Development and Evaluation of a Patient Cirrhosis Knowledge Assessment.

BACKGROUND AND AIMS: Self-management skills improve outcomes for patients with cirrhosis. While education programs exist to teach these skills, there are limited patient assessments to evaluate their efficacy. We aimed to develop and evaluate cirrhosis knowledge assessments for patients with compensated and decompensated cirrhosis. METHODS: Across two institutions, a 4-stage process was undertaken: first, we developed a comprehensive set of questions regarding cirrhosis self-management. Second, the questions underwent critical review by patients and hepatology providers. Third, patients with cirrhosis answered these questions before and after a written educational tool. Questions were updated based on results. Fourth, patients answered the updated questions before and after a video educational tool. Binomial test or paired sample t-test was used to compare pre- and post-tests depending on question type. RESULTS: In phase 3, 134 patients completed pre- and post-tests. 44% were decompensated, 81% were diagnosed with cirrhosis at least 3 years, and 52% were 60-75 years. 95% of single-answer questions were answered correctly by at least 70% of patients in the pre-test. None of the answers improved significantly with education. After phase 3, 6 questions were removed and 6 questions were edited to increase challenge. In phase 4, 96 patients (42 compensated, 54 decompensated) completed pre- and post-tests. In the compensated assessment, 3 questions improved after education and the summative score increased (7.9 to 9.0, P < 0.001). In the decompensated assessment, 4 questions improved after education and the summative score increased (7.0 to 7.7, P = 0.004). CONCLUSION: Through a rigorous process, we created and evaluated cirrhosis knowledge assessments for patients with compensated and decompensated cirrhosis. Further validation is required and then these assessments can be used to improve patient education.

The Assessment of Driving Fitness Using an On-Road Evaluation in Patients With Cirrhosis.

INTRODUCTION: The association between cirrhosis and driving performance is of particular clinical relevance because of the life-threatening safety issues both for the driver with cirrhosis and the general public. Study aims were to assess (i) driving competency through the use of an in-office computerized battery and on-road driving assessment (DriveABLE) and (ii) the association between minimal hepatic encephalopathy (MHE), in-office paper-pencil tools, and additional measures (e.g., frailty, depression, cognitive testing) with unsafe driving. METHODS: Patients were prospectively recruited from 2 tertiary care liver clinics. In-office tests and in-office and on-road assessments of driving competence were completed. The χ 2 test and 1-way analysis of variance were used to analyze differences among those with and without MHE. Logistic regression was used to evaluate predictors of an indeterminate/fail result on the in-office computerized driving assessment battery (DriveABLE Cognitive Assessment Tool [DCAT]). RESULTS: Eighty patients participated with a mean age of 57 years, 70% male, 75% Child-Pugh B/C, and 36% with a history of overt hepatic encephalopathy. Thirty percent met MHE criteria on both the psychometric hepatic encephalopathy score and the Stroop app tests. Only 2 patients (3%) were categorized as "unfit to drive" in the on-road driving test, one with MHE and the other without. Fifty-eight percent of the patients were scored as indeterminate/fail on the DCAT. This corresponded to a higher mean number of on-road driving errors (5.3 [SD 2.1] vs 4.2 [SD 1.6] in those who passed the DCAT, P = 0.01). Older age (odds ratio 1.3; confidence interval 1.1, 1.5; P = 0.001) and MHE by Stroop/psychometric hepatic encephalopathy score (odds ratio 11.0; confidence interval 2.3, 51.8; P = 0.002) were independently predictive of worse performance on the DCAT. DISCUSSION: Worse performance in in-office testing was associated with worse scores on a computerized driving assessment battery and more on-road driving errors, but in-office tools were insufficient to predict on-road driving failures. A diagnosis of MHE should not be used alone to restrict driving in patients with cirrhosis. At-risk patients require on-road driving tests under the supervision of driving regulatory agencies. Future studies should continue to refine and evaluate in-office or at-home testing to predict driving performance.

International Classification of Diseases Codes are Useful in Identifying Cirrhosis in Administrative Databases.

BACKGROUND: Health administrative databases are essential to define patient populations, make socioeconomic predictions, and facilitate medical research and healthcare planning. The accuracy of this data is dependent on valid codes/coding algorithms. AIMS: The aim of this study was to systematically identify and summarize the validity of International Classification of Diseases (ICD) codes for identifying patients with cirrhosis in administrative data. METHODS: Electronic databases, MEDLINE (via Ovid), EMBASE (via Ovid), the Web of Science, and CINAHL (via EBSCOhost), were searched for validation studies which compared ICD codes related to cirrhosis to a clinical reference standard, and reported statistical measures of performance. RESULTS: Fourteen studies were included in the review. There was a large variation in the algorithms used to validate ICD codes to diagnose cirrhosis. Despite the variation, the positive predictive value (PPV) was greater than 84% and the specificity was greater than 75% in the majority of the studies. The negative predictive value (NPV) was lower, but still was associated with values greater than 70% in the majority of studies. Sensitivity data varied significantly with values ranging from 0.27 to 99%. CONCLUSIONS: Evaluated ICD codes for cirrhosis, including codes for chronic liver disease, cirrhosis-specific codes, and cirrhosis-related complications, have demonstrated variable sensitivity and reasonable specificity for the identification of cirrhosis. Additional research is needed to maximize the identification of persons with cirrhosis to avoid underestimating the burden of disease.

Understanding Preferences Toward Virtual Care: A Pre-COVID Mixed Methods Study Exploring the Perspectives of Patients with Chronic Liver Disease.

Background: Traditionally, outpatient visits for those with chronic liver disease (CLD) have been delivered in-person with the patient traveling to a centralized location to see the health care provider. The use of virtual care in health care delivery has been gaining popularity across a variety of patient populations, especially within the COVID-19 context. Performed before COVID-19, the aim of the present study was to explore the perspectives of patients with CLD toward the use of virtual care with their liver specialists. Methods: A cross-sectional, mixed methods study was used to conduct this work. Results: A total of 101 patients with CLD participated in this study. Participants had a mean age of 54.5 years (range 19-87 years). Quantitative analysis revealed that 86% were willing to attend a virtual visit with their liver specialist in the future. There was a significant relationship between both age and income level and acceptance of virtual care. The themes emerging from the qualitative analysis included: (1) past experiences attending in-person visits, (2) perspectives on the use of virtual visits, and (3) perceived challenges of virtual visits. Conclusions: Although there are many potential benefits of virtual care to both the patient and the health care system, there are instances (older age, low income level) when in-person care may be preferred by patients. A tailored approach that is mindful of the individual patient's health status, ease of access to technology, and preferences must be considered when offering virtual care. These findings are of particular relevance during COVID-19, an era that has forced us into the virtual space.

The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial.

BACKGROUND: Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta. METHODS: A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework. DISCUSSION: The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04149223, November 4, 2019.

Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient-centered care.

Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life-limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician-patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. CONCLUSION: In our clinics, this assemblage of "best practice tools" has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well-informed surrogates. (Hepatology 2018;67:2025-2040).

A Model to Identify Sarcopenia in Patients With Cirrhosis.

BACKGROUND & AIMS: The severe depletion of muscle mass at the third lumbar vertebral level (sarcopenia) is a marker of malnutrition and is independently associated with mortality in patients with cirrhosis. Instead of monitoring sarcopenia by cross-sectional imaging, we investigated whether ultrasound-based measurements of peripheral muscle mass, measures of muscle function, along with nutritional factors, are associated with severe loss of muscle mass. METHODS: We performed a prospective study of 159 outpatients with cirrhosis (56% male; mean age, 58 ± 10 years; mean model for end-stage liver disease score, 10 ± 3; 60% Child-Pugh class A) evaluated at the Cirrhosis Care Clinic at the University of Alberta Hospital from March 2011 through September 2012. Lumbar skeletal muscle indices were determined by computed tomography or magnetic resonance imaging. We collected clinical data and data on patients' body composition, nutrition, and thigh muscle thickness (using ultrasound analysis). We also measured mid-arm muscle circumference, mid-arm circumference, hand grip, body mass index, and serum level of albumin; patients were evaluated using the subjective global assessment scale. Findings from these analyses were compared with those from cross-sectional imaging, for each sex, using logistic regression analysis. RESULTS: Based on cross-sectional imaging analysis, 43% of patients had sarcopenia (57% of men and 25% of women). Results from the subjective global assessment, serum level of albumin, and most nutritional factors were significantly associated with sarcopenia. We used multivariate analysis to develop a model to identify patients with sarcopenia, and developed a nomogram based on body mass index and thigh muscle thickness for patients of each sex. Our model identified men with sarcopenia with an area under the receiver operating characteristic curve value of 0.78 and women with sarcopenia with an area under the receiver operating characteristic curve value of 0.89. CONCLUSIONS: In a prospective study of patients with cirrhosis, we found that the combination of body mass index and thigh muscle thickness (measured by ultrasound) can identify male and female patients with sarcopenia almost as well as cross-sectional imaging (area under the receiver operating characteristic curve values of 0.78 and 0.89, respectively). These factors might be used in screening and routine nutritional monitoring of patients with cirrhosis.

A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients With Cirrhosis: A Prospective Evaluation of the Clinical Frailty Scale.

OBJECTIVES: Screening tools to determine which outpatients with cirrhosis are at highest risk for unplanned hospitalization are lacking. Frailty is a novel prognostic factor but conventional screening for frailty is time consuming. We evaluated the ability of a 1 min bedside screen (Clinical Frailty Scale (CFS)) to predict unplanned hospitalization or death in outpatients with cirrhosis and compared the CFS with two conventional frailty measures (Fried Frailty Criteria (FFC) and Short Physical Performance Battery (SPPB)). METHODS: We prospectively enrolled consecutive outpatients from three tertiary care liver clinics. Frailty was defined by CFS >4. The primary outcome was the composite of unplanned hospitalization or death within 6 months of study entry. RESULTS: A total of 300 outpatients were enrolled (mean age 57 years, 35% female, 81% white, 66% hepatitis C or alcohol-related liver disease, mean Model for End-Stage Liver Disease (MELD) score 12, 28% with ascites). Overall, 54 (18%) outpatients were frail and 91 (30%) patients had an unplanned hospitalization or death within 6 months. CFS >4 was independently associated with increased rates of unplanned hospitalization or death (57% frail vs. 24% not frail, adjusted odds ratio 3.6; 95% confidence interval (CI): 1.7-7.5; P=0.0008) and there was a dose response (adjusted odds ratio 1.9 per 1-unit increase in CFS, 95% CI: 1.4-2.6; P<0.0001). Models including MELD, ascites, and CFS >4 had a greater discrimination (c-statistic=0.84) than models using FFC or SPPB. CONCLUSIONS: Frailty is strongly and independently associated with an increased risk of unplanned hospitalization or death in outpatients with cirrhosis. The CFS is a rapid screen that could be easily adopted in liver clinics to identify those at highest risk of adverse events.

Risk of Bacterial Infection in Patients With Cirrhosis and Acute Variceal Hemorrhage, Based on Child-Pugh Class, and Effects of Antibiotics.

BACKGROUND & AIMS: Antibiotics frequently are overused and are associated with serious adverse events in patients with cirrhosis. However, these drugs are recommended for all patients presenting with acute variceal hemorrhage (AVH). We investigated whether patients should be stratified for antibiotic prophylaxis based on Child-Pugh scores, to estimate risks of bacterial infection, rebleeding, and mortality, and whether antibiotics have equal effects on patients of all Child-Pugh classes. We performed a sensitivity analysis using model for end-stage liver disease (MELD) scores. METHODS: In a retrospective study, we analyzed data from 381 adult patients with cirrhosis and AVH (70% men; mean age, 56 y), admitted from 2000 through 2009 to 2 tertiary care hospitals in Edmonton, Alberta, Canada. We excluded patients with bacterial infection on the day of AVH. The association between antibiotic prophylaxis and outcomes was adjusted by liver disease severity and by a propensity score. RESULTS: The patients included in the study had mean MELD scores of 16, and 54% received antibiotic prophylaxis. Overall, antibiotic therapy was associated with lower risks of infection (adjusted odds ratio, 0.37; 95% confidence interval, 0.91-0.74) and mortality (adjusted odds ratio, 0.63; 95% confidence interval, 0.31-1.29). Among patients categorized as Child-Pugh class A given antibiotics, only 2% developed infections and the mortality rate was 0.4%. Among patients categorized as Child-Pugh class B given antibiotics, 6% developed infections, compared with 14% of patients who did not receive antibiotics; antibiotics did not affect mortality. Administration of antibiotics to patients categorized as Child-Pugh class C reduced infections and mortality by approximately 50%, compared with patients who did not receive antibiotics. MELD scores were not as useful as Child-Pugh class in identifying patients at risk for infection. CONCLUSIONS: Based on a retrospective analysis of patients with cirrhosis and AVH, those categorized as Child-Pugh class A had lower rates of bacterial infection and lower mortality rates in the absence of antibiotic prophylaxis than patients categorized as classes B or C. The recommendation for routine antibiotic prophylaxis for this subgroup requires further evaluation.

Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis have reduced exercise tolerance, measured objectively as decreased peak exercise oxygen uptake (peak VO2). Reduced peak VO2 is associated with decreased survival time. The effect of aerobic exercise training on peak VO2 has not been well studied in patients with cirrhosis. We evaluated the safety and efficacy of 8 weeks of supervised exercise on peak VO2, quadriceps muscle thickness, and quality of life. METHODS: In a prospective pilot study, stable patients (79% male, 57.6 ± 6.7 years old) with Child-Pugh class A or B cirrhosis (mean Model for End-Stage Liver Disease score, 10 ± 2.2) were randomly assigned to groups that received exercise training (n = 9) or usual care (controls, n = 10) at the University of Alberta Hospital in Canada from February through June 2013. Supervised exercise was performed on a cycle ergometer 3 days/week for 8 weeks at 60%-80% of baseline peak VO2. Peak VO2, quadriceps muscle thickness (measured by ultrasound), thigh circumference, answers from Chronic Liver Disease Questionnaires, EQ-visual analogue scales, 6-minute walk distance, and Model for End-Stage Liver Disease scores were evaluated at baseline and at week 8. Analysis of covariance was used to compare variables. RESULTS: At week 8, peak VO2 was 5.3 mL/kg/min higher in the exercise group compared with controls (95% confidence interval, 2.9-7.8; P = .001). Thigh circumference (P = .001), thigh muscle thickness (P = .01), and EQ-visual analogue scale determined self-perceived health status (P = .01) was also significantly higher in the exercise group compared with controls at week 8; fatigue subscores of the Chronic Liver Disease Questionnaires were lower in the exercise group compared with controls (P = .01). No adverse events occurred during cardiopulmonary exercise testing or training. CONCLUSIONS: In a controlled prospective pilot trial, 8 weeks of supervised aerobic exercise training increased peak VO2 and muscle mass and reduced fatigue in patients with cirrhosis. No relevant adverse effects were observed. Larger trials are needed to evaluate the effects of exercise in patients with cirrhosis. ClinicalTrials.gov number: NCT01799785.

Asymptomatic bacteriuria is an independent predictor of urinary tract infections in an ambulatory cirrhotic population: a prospective evaluation.

BACKGROUND & AIMS: Asymptomatic bacteriuria (ASB) is a risk factor for urinary tract infections (UTIs) in many patients without liver disease. It remains unclear whether a diagnosis of ASB in an outpatient with cirrhosis could be utilized to predict the subsequent development of a UTI. We undertook this study to determine the prevalence and incidence of ASB in an outpatient population and its association with UTI. METHODS: We prospectively evaluated 108 adult outpatients with cirrhosis over a 6-month period. Monthly midstream urines (MSU) were performed to detect the occurrence of UTI and ASB (culture of ≥10(8) CFU/L of a urinary pathogen in the absence of UTI symptoms). RESULTS: Of 108 patients enrolled, 99 completed at least one MSU, for a total of 489 MSUs. Total follow-up was 44 person-years. The incidences of ASB and UTI were 181 and 250 per 1000 person-years, respectively. The prevalences of ASB and UTI on the first MSU were 5 and 1%, respectively. In total, 8% of patients developed an episode of ASB and 11% developed a UTI during the study period. Univariate predictors of UTI were female gender, primary biliary cirrhosis, number of previous UTIs and preceding ASB. Preceding ASB was the only independent predictor of UTI on multivariate analysis, with an odds ratio of 6.2 (1.1-34.3), P = 0.04. CONCLUSIONS: Cirrhotic patients have higher rates of ASB and UTI than reported in the general population. ASB is an independent predictor of UTI. Further studies are necessary to determine whether routine screening and antimicrobial treatment of ASB is warranted.

Understanding Nurse Perceptions of Caring for Patients With Alcohol Use Disorder: A Cross-Sectional Study.

BACKGROUND: Alcohol use disorder (AUD), the problematic consumption of alcohol, affects 107 million people worldwide. Individuals with AUD experience high morbidity and increased mortality. Nurses practicing in acute care are ideally positioned to deliver quality interventions to patients with AUD, including screening and brief intervention; formal training and assessment of baseline knowledge, attitudes, and perceptions are necessary. AIMS AND OBJECTIVES: The aim of this study was to explore the knowledge, attitudes, and perceptions of acute care nurses caring for patients with AUD. DESIGN: This study used a cross-sectional survey design. METHODS: The Survey of Attitudes and Perceptions was completed by 93 nurses working in six acute care centers (seven medicine units) across Alberta. Data were analyzed using descriptive and inferential statistics. RESULTS: Few participants reported receiving any prior structured training on AUD, with the majority reporting limited knowledge of alcohol and the effects of alcohol consumption. Although most participants said that caring for patients with AUD was a part of their professional role, few felt satisfied or motivated to work with this group of patients. Responses to individual questions or subdomains of the survey did not significantly differ by length of time in professional role, employment status, or sex. CONCLUSION: Our results indicate that nurses need to learn more about caring for patients with AUD. Developing tailored educational interventions that are mindful of the importance of knowledge, support, satisfaction, and motivation is necessary to improve the quality of care for patients with AUD.

The 22/11 risk prediction model: a validated model for predicting 30-day mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

OBJECTIVES: Clinicians do not have a validated tool for estimating the short-term mortality associated with spontaneous bacterial peritonitis (SBP). Accurate prognosis assessment is important for risk stratification and for individualizing therapy. We aimed therefore to develop and validate a model for the prediction of 30-day mortality in SBP patients receiving standard medical treatment (antibiotics and if indicated by guidelines, intravenous albumin therapy). METHODS: We retrospectively identified SBP patients treated at a tertiary care center between 2003 and 2011 (training set). Multivariate regression modeling and receiver operating characteristic (ROC) curves were utilized for statistical analysis. An external data set of 109 SBP patients was utilized for validation. RESULTS: Of the 184 patients in the training set, 66% were men with a median age of 55 years, a median MELD (Model for End-Stage Liver Disease) score of 20, and a 30-day mortality of 27%. Peripheral blood leukocyte count ≥11×109 cells/l (odds ratio (OR) 2.5; 95% confidence interval CI: 1.2-5.2) and MELD score ≥22 (OR 4.6; 95% CI: 2.3-9.6) were independent predictors of 30-day mortality. Patients with neither, one, or both variables had 30-day mortality rates of 8%, 32%, and 52%, respectively. The findings in the validation set mirrored the training set. CONCLUSIONS: In cirrhotic patients with SBP receiving standard therapy, MELD score ≥22 and peripheral blood leukocyte count ≥11×109 cells/l are validated independent predictors of mortality. The mortality in a patient without either poor prognostic variable is ≤10% and with both variables is ≥50%. Trials aiming to reduce mortality should target patients in the moderate-risk to high-risk groups.

VSL#3 ® probiotic therapy does not reduce portal pressures in patients with decompensated cirrhosis.

BACKGROUND & AIMS: In patients with decompensated cirrhosis, bacterial translocation can contribute to splanchnic vasodilatation, decreased effective circulating volume, and portal hypertension. The primary objective of this randomized, double blind placebo controlled trial was to evaluate the effect of the probiotic VSL#3(®) on the hepatic venous pressure gradient (HVPG). METHODS: Seventeen patients with decompensated cirrhosis and an HVPG of ≥ 10 mmHg were randomized to receive 2 months of VSL#3(®) or an identical placebo. HVPG, endotoxin, interleukin (IL)-6, IL-8, IL-10, renin, aldosterone, nitric oxide and stool microbiota were measured at baseline and study end. RESULTS: Two of the 17 patients were taken off the trial before completion (one for alcohol abuse and the second for SBP - both in placebo arm). Data were analysed on the remaining 15 patients. The median model for end-stage liver disease score was 12, and 80% of patients had Child Pugh B disease. The treatment arm had a greater decrease in HVPG from baseline to study end than the placebo arm (median change from baseline -11.6% vs +2.8%), although this reduction was not statistically significant in either group. There was a significant reduction in the plasma aldosterone level in the VSL#3(®) group, but no significant changes in the other measured parameters, including the stool microflora analysis. CONCLUSIONS: Within the limitations of our sample size, VSL#3(®) therapy does not appear to have a significant impact on portal pressure reduction in patients with decompensated cirrhosis.

Collaborating with patients and caregivers to create web-based educational resources for people affected by cirrhosis.

Objective: To describe the development of multimodal, web-based educational resources about cirrhosis alongside patients and caregivers. Methods: We used an iterative process that was guided by the Strategy for Patient Oriented Research (SPOR) patient engagement framework in describing patient engagement activities to partner with a team of 16 patients and caregivers (Patient Advisory Team (PAT)). This process included five phases: a) Prioritize and gather content, b) design and build the website and videos, c) gather and integrate feedback, d) improve user accessibility, and e) assess usability and knowledge uptake for users. Results: This 2-year process resulted in a 55-page website and 78 animated and live-action videos on cirrhosis complications, procedures, nutrition, and exercise. We implemented usability testing through pre-defined tasks and a think-aloud method from individuals with no previous exposure to the website to assess navigation, appearance, and content issues. Following usability testing, we have been gathering quantitative data from each unique page about relevance and ease of use, as well as qualitative data on the value of the content itself. Conclusions: Collaboration between clinicians, patients, and caregivers is key to developing high-quality digital educational resources. Lessons from our process may help other organizations looking to address disease-specific knowledge gaps. Next steps with www.cirrhosiscare.ca will be continued iterative refinement and structured impact evaluation. Innovation: This project used a patient-centered approach to develop a comprehensive online educational resource for patients with cirrhosis. By having patients with cirrhosis as a key part of our team, we ensured that the site met the needs of this unique population.

Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization.

Background: Multidisciplinary care has the potential to improve outcomes among patients with cirrhosis, yet its impact on this population remains unclear, with existing studies demonstrating discrepant results. Using data from the multidisciplinary outpatient Cirrhosis Care Clinic (CCC) at the University of Alberta Hospital, we aimed to evaluate acute care utilization and survival outcomes of patients followed by the CCC compared with those receiving standard care (SC). Methods: We performed a retrospective chart review of 212 patients with cirrhosis admitted to University of Alberta Hospital between 2014 and 2015. CCC patients (n = 36) were followed through the CCC before index admission. SC patients (n = 176) were managed outside of the CCC. Readmission time in hospital was collected until 1 year, death, or liver transplant. Results: CCC patients had more advanced liver disease (higher prevalence of ascites, encephalopathy, and varices). Despite this, acute care utilization was significantly lower among CCC patients (adjusted length of stay lower by 3 days, p = 0.03, and adjusted survival days spent in hospital lower by 9%, p = 0.02). CCC patients also had improved 1-year transplant-free survival, with an adjusted 1-year relative risk reduction of 53% (p = 0.03). Total mean cost of care was lower in the CCC group by $2,280 per patient-month of life. Discussion: For patients admitted with cirrhosis, specialized post-discharge multidisciplinary outpatient care is associated with decreased acute care utilization, improved 1-year transplant-free survival probability, and the potential for cost savings to the system.

Alcohol use while on the liver transplant waiting list: a single-center experience.

Alcoholic liver disease (ALD) is a leading indication for liver transplantation. Our center has randomly checked blood alcohol levels (BALs) in ALD patients on the waiting list since 2004. We aimed to identify the incidence and predictors of inactivation on the transplant list due to alcohol use and to determine the utility of BAL-screening in this process. We conducted a retrospective review of patients with ALD listed for liver transplantation with at least 3 months of postlisting follow-up. Alcohol use while on the transplant list was defined as a positive BAL, an admission of alcohol use, or refusal to perform screening within 12 hours of request. Cox proportional hazards regression was used to estimate risk ratios (RRs). Of 134 patients meeting eligibility criteria, 78% were male, and mean age was 52 years. Alcohol use was documented in 23 patients (17%). Of these, 12 refused to have a random screen, 8 had detectable serum ethanol levels, and 3 had self-reported alcohol use. On multivariable analysis, a higher number of random BAL-checks [RR = 0.63(0.52, 0.76), P = 0.001] and a longer duration of prelisting abstinence [RR = 0.88(0.83, 0.94), P = 0.001] independently reduced the risk of alcohol use by patients while on the waiting list. None of the patients with >24 months of prelisting abstinence had a positive screen. In conclusion, this study supports random BAL-screening before transplantation and reinforces the importance of abstinence duration as a predictor of relapse. For patients with <24 months of prelisting abstinence, our center will increase the frequency of random BAL screening and increase the rehabilitation requirements to include an intensive 3-week rehabilitation program. We hope that these measures will reduce the rate of relapse to alcohol use post-transplantation.

Advance Care Planning Preferences and Readiness in Cirrhosis: A Prospective Assessment of Patient Perceptions and Knowledge.

Background: In 2014, the province of Alberta launched a campaign to promote public awareness of advance care planning (ACP) and its associated two-part documentation-a Goals of care designation (GCD, a medical order written by a health care practitioner detailing wishes for care) and a personal directive (PD, a document naming a surrogate decision maker). Notably, unlike the GCD, the PD can be self-initiated independent of a health practitioner. Objective: Two years after the campaign, we aimed to assess knowledge and recall of participation in ACP among cirrhosis patients. Design/Setting: Consecutive adult cirrhosis patients attending one of two specialty cirrhosis clinics in Edmonton, Alberta, were surveyed. Results: Ninety-seven patients were included. Mean model for end-stage liver disease was 12. Although 97% of patients indicated it was extremely important to know the reality of their illness, only 53% understood that cirrhosis would affect their future quality of life. Thirty-three percent of patients had completed a PD and 14% had completed a GCD. Seventy-eight percent of patients believed a GCD was important to them and 85% preferred to complete it in an outpatient clinic setting. Only a minority of patients who had taken the initiative to complete a PD in the community also had a GCD. Conclusions: Despite efforts to raise awareness of and educate Albertans about ACP, <20% of cirrhosis patients have a completed GCD. Additional strategic prioritization is required in both patients and providers to ensure that health practitioner-facilitated ACP is carried out as standard-of-care in all patients with cirrhosis.

A shorter duration of pre-transplant abstinence predicts problem drinking after liver transplantation.

OBJECTIVES: Liver transplantation for alcoholic liver disease (ALD) can be complicated by abusive or "problem" drinking (PD) after transplant. There are limited data for evaluating the effect of pre-transplant abstinence on post-transplant PD. Few existing studies have included a substantial number of patients with co-existing causes of hepatic dysfunction, and the effect of PD on survival in recent European studies has been controversial. We hypothesized that a longer duration of pre-transplant abstinence would lead to less PD after transplantation. Accordingly, the objectives of this study are to analyze a North American cohort of patients with ALD with or without a secondary diagnosis of liver disease to estimate (i) the incidence of PD and its predictors, as well as (ii) the effect of PD on patient survival. METHODS: We conducted a retrospective review of all patients transplanted for ALD surviving for more than 3 months after transplant. PD was defined as either any drinking (AD) to the point of intoxication or drinking above the toxic threshold (>20 g/day in women and >40 g/day in men) on at least two separate occasions. We used Cox's proportional hazards regression to estimate risk ratios and Kaplan-Meier curves with log-rank analysis to compare survival. RESULTS: Of 213 eligible transplant patients, 42 were excluded. Of the 171 remaining patients, 78% were male; mean age was 52 years. Overall 53% of patients had co-existing causes of liver dysfunction. The mean follow-up was 64.8 months. The median pre-transplant abstinence was 19 months. In all patients, the risk of AD was 24% and PD 13%. Pre-transplant abstinence duration was the only independent predictor of PD after transplant. For every 1-month increment in pre-transplant abstinence, there was a 5% decrease in the adjusted relapse rate. There was no survival difference noted between problem drinkers and non-drinkers. CONCLUSIONS: The risk of PD decreased with increasing pre-transplant abstinence. Our data support pre-transplant abstinence as an important predictor of post-transplant recidivism; however, the optimal period of abstinence remains unclear. Patients with <18 months of abstinence may benefit from more intensive follow-up and rehabilitation after transplant.