Collaborative planning and delivery of treatment and the timely inclusion of palliative care are essential elements to ensuring quality care for patients with advanced liver disease, and to controlling costs, Victor J. Navarro, MD, explained at the American Association for the Study of Liver Diseases annual meeting on November 13, 2020.

Dr Navarro is the Paul J. Johnson Chair of the Department of Medicine at the Einstein Healthcare Network and professor of medicine at Sidney Kimmel Medical College in Philadelphia, Pennsylvania.

“The main messages from recent epidemiological studies are that advanced liver disease is increasing in prevalence; that patients are presenting with more severe and advanced liver disease; and that health care costs attributable to advanced liver disease are rising,” he explained.

When measuring the impact on patients and families, Dr Navarro said, factors such as symptoms, quality of life, depression and distress, caregiver burdens, finances, and employment, have a major effect on quality of life.

A review of palliative care literature shows that patients with end-stage liver disease (ESLD) are much like patients with cancer, heart failure, and end-stage renal disease in terms of symptoms such as pain, insomnia, depression, fatigue and anxiety, he explained. Other literature reviews indicate that patients with ESLD are less likely to be employed, have high health care expenses, suffer more depression and distress, and have a lower quality of life.

Dr Navarro defined the concept of teamwork in health care as “providing care that meets all needs, very simply stated. We learned very much from a group in Dallas at UT-Southwestern that confirmed that teams we’ve built in our institutions offer important benefits to patients, including survival.”

A study of patient outcomes conducted at a multidisciplinary cancer care clinic revealed that patients with liver cancer had improved survival after the clinic was established compared with patients who were treated at this institution prior to the clinic’s creation. “This is the epitome of team-based care, as many clinics like this incorporate various stakeholders, including not only hepatologists but our advanced practice clinicians, interventional radiologists, oncologists, surgeons, case managers, and in some instances, even supportive and palliative care providers,” Dr Navarro explained.

He also noted the work at a Veterans Administration Medical Center in Houston, Texas, using an integrated model for patient-centered care for advanced liver disease. The requirements of such an approach, he said, include informed patients and caregivers, receptive and responsive clinicians, and a health care environment that supports the collaborative efforts of patients, caregivers, and their clinicians.”

There are barriers to effective teamwork that must be addressed, Dr Navarro stated, beginning with discoordination and fragmentation that can result in duplicative testing, polypharmacy, and conflicting treatment approaches. “In a perfect situation we could provide perfect continuity of care,” but there are many providers involved in caring for patient with ESLD,  and that can lead to fragmentation. This can create frustrations among caregivers and patients alike, but more importantly, poor coordination has been shown to increase mortality and hospitalization and is associated with a higher likelihood of hospital readmission within 30 days, according to a study of 26,000 Medicare enrollees in Michigan.

Access presents an additional barrier, Dr Navarro stated. This can be caused by the distance patients have to travel, by lack of availability of hepatological care, and by hesitancy of primary care providers to refer patients to hepatology.

Debility, Dr Navarro said, describes the combination of malnutrition, sarcopenia, and frailty, which decreases physiologic reserves and makes the patient vulnerable to health stressors. Debility can directly limit a patient’s own engagement in health care. “They don’t feel well, they may have difficulty traveling, interacting with caregivers.” Frailty is extraordinarily common in patients awaiting liver transplant, according to a study. Sarcopenia is present in half of patients with cirrhosis and is a predictor of mortality and increased costs, and malnutrition is present among up to 90% of patients with ESLD.

“It’s clear to me that supportive care requires a team, not only the medical provider but also a  social worker, dietitian, physical therapist, pharmacist, perhaps a behavioral therapist,” Dr Navarro said. This group can address not only management of symptoms but also ensures better communication and engagement with patients.

Dr Navarro said that the literature on palliative care—which he equates to supportive care—reveals that patients receiving palliative care are less likely to present at the emergency room or to be admitted to the intensive care unit. They report improvement in quality of life, symptoms, and mood, and palliative care is shown to reduce health care costs. And in one study, lung cancer patients who received palliative care had 30% longer median survival.

In regard to providing palliative care for ESLD, Dr Navarro stated that access is improving but more work needs to be done. He noted that patients and some providers often assume palliative care is actually hospice care, and are thus reluctant to discuss it. Provider availability and health insurance coverage and payment limits also contribute to barriers to supportive care.

Dr Navarro and his colleague Manisha Verma, MD, MPH are conducting a 6- to 7-year study, the PAL-LIVER study, with 18 sites around the country to “demonstrate the value of supportive care in ESLD and how to incorporate such care into routine liver care.” This will examine whether receiving palliative care from a hepatologist versus receiving such care  from a palliative care provider improves quality of life for patients with ESLD and for their caregivers.

“We must find ways to incorporate palliative care earlier in the treatment of advanced liver disease,” Dr Navarro said.

—Rebecca Mashaw

Reference:

Navarro V. Care of the patient with advanced liver disease. Talk presented at: American Association for the Study of Liver Diseases annual meeting. November 13, 2020. Virtual.