|Dr Sahhar, Dr Ha, Professor Sievert and Dr Le|
While other chronic diseases such as heart failure are well managed by a range of health professionals and a dedicated ambulatory care service, there is no comprehensive model of care for people living with cirrhosis.
Published recently in the prestigious American Journal of Gastroenterology, a team of researchers at Monash University and Monash Health have shown for the first time that early intervention using diuretic therapy or paracentesis (removing fluid from the abdomen) for patients with cirrhosis and ascites significantly reduces hospital readmission and mortality.
“Cirrhosis, or scarring of the liver, is commonly caused by alcohol and viral hepatitis. 50% of cirrhosis patients develop ascites, the most common complication of this debilitating disease” said gastroenterologist and lead researcher Dr Suong Le.
Ascites is the build-up of fluid in the abdomen and results from scarred liver tissue unable to filter substances in the body.
“Some of our patients present in the emergency department looking like they’re nine months pregnant; they can’t breathe; they can’t walk and they’re extremely sick,” said Dr Le. “We often drain 5 to 10 litres of fluid from their abdomen.”
While there is no cure for cirrhosis related ascites other than liver transplantation, it can be managed to improve quality of life.
“Our study found that giving patients diuretics as early as possible lowers 90-day mortality, and early paracentesis lowers 30-day hospital admission rates,” said Dr Le.
Senior author and Monash University Professor of Medicine William Sievert said 70% of patients initially hospitalised for new onset cirrhotic ascites were being readmitted within 90 days because of recurrent ascites.
“People with cirrhotic ascites have a higher mortality rate than those with cirrhosis who have never developed ascites, and 30 day readmission was a very strong predictor of 90 day mortality,” said Professor Sievert, who is also Director, Gastroenterology and Hepatology Unit at Monash Health.
“We found that if patients had a paracentesis within 30 days of the diagnosis of ascites or during their initial hospitalization then those patients were significantly less likely to be readmitted for recurrent ascites and that early initiation of diuretics significantly lowered the risk of mortality at 90 days.”
“Adherence to these two quality of care indicators had the greatest benefit for patients, which was especially important given that 40% of the unplanned 30-day readmissions were to the ICU,” said Professor Sievert. Dr Le said there’s a lack of awareness in the community about cirrhosis and patients and medical staff need to be educated that these simple and early interventions will extend and significantly improve quality of life.
“One of the most shocking findings of our study was that 58% of patients did not even know they had liver disease until they presented to hospital with ascites,” said Dr Le.
“These patients have previously had no formal diagnosis—cirrhosis is a long process, taking 10 to 20 years to develop and progress.”
More than 300 patient records were analysed for the research study, revealing that most patients with the disease were men who lived alone, with a mean age of 57 years.
The Monash research team included Dr Phil Ha, Dr Lukas Sahhar, Dr Julian Lim and Dr Tony He, all of whom were medical students when the project commenced.
Dr Tony He said he had a particular interest in gastroenterology and was keen to help facilitate better management of patients with chronic liver disease and their complications.
Of the research project, Dr Lukas Sahhar said he’d learnt about the conduct and application of real-world medical research.
“It was a very satisfying experience working with doctors and researchers at Monash Health and Monash University and we are all grateful to Dr Le and Professor Sievert for the opportunity,” said Dr Sahhar.
Monash Health intern Dr Phil Ha said it was a fascinating project that assessed the degree to which current practices had followed best practice guidelines.
“Investigating whether higher adherence to evidence-based medicine translates into better outcomes for patients with advanced liver disease was a fantastic learning experience,” said Dr Ha.
In 2014, then medical student Phil Ha undertook at Bachelor of Medical Science (Honours) under the supervision of Professor Sievert to investigate the use of a smartphone app to improve outpatient care for patients with cirrhotic ascities.
“In Dr Le’s research project, we found there was a particularly high readmission and mortality rate for patients with advanced liver disease, and strategies to identify outpatients at risk of deteriorating could improve these outcomes,” said Dr Ha.
“For my BMedSc research project, I developed and implemented a remote monitoring system for outpatients with cirrhotic ascites using a smartphone app, enabling the transmission of real-time information to the treating team.”
Simple indicators such as weight and symptoms suggestive of decompensation were transmitted via the smartphone app to the liver team, and abnormal values were automatically flagged, and prompted a telephone consultation with the patient.
Dr Ha said they trialled the system with nine patients and found some promising results.
“Future studies will evaluate the potential benefits of using this technology to improve patient outcomes.”