RESUMO
Background and aims: The global pandemic has inevitably diverted resources away from management of chronic diseases, including cirrhosis, where up to 40% of patients are readmitted with new cirrhosis decompensation events. Whilst there is increasing knowledge on COVID-19 infection in liver cirrhosis, little is described on the impact of the pandemic on decompensated cirrhosis admissions and outcomes, which was the aim of this study. Method: A single-centre, retrospective study, evaluated decompensated cirrhosis admissions to a tertiary London hepatology and transplantation centre, from October 2018 to February 2021. Patients were included if they had an admission with cirrhosis decompensation defined as new onset jaundice or ascites, infection, encephalopathy, portal hypertensive bleeding or renal dysfunction. Admissions were excluded if they lasted <24 hours,were elective or occurred post liver-transplant. Results: Therewere 351 admissions in the pre-COVID period (October 2018 to February 2020) and 240 admissions during the COVID period (March 2020 to February 2021), with an average of 20.4 admissions per month throughout. Patients transferred in from secondary centres had consistently higher severity scores during the COVID period (UKELD 58 versus 54;p = 0.007, MELD Na 22 versus 18;p = 0.006, AD score 55.0 versus 51.0;p = 0.055). The proportion of ITU admissions pre versus during-COVID stayed constant (22.9% versus 19.2%), but there was a trend towards increased ICU admissions with acute-on-chronic liver failure (ACLF) (73.9% versus 63.8% prepandemic). Of those admitted to the intensive care without ACLF, there was a significant increase in EF-CLIF acute decompensation (AD) scores during the COVID period (58 versus 48, p = 0.009). In addition, there was a trend towards increased hospital re-admission rates during the COVID period (29.5% versus 21.5%, p = 0.067). When censored at 30 days, time to death post discharge was significantly reduced during the COVID period (p < 0.05) with a median time to death of 35 days compared to 62 days pre-COVID.(Figure Presented)Conclusion: This study provides a unique perspective on the impact that the global pandemic had on the clinical course and characteristics of decompensated cirrhosis admissions. The findings of increased early mortality and re-admissions, and higher AD scores, indicating increased disease morbidity, highlight the need to maintain resourcing on providing high-level hepatology care. Given that COVID-19 will likely be a chronic issue, alternative care pathways such as remote monitoring may need adoption to facilitate continuity of care post-discharge and to reduce readmission rates and morbidity in the future
RESUMO
Background: Oncology telehealth (TH) services may improve access, mitigate care delays, and augment care in select settings. However, logistical and workflow barriers hinder the sustainable adoption of TH services by providers. We created a novel oncology TH nurse (OTN) position to address these barriers. Methods: An OTN was introduced into oncology provider groups (physician + advanced practice provider) in a staggered, opt-in fashion across the Duke Cancer Institute between 9/2020 and 12/2020. The OTN performed individualized interventions to decrease provider burden, improve TH workflows, and increase TH utilization. Specific interventions performed by the OTN were recorded. We monitored the primary outcome, TH utilization, as a proportion of all visits at baseline (month 0) and 3 months post-OTN intervention. Patient TH satisfaction surveys were reviewed at baseline and 3 months post-OTN intervention. Provider surveys were sent 3 months post-OTN intervention. Results: The OTN was implemented across 10 provider groups and 25 providers [gastrointestinal (GI) medical oncology (n = 10), thoracic medical oncology (n = 3), melanoma medical oncology (n = 3), adult bone marrow transplant (n = 2), lung cancer screening (n = 2), melanoma surgical oncology (n = 1), hematological malignancies (n = 1), head and neck medical oncology (n = 1), central nervous system radiation oncology (n = 1), and GI radiation oncology (n = 1)]. 25 providers utilized 1 or more OTN interventions: Support for patients on the TH platform (n = 13), construction of TH clinic schedule templates (n = 6), creation of workflows to order and obtain outside imaging/labs (n = 5), provider TH education (n = 4), creation of Epic SmartPhrases (n = 4), and identifying patients appropriate for TH (n = 3). Baseline TH utilization was 15.6% of all visits, and 3-month post-OTN utilization was 23.8%. TH patient satisfaction data was available for 10 providers at baseline and 13 providers at 3 months post-OTN. Patients' global approval rating of TH was 85.0% at baseline and 98.5% at month 3. 16/25 providers returned the postintervention survey. Providers requested continued assistance from the OTN for supporting patients on the TH platform (43.5%), staff TH education (43.5%), provider TH education (25%), creation of SmartPhrases (25%), and creation of TH clinic templates (13%). Providers requested new additional OTN support to 1) order and retrieve imaging/laboratory tests for TH visits and 2) explore patients' willingness to undergo TH visits. Conclusions: OTN interventions were individualized to providers and evolved over time. While TH utilization was increased at 3 months post-OTN, it is possible that utilization was confounded by the dynamic COVID-19 pandemic and provider/patient preferences over time. Nevertheless, these results demonstrate feasibility of OTN implementation and provide support for this novel role in promoting TH services in oncology.