Care coordination for patients with cirrhosis: A “win-win” solution for patients, caregivers, providers, and healthcare expenditures
Authors: Phillip S. Ge, Bruce A. Runyon
Journal: Journal of Hepatology (2013)

How to improve care in outpatients with cirrhosis and ascites: A new model of care coordination by consultant hepatologistsJournal of HepatologyVol. 59Issue 2PreviewThe development of ascites in patients with cirrhosis is associated with a high rate of health care utilization. New models of specialized caregiving support are necessary to optimize its management. The aim of the study was to evaluate the efficacy and financial sustainability of the "Care management check-up" as a new model of specialized caregiving support based on a series of diagnostic facilities performed in real time and on the integrated activity of consultant hepatologists at the hospital unit for outpatients, dedicated nurses, physicians in training and primary physicians, compared to standard care in outpatients with cirrhosis and ascites. Full-Text PDF We receive with great enthusiasm the recently published article by Morando and his colleagues from the University of Padova regarding their experience with a new model of care coordination in the setting of cirrhosis [[1]Morando F. Maresio G. Piano S. Fasolato S. Cavallin M. Romano A. et al.How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists.J Hepatol. 2013; 59: 257-264Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar]. The burden of chronic disease is greater now than ever. In the absence of a coordinated effort to prevent, diagnose, and better manage chronic disease, we as a society will bear increasing socioeconomic costs over time. Almost one half of all Americans suffer from one or more chronic diseases [[2]Wu S. Green A. Projection of chronic illness prevalence and cost inflation. RAND Health, Santa Monica (CA)2000Google Scholar]. Millions are diagnosed and millions more die annually from a chronic disease. This is a reflection of the changing demographics in the developed world, where mortality from communicable infectious diseases decreases and mortality from non-communicable chronic diseases continues to increase. Enormous scientific advancements in treatment have largely failed to curb this steady rise. Although current health care financing and delivery systems focus on the treatment of acute conditions, 78% of actual healthcare spending is spent on the treatment of chronic conditions [[3]Anderson G. Horvath J. The growing burden of chronic disease in America.Public Health Rep. 2004; 119: 263-270Crossref PubMed Scopus (370) Google Scholar]. The total burden of chronic diseases on the economy exceeds $1.3 trillion annually; of this amount, $277 billion is spent annually on treatment, with lost productivity totaling $1.1 trillion. At our current pace, by 2023 we can expect a 42% increase in the incidence of chronic disease, totaling $4.2 trillion annually in treatment costs and lost economic output [[4]DeVol R. Bedroussian A. Charuworn A. Chatterjee A. Kim I. Kim S. An unhealthy America: the economic burden of chronic disease. Milken Institute, Santa Monica (CA)2007Google Scholar]. Chronic liver disease and cirrhosis are leading causes of death in the United States and worldwide. In the United States, an estimated 30,000 new cases of cirrhosis are diagnosed each year, and cirrhosis overall accounts for over 150,000 annual hospitalizations [[5]Bell B.P. Manos M.M. Zaman A. Terrault N. Thomas A. Navarro V.J. et al.The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance.Am J Gastroenterol. 2008; 103 (quiz 2737): 2727-2736Crossref PubMed Scopus (116) Google Scholar]. Treatment costs associated with the sequelae of cirrhosis such as variceal bleeding, ascites, encephalopathy, and hepatocellular carcinoma exceed $4 billion annually, exclusive of estimates of lost economic output [[6]Mellinger J.L. Volk M.L. Multidisciplinary management of patients with cirrhosis: a need for care coordination.Clin Gastroenterol Hepatol. 2013; 11: 217-223Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar]. In stark contrast to most other malignancies, hepatocellular carcinoma is increasing in frequency, with associated expenditures doubling from 1988 to 2000 after adjusting for inflation [[7]Kim W.R. Gores G.J. Benson J.T. Therneau T.M. Melton 3rd., L.J. Mortality and hospital utilization for hepatocellular carcinoma in the United States.Gastroenterology. 2005; 129: 486-493Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar]. Given our society's struggles with metabolic syndrome and obesity, emerging chronic diseases such as fatty liver disease and non-alcoholic steatohepatitis are predicted to become the most common cause of cirrhosis, and will overtake hepatitis C as the most common indication for liver transplantation in the United States by 2030 [[8]Charlton M. Nonalcoholic fatty liver disease: a review of current understanding and future impact.Clin Gastroenterol Hepatol. 2004; 2: 1048-1058Abstract Full Text Full Text PDF PubMed Scopus (316) Google Scholar]. Frequent hospital readmissions for management of fluid overload, hepatic encephalopathy, and/or gastrointestinal hemorrhage are commonplace among patients with cirrhosis. A recent study from Volk and colleagues from the University of Michigan found that 69% of patients with cirrhosis had at least one non-elective readmission, with a median time to first readmission of 67 days [[9]Volk M.L. Tocco R.S. Bazick J. Rakoski M.O. Lok A.S. Hospital readmissions among patients with decompensated cirrhosis.Am J Gastroenterol. 2012; 107: 247-252Crossref PubMed Scopus (314) Google Scholar]. In a sobering statistic, 14% of patients were readmitted within one week, and 37% within one month. One patient was readmitted 40 times. 22% of readmissions were found to be possibly preventable. The study concluded that readmission among patients with cirrhosis was common, costly, moderately predictable, possibly preventable, and independently associated with mortality [[9]Volk M.L. Tocco R.S. Bazick J. Rakoski M.O. Lok A.S. Hospital readmissions among patients with decompensated cirrhosis.Am J Gastroenterol. 2012; 107: 247-252Crossref PubMed Scopus (314) Google Scholar]. In recent years, care coordination, or "collaborative care", has emerged as a highly effective concept that can help reduce readmission rates in patients who are known to be at high risk for readmission. The concept of care coordination has been applied in disorders such as depression, coronary artery disease, congestive heart failure, and poorly-controlled diabetes, with studies generally demonstrating improved control of the underlying diseases [[10]Katon W.J. Lin E.H. Von Korff M. Ciechanowski P. Ludman E.J. Young B. et al.Collaborative care for patients with depression and chronic illnesses.N Engl J Med. 2010; 363: 2611-2620Crossref PubMed Scopus (1162) Google Scholar]. In theory, care coordination by specifically trained personnel should result in fewer readmissions, improved outcomes, and reduced expenditures. However, studies have also suggested that viable programs without a strong transitional care component are unlikely to yield significant savings [[11]Peikes D. Chen A. Schore J. Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among medicare beneficiaries: 15 randomized trials.JAMA. 2009; 301: 603-618Crossref PubMed Scopus (614) Google Scholar]. Current care of patients with cirrhosis is fragmented and poorly coordinated. While many "evidence-supported" practice guidelines have been published in recent years regarding the common complications of cirrhosis, current literature suggests that patients with cirrhosis often fail to receive these evidence and guideline-supported treatments [6Mellinger J.L. Volk M.L. Multidisciplinary management of patients with cirrhosis: a need for care coordination.Clin Gastroenterol Hepatol. 2013; 11: 217-223Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 12Kanwal F. Kramer J.R. Buchanan P. Asch S.M. Assioun Y. Bacon B.R. et al.The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.Gastroenterology. 2012; 143: 70-77Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar]. Furthermore, the hospitalist movement has separated the outpatient physician from the inpatient physician, creating discontinuity at a critical juncture in patient care. A study of physician continuity of care between 1996 and 2006 showed that while continuity of care decreased overall, one-third of this decrease was attributed to the increasing involvement of hospitalists [[13]Sharma G. Fletcher K.E. Zhang D. Kuo Y.F. Freeman J.L. Goodwin J.S. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults.JAMA. 2009; 301: 1671-1680Crossref PubMed Scopus (96) Google Scholar]. This and many other reasons have made the process of coordinating care perilous and challenging [[14]Bodenheimer T. Coordinating care – a perilous journey through the health care system.N Engl J Med. 2008; 358: 1064-1071Crossref PubMed Scopus (729) Google Scholar]. It is in this context that the study by Morando and colleagues is highly significant [[1]Morando F. Maresio G. Piano S. Fasolato S. Cavallin M. Romano A. et al.How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists.J Hepatol. 2013; 59: 257-264Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar]. This study represents the first prospective trial in the cirrhosis population comparing the traditional system involving the family physician and punctual consultation to a specialist, with a new coordinated care system involving close monitoring by a specialized team of nurses, physicians-in-training, and hepatologists. The results clearly favor the care coordination model, both in costs and survival. The study demonstrated reduced 30-day readmission (42% vs. 15%), reduced 12-month readmission (71% vs. 46%), reduced 12-month mortality (46% vs. 23%), and a 46% cost reduction overall. An important point to emphasize is that patients with cirrhosis and ascites who are discharged from the hospital following treatment of an acute decompensation represent a unique population for which follow-up and specialist management is highly relevant, as they are predisposed to developing potentially preventable major complications resulting in readmission or mortality. Expertise is needed for early detection and treatment of these complications. The integration of care coordination at this critical juncture likely explains the impressive results of the study; in other diseases the number of cases required to find significant differences is often much higher. The study is obviously not without its limitations. Understandably, the study was not randomized as it would be difficult to recruit patients for a randomized study in which they would receive either "standard care" vs. orchestrated care from a multidisciplinary team of specialists and nurses. Further, it was not clear whether the specialists involved in the care coordination group provided a standardized level of care or whether certain specialists had disproportionately better outcomes. It has been shown in a previous study of patients with cirrhosis and ascites in the Veterans Affairs Health System that health care quality was higher in patients who received specialist care from a gastroenterologist [[12]Kanwal F. Kramer J.R. Buchanan P. Asch S.M. Assioun Y. Bacon B.R. et al.The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.Gastroenterology. 2012; 143: 70-77Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar]. In our opinion, a liver-focused gastroenterologist would probably provide higher quality specialty care as compared to a general gastroenterologist. Finally, the study does not include various non-hospital expenses such as nursing home stays and home caregiving, although the overall savings in reducing emergent hospital readmissions should still make this model economically feasible. Because the management of cirrhosis and other chronic diseases are multidisciplinary in nature and quickly becoming a high policy priority in the era of healthcare reform, improving care coordination should improve the quality and efficiency of care and provide business opportunities for gastroenterologists [[6]Mellinger J.L. Volk M.L. Multidisciplinary management of patients with cirrhosis: a need for care coordination.Clin Gastroenterol Hepatol. 2013; 11: 217-223Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar]. At our current institution, we are investigating efforts to integrate a similar model of care coordination in an attempt to reduce readmissions, reduce expenditures, and improve survival. Our coordinator would help coordinate inpatient-to-clinic transitions, call patients on a routine basis to prevent non-elective visits to the Emergency Department, place "smart-scales" in patient homes to monitor body weight remotely, and facilitate interaction with other healthcare professionals. They would also help facilitate transfers to hospice or skilled nursing facilities, especially for patients who are either unsuitable for transplantation due to medical comorbidities or who are unable to undergo transplantation due to technical reasons or due to organ shortage. Patients in this latter category are left in a challenging situation as they may be "too well for transplant", yet are extremely sick with a decreased quality of life and decreased life expectancy due to the development of other cirrhosis-related complications. Too many die awaiting liver transplantation [[15]Larson A.M. Curtis J.R. Integrating palliative care for liver transplant candidates: "too well for transplant, too sick for life".JAMA. 2006; 295: 2168-2176Crossref PubMed Scopus (90) Google Scholar]. In this setting, care coordination would serve an instrumental role in providing the best possible quality of life in the face of a terminal diagnosis, with seamless timely transitions from "listed for transplant" to palliative care [[16]Iredale J. End-stage chronic liver disease: time to define a good death.Hepatology. 2008; 47: 1799-1800Crossref PubMed Scopus (7) Google Scholar]. As our healthcare expenditures continue to grow and the burden of chronic disease continues to increase, care coordination is an obvious solution and a "win-win" situation for patients, caregivers, providers, and healthcare expenditures alike. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.