Abstract

Background: Providers at community hospitals often seek to transfer hospitalized patients with advanced liver disease to tertiary/quaternary care hospitals for further management due to lack of expertise in caring for these patients. However, it is possible to co-manage such patients at local hospitals by providing virtual consultation by tertiary care hepatologists via inpatient telehepatology (INP-TH) consultation. We aimed to describe demographics, liver disease severity, and related outcomes such as transfer rate, subsequent outpatient follow-up, readmission rate, and 30-day mortality.

Methods: Indiana University Health (IUH) is a 16-hospital integrated health system with a single adult academic health center (AAHC) with concentrated hepatology expertise and a liver transplant program. We established a pilot INP-TH team led by a Hepatologist, an Advanced Practice Provider, and a Medical Assistant in July 2022 to co-manage hospitalized patients with advanced liver disease at an affiliated IUH community hospital. In this model, providers caring at the community IUH hospital request a telemedicine consultation from INP-TH team in lieu of a hospital transfer. American Well platform embedded with Cerner’s electronic health record (EHR) with a patient facing Apple iPad was utilized for the current study.

Results: A total of 81 INP-TH consultations were provided, with only 9 (11%) patients requiring a transfer to the AAHC. Of these 81 consultations, 66 consultations on 61 unique patients had outcomes data with greater than 30-day follow-up. The median age was 60 (range: 19-80) years with 65% having a diagnosis of cirrhosis. At the time of INP-TH consult, 80% had signs of liver decompensation with MELD 21 ± 7; 83% had MELD ≥15. The more common etiologies of liver disease included alcohol associated liver disease (30%) and non-alcoholic fatty liver disease (29%). The duration of hospitalization was 9.2 ± 8.3 days with duration of stay 3.2 ± 3.9 days prior to INP-TH consultation. There were 20 (30%) patients requiring readmission. Thirty (45%) patients who were not transferred were seen in the outpatient setting at AAHC within 30 days. In 61 patients with 30-day post-discharge follow-up, there were 7 (11%) deaths (1 transferred and 6 non-transferred) with 61% deaths occurring inpatient.

Conclusion: This proof-of-principle study shows that a telemedicine consultation service by tertiary care hepatologists is feasible to co-manage patients with advanced liver disease hospitalized to a community hospital within an integrated healthcare system. Hospital to hospital transfers can be dramatically minimized but a comprehensive evaluation of provider, patient, and caregiver with satisfaction surveys along with patient outcomes is necessary.