A better approach to caring for cirrhosis

An estimated one in every 400 Americans has cirrhosis, a condition in which the liver malfunctions due to an increasing amount of scar tissue. When left untreated, the disease can ultimately lead to liver failure and death. 

According to liver specialist Elliot Tapper, M.D., an assistant professor of internal medicine at Michigan Medicine, "the increasing burden of cirrhosis" has led many experts to evaluate the quality of care currently delivered to this high-risk patient population.

Tapper and Neehar Parikh, M.D., M.S., assistant professor at Michigan Medicine, evaluated the existing gaps in care for individuals with cirrhosis and honed in on several key factors. Their research on cirrhosis treatment, which was recently published in Liver Transplantation, focused on improving the quality of life for these patients, as well as implementing effective preventative measures.

Here, Tapper speaks to Michigan Health Lab about their findings.

Why is quality improvement for cirrhosis so notable and what makes this patient population unique?

Cirrhosis is a unique condition, involving incredible medical complexity, coupled with the challenges of unattended social determinants of health and complicated by several unique factors.

This disease can ultimately lead to encephalopathy, which alters brain function and can lead to cognitive challenges in understanding care recommendations and subsequently acting on them.

The liver is where most medications are processed, which means everything providers do in regards to treating cirrhosis has unintended consequences and narrow therapeutic windows. Too much medication, for example, can be too risky, while too little may not be effective.

While cirrhosis can be debilitating for the person that has the condition, it can also have a resounding impact on a person's community. When someone has cirrhosis, they are likely dependent on others to help them with their care.

Various factors, including the social determinants of health, often make individuals with cirrhosis more ill over time. This, in turn, can create even more burnout for those that are caring for these patients in health care settings and at home.  

A history of substance abuse disorder(s) oftentimes go along with this condition and are sometimes ongoing. This can lead to incredibly complicated scenarios in which patients may be recovered from such a disorder, but their relationships with others are still permanently affected.

When it comes to measuring gaps in quality of cirrhosis care, why is this research so important?

Cirrhosis is a super complicated condition and sometimes, even front line providers may not know how best to handle its intricacies. This is when quality improvement makes a difference.

There are wide disparities in the rates of best practices, as well as how they're applied when it comes to caring for patients with cirrhosis. In addition, there are also physician-related factors that come into play for gaps in knowledge on the front line of care.

Quality improvement aims to effectively disseminate and implement those best practices. My number one take home message these days is this – we all think people with alcohol-use disorder should be linked to care for their dependency. Yet, we fail to do so.

This led us to evaluate how best to democratize access to care; what is the best way to universalize access to care for these patients, specifically? Innovators like my colleague, Jessica Mellinger, M.D., are visionaries in the realm of increasing access to care for so many individuals with her multidisciplinary clinic. But this is just the first step on a long road of care.

How do you feel that your research will impact the future of care for patients with cirrhosis?

The use of system-wide electronic interventions to improve care will positively impact the future for individuals with cirrhosis. I'm really proud of the work we're doing to start closing some of these gaps. Neehar Parikh, M.D., M.S., has developed better and more refined cancer screening tools to serve this patient population, as well.

Eventually, we hope to expand the impact of best practices sevenfold through the optimal use of EMR systems.

We are also focusing on preventative care; by avoiding cirrhosis, we're shifting our focus on keeping people as healthy as possible for as long as possible. We're honing in on preventative measures when it comes to the complications that cirrhosis patients endure. It might be linkage to care for alcohol use disorder, preventative treatments like beta-blockers for portal hypertension, or early identification of cognitive dysfunction.

If quality improvement is defined by expanding the use of preventative therapies, we are impacting patients that have the capacity to both live better – and much longer – lives than what the previous focus of quality improvement would have done.

Paper cited: "The Future of Quality Improvement for Cirrhosis," Liver Transplantation. DOI: 10.1002/lt.26079