Practice Management Toolbox

Current and future applications of telemedicine to optimize the delivery of care in chronic liver disease

Publish date: July 2, 2018

 

Telemedicine to aid in procedural/surgical management

A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.9 Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.10 A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.11 Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.12

Telemedicine to support evaluation and management of hepatocellular carcinoma

One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.13 A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.

Remote monitoring interventions

Dr. Michael L. Volk, division of gastroenterology and Transplantation Institute, Loma Linda (Calif.) University

Dr. Michael L. Volk

The literature for remote monitoring in chronic liver disease or after liver transplant currently is emerging. A prospective pilot study by Thomson et al14 evaluated the utility of a telephone-based interactive voice response intervention in predicting hospitalizations and death among 79 patients with decompensated cirrhosis. Parameters such as self-reported weakness and more than a 5-pound weight gain in 1 week were associated with increased rates of hospitalization. Ertel et al15 recently published results of a nonrandomized pilot study of remote monitoring using smart tablets among 20 liver transplant recipients. Patients were followed up for 90 days after the liver transplant surgery whereby daily weights, blood glucose reading, and vital signs were transmitted to the transplant center; violations of preset thresholds were recorded, although it was not clear whether members of the clinical team were asked to act upon the violations. Readmission rates among patients in the pilot study at 30 and 90 days were 20% and 30%, respectively, compared with 40% and 45% among historical controls. Patients with 100% daily interaction with the smart tablets did not experience any readmissions. Another abstract described a nurse-led remote monitoring intervention paired with at-home video teleconference visits among 31 patients with alcoholic cirrhosis.16 The majority of patients were able to stop alcohol intake, improve their nutrition, and increase physical activity. Supplementary Table 3 (https://doi.org/10.1016/j.cgh.2017.10.004) shows additional ongoing or completed telemedicine interventions in liver disease as obtained from www.clinicaltrials.gov.

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