When to refer end-stage liver disease patients to palliative care: a survey of practicing liver and palliative care clinicians

POSTER PRESENTATIONS FRI-023 When to refer end-stage liver disease patients to palliative care: a survey of practicing liver and palliative care clinicians J.P. Esteban1, L. Rein2, A. Szabo2, K. Saeian1, S. Marks3. 1Division of Gastroenterology and Hepatology; 2Division of Biostatistics, Institute for Health and Society; 3Section of Palliative Care, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, United States E-mail: [email protected] Background and Aims: Despite evidence that specialty palliative care (PC) consultation can improve quality of care and health care utilization for seriously ill patients, patients with end-stage liver disease (ESLD) are frequently referred late, if at all, to PC specialists. A possible reason for low PC referral rates is a lack of consensus regarding appropriate indications for referral. The study aimed to look into prevalent opinions of practicing liver and PC clinicians on acceptable reasons for referring and not referring ESLD patients to PC. Methods: Active members of American Association for the Study of Liver Diseases (AASLD) and American Academy of Hospice and Palliative Medicine (AAHPM) were invited via e-mail to participate voluntarily in a 56-item web-based survey. Several possible PC roles, indications for PC referral, and reasons for PC non-referral were shown to respondents, who were then asked to rate their respective agreement or comfort level using a 5-point Likert scale. Members of both organizations received identical surveys modified only to reflect specific clinician’s role. Results: A total of 311 AASLD and 379 AAHPM (6.2% and 8.1% response rates, respectively) members completed the survey. Attending physicians made up 75.5% and 85.2% of AASLD and AAHPM respondents, respectively. Seventy percent of AASLD and >95% of AAHPM respondents were based in US or Canada. Wave analysis suggested that AAHPM non-respondents were more likely to be trainees or based in US or Canada. For AASLD members, acceptable indications for PC referral were transplant-ineligible decompensated cirrhosis and hepatocellular cancer (HCC), expected life expectancy <1 year, and Child-Pugh C, while reasonable situations to defer referral included mild disease, non-imminent death, transplant candidacy, absence of specific addressable PC needs, and concerns about demotivating a transplant candidate. AAHPM responders were significantly more likely to describe all cases of decompensated cirrhosis and HCC, regardless of transplant eligibility, as appropriate indications for PC referral.

FRI-024 An Innovative app focused on patients and caregivers significantly decreases avoidable and HE-related readmissions in cirrhotic patients D. Ganapathy1, J. Lachar1, C. Acharya1, M. White1, R.K. Sterling1, S. Matherly1, P. Puri1, R.T. Stravitz1, M.S. Siddiqui1, A.J. Sanyal1, H. Lee1, V. Luketic1, K. Patidar1, C. Ignudo2, S. Bommidi2, J.S. Bajaj1. 1Virginia Commonwealth university, Richmond; 2CITI Corporation, Falls Church, United States E-mail: [email protected] Background and Aims: Cirrhotic patients have a high rate of avoidable readmissions, which could be potentially preventable by greater communication. PatientBuddy in an innovative App developed to reduce readmissions by enhancing communication. Aim: To determine if the use of PatientBuddy can prevent avoidable readmissions in cirrhosis compared to a historical cohort. Methods: PatientBuddy was adapted for cirrhosis with 3 foci; hepatic encephalopathy (HE), ascites & falls. It includes medicine adherence, orientation questions, weights & Na monitoring. Inpt cirrhotics & caregivers were trained on PatientBuddy & given iPhones that directly linked with the App loaded onto case manager devices. In addition to daily communications, the dyads were followed at day 7,14,21 & 30. Pts without caregivers, discharged to hospice/facilities & active drinkers were excluded. Readmissions within 30 days were recorded. Readmission reasons were adjudicated by a hepatologist not participating as avoidable or not. These were compared to a cohort of inpatient cirrhotics enrolled with their caregivers 1 year prior whose readmissions were studied without Patient Buddy. Results: PatientBuddy cohort: 57 subjects were considered; 9 did not have caregivers, 12 refused, 8 were discharged to hospice/facilities. 40 pts/caregiver dyads were included (Age 58 ± 9, MELD 20 ± 5, 70% prior HE, 90% ascites). Four dyads withdrew within 1 wk due to the complexity. Of the remainder 15 (37.5%) were readmitted in 30 days (5 infections, 3 anasarca, 2 GI bleeding, 2 chest pain, 1 anemia, 1 opioid overdose & 1 jaundice post-TIPS). Of these 3 (7.5%) were considered avoidable; 2 had ascites that could have receoved an outpt tap & 1 had opioid overdose on drugs given by outside MD. None were readmitted for HE. Historical cohort: 73 cirrhotic pts/caregivers were enrolled with similar disease severity as PatientBuddy (Age 57 ± 7, MELD 18 ± 10, 66% prior HE, 88% ascites, all p >0.05). 34 (46%) had a 30-day readmission (HE 17, ascites 7, infection 5, GI bleeding 3, others 2). Of these 18 (25%) were considered avoidable (12 HEs due to nonadherence, 6 ascites that could have received outpatient taps). While the total was similar, avoidable & HE-related readmissions were significantly lower in the PatientBuddy cohort (Figure).

Conclusions: While many PC clinicians found all cases of decompensated ESLD and HCC as appropriate for PC referral, liver clinicians were more likely to restrict PC referrals to transplant-ineligible ESLD patients. Potential demotivation of a transplant candidate and a perception that the disease is mild and death non-imminent were considered by liver clinicians as reasonable justifications for not referring an ESLD patient to PC.

Journal of Hepatology 2017 vol. 66 | S333–S542

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