Abstract

Background: Patients with decompensated cirrhosis have poor quality of life and complex care needs that could be addressed with existing services; but the fragmented healthcare system does not provide the necessary coordination to best care for this population. Collaborative care models (CCM) can bridge this gap by providing coordinated, personalized care using care coordinators. In this pilot randomized trial, we developed and tested a CCM for cirrhosis: The Cirrhosis Medical Home (CMH).

Methods: We randomized 40 hospitalized patients with decompensated cirrhosis and poor quality of life (SF-36 physical and/or mental component score <40) to receive care through the CMH or usual care in a 1:1 ratio for 6 months following hospital discharge. In the CMH, a nurse coordinator, supported by an interdisciplinary clinical team, provides personalized protocol-driven care guided by dynamic feedback measures. Quality of life (SF-36) and mortality were compared at 3 and 6 months after enrollment.

Results: The median age was 58, 70% were female, and 95% were White. 74% had Medicare or Medicaid insurance, 21% were employed, and 20% were discharged to a healthcare facility. The median MELD-Na was 24. Median baseline SF-36 domains ranged from 0 (role limitations) to 56 (emotional wellbeing), and median physical and mental component scores were 25.9 and 40, respectively. After 3 months, 13 patients (32.5%) died or enrolled in hospice (7 usual care and 6 CMH; p=0.74), 4 (10%) underwent liver transplant (2 each), and 12 (30%) provided follow-up patient-reported outcomes (PROs). At 3 months, patients in the CMH had increases in all but one SF-36 domain; patients in usual care had decreases in all but two (Table). None of the differences were statistically significant. After 6 months, an additional 5 patients died (total 11 usual care and 7 CMH; 45% overall, p=0.20), and 8 (20%) provided PROs. At 6 months, physical functioning increased in the usual care arm and decreased in the CMH arm (p=0.02, Table). The remaining differences were not significant.

Conclusion: Hospitalized patients with decompensated cirrhosis and poor quality of life have high short-term mortality, which may limit the impact of collaborative care interventions focused on improving PROs. Future transitional care interventions may have more impact by triaging those at lower risk of short-term mortality to interventions like the CMH while linking those at higher risk to high quality palliative care services.