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Care Coordination in Cirrhosis

  • Management of Cirrhotic Patient (A Cardenas and P Tandon, Section Editors)
  • Published:
Current Hepatology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Care coordination involves the process of care delivery. Patients with decompensated cirrhosis represent a population with high care coordination needs. The goal of this review is to analyze the utility of care coordination strategies in cirrhosis.

Recent Findings

Target areas for care coordination strategies include transitions through care locations and disease trajectories, provider and patient communication, provider’s roles, and care delivery models. Cirrhosis research has primarily been focused on improving adherence to guideline-based care and clinical outcomes. Discrete process approaches are a reasonable place to start; however, interventions that include multidisciplinary care, patient involvement, and system redesign have greater widespread effect.

Summary

Significant gaps and unanswered questions exist, calling for a larger focus on care coordination among quality improvement initiatives in cirrhosis. Patient, provider, and economic outcomes warrant further evaluation in future studies.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the quality gap: a critical analysis of quality improvement strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under contract 290-02-0017), vol 7. AHRQ Publication No. 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

  2. Okunogbe A, Meredith LS, Chang ET, Simon A, Stockdale SE, Rubenstein LV. Care coordination and provider stress in primary care management of high-risk patients. J Gen Intern Med. 2017;33(1):65–71. https://doi.org/10.1007/s11606-017-4186-8.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Capp R, Misky GJ, Lindrooth RC, Honigman B, Logan H, Hardy R, et al. Coordination program reduced acute care use and increased primary care visits among frequent emergency care users. Health Aff (Millwood). 2017;36(10):1705–11. https://doi.org/10.1377/hlthaff.2017.0612.

    Article  Google Scholar 

  4. Frandsen BR, Joynt KE, Rebitzer JB, Jha AK. Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care. 2015;21(5):355–62.

    PubMed  Google Scholar 

  5. Blumenthal D, Abrams MK. Tailoring complex care management for high-need, high-cost patients. JAMA. 2016;316(16):1657–8. https://doi.org/10.1001/jama.2016.12388.

    Article  PubMed  Google Scholar 

  6. Rakoski MO, McCammon RJ, Piette JD, Iwashyna TJ, Marrero JA, Lok AS, et al. Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. Hepatology. 2012;55(1):184–91. https://doi.org/10.1002/hep.24616.

    Article  PubMed  Google Scholar 

  7. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18(10):1209–16. https://doi.org/10.1002/lt.23495.

    Article  PubMed  Google Scholar 

  8. Patel AA, Walling AM, Ricks-Oddie J, May FP, Saab S, Wenger N. Palliative care and health care utilization for patients with end-stage liver disease at the end of life. Clin Gastroenterol Hepatol. 2017;15(10):1612–9 e4. https://doi.org/10.1016/j.cgh.2017.01.030.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rush B, Walley KR, Celi LA, Rajoriya N, Brahmania M. Palliative care access for hospitalized patients with end-stage liver disease across the United States. Hepatology. 2017;66(5):1585–91. https://doi.org/10.1002/hep.29297.

    Article  PubMed  Google Scholar 

  10. Valery PC, Clark PJ, McPhail SM, Rahman T, Hayward K, Martin J, et al. Exploratory study into the unmet supportive needs of people diagnosed with cirrhosis in Queensland, Australia. Intern Med J. 2017;47(4):429–35. https://doi.org/10.1111/imj.13380.

    Article  PubMed  Google Scholar 

  11. Low J, Davis S, Vickerstaff V, Greenslade L, Hopkins K, Langford A, et al. Advanced chronic liver disease in the last year of life: a mixed methods study to understand how care in a specialist liver unit could be improved. BMJ Open. 2017;7(8):e016887. https://doi.org/10.1136/bmjopen-2017-016887.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Vaughn-Sandler V, Sherman C, Aronsohn A, Volk ML. Consequences of perceived stigma among patients with cirrhosis. Dig Dis Sci. 2014;59(3):681–6. https://doi.org/10.1007/s10620-013-2942-0.

    Article  PubMed  Google Scholar 

  13. Volk ML, Fisher N, Fontana RJ. Patient knowledge about disease self-management in cirrhosis. Am J Gastroenterol. 2013;108(3):302–5. https://doi.org/10.1038/ajg.2012.214.

    Article  PubMed  Google Scholar 

  14. Polis S, Zang L, Mainali B, Pons R, Pavendranathan G, Zekry A, et al. Factors associated with medication adherence in patients living with cirrhosis. J Clin Nurs. 2016;25(1–2):204–12. https://doi.org/10.1111/jocn.13083.

    Article  PubMed  Google Scholar 

  15. Hayward KL, Valery PC, Cottrell WN, Irvine KM, Horsfall LU, Tallis CJ, et al. Prevalence of medication discrepancies in patients with cirrhosis: a pilot study. BMC Gastroenterol. 2016;16(1):114. https://doi.org/10.1186/s12876-016-0530-4.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Ney M, Gramlich L, Mathiesen V, Bailey RJ, Haykowsky M, Ma M, et al. Patient-perceived barriers to lifestyle interventions in cirrhosis. Saudi J Gastroenterol. 2017;23(2):97–104. https://doi.org/10.4103/1319-3767.203357.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Morando F, Rosi S, Gola E, Nardi M, Piano S, Fasolato S, et al. Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: a real-life cross-sectional study. Liver Int. 2015;35(5):1508–15. https://doi.org/10.1111/liv.12583.

    Article  PubMed  CAS  Google Scholar 

  18. Bajaj JS, Wade JB, Gibson DP, Heuman DM, Thacker LR, Sterling RK, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. Am J Gastroenterol. 2011;106(9):1646–53. https://doi.org/10.1038/ajg.2011.157.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kimbell B, Boyd K, Kendall M, Iredale J, Murray SA. Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study. BMJ Open. 2015;5(11):e009241. https://doi.org/10.1136/bmjopen-2015-009241.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Liu TL, Barritt AI, Weinberger M, Paul JE, Fried B, Trogdon JG. Who treats patients with diabetes and compensated cirrhosis. PLoS One. 2016;11(10):e0165574. https://doi.org/10.1371/journal.pone.0165574.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. Beste LA, Harp BK, Blais RK, Evans GA, Zickmund SL. Primary care providers report challenges to cirrhosis management and specialty care coordination. Dig Dis Sci. 2015;60(9):2628–35. https://doi.org/10.1007/s10620-015-3592-1.

    Article  PubMed  Google Scholar 

  22. Mellinger JL, Moser S, Welsh DE, Yosef MT, Van T, McCurdy H, et al. Access to subspecialty care and survival among patients with liver disease. Am J Gastroenterol. 2016;111(6):838–44. https://doi.org/10.1038/ajg.2016.96.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Ghaoui R, Friderici J, Desilets DJ, Lagu T, Visintainer P, Belo A, et al. Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis. J Hosp Med. 2015;10(4):236–41. https://doi.org/10.1002/jhm.2314.

    Article  PubMed  Google Scholar 

  24. Desai AP, Satoskar R, Appannagari A, Reddy KG, Te HS, Reau N, et al. Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease. J Clin Gastroenterol. 2014;48(4):e30–6. https://doi.org/10.1097/MCG.0b013e3182a87f70.

    Article  PubMed  Google Scholar 

  25. Lim N, Lidofsky SD. Impact of physician specialty on quality care for patients hospitalized with decompensated cirrhosis. PLoS One. 2015;10(4):e0123490. https://doi.org/10.1371/journal.pone.0123490.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  26. Goldberg DS, Taddei TH, Serper M, Mehta R, Dieperink E, Aytaman A, et al. Identifying barriers to hepatocellular carcinoma surveillance in a national sample of patients with cirrhosis. Hepatology. 2017;65(3):864–74. https://doi.org/10.1002/hep.28765.

    Article  PubMed  Google Scholar 

  27. Buchanan PM, Kramer JR, El-Serag HB, Asch SM, Assioun Y, Bacon BR, et al. The quality of care provided to patients with varices in the Department of Veterans Affairs. Am J Gastroenterol. 2014;109(7):934–40. https://doi.org/10.1038/ajg.2013.487.

    Article  PubMed  Google Scholar 

  28. Kanwal F, Kramer JR, Buchanan P, Asch SM, Assioun Y, Bacon BR, et al. The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs. Gastroenterology. 2012;143(1):70–7. https://doi.org/10.1053/j.gastro.2012.03.038.

    Article  PubMed  Google Scholar 

  29. Ghaoui R, Friderici J, Visintainer P, Lindenauer PK, Lagu T, Desilets D. Measurement of the quality of care of patients admitted with decompensated cirrhosis. Liver Int. 2014;34(2):204–10. https://doi.org/10.1111/liv.12225.

    Article  PubMed  Google Scholar 

  30. Zhao C, Nguyen MH. Hepatocellular carcinoma screening and surveillance: practice guidelines and real-life practice. J Clin Gastroenterol. 2016;50(2):120–33. https://doi.org/10.1097/MCG.0000000000000446.

    Article  PubMed  CAS  Google Scholar 

  31. Aberra FB, Essenmacher M, Fisher N, Volk ML. Quality improvement measures lead to higher surveillance rates for hepatocellular carcinoma in patients with cirrhosis. Dig Dis Sci. 2013;58(4):1157–60. https://doi.org/10.1007/s10620-012-2461-4.

    Article  PubMed  Google Scholar 

  32. Johnson EA, Spier BJ, Leff JA, Lucey MR, Said A. Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study. Aliment Pharmacol Ther. 2011;34(1):76–82. https://doi.org/10.1111/j.1365-2036.2011.04692.x.

    Article  PubMed  CAS  Google Scholar 

  33. Wundke R, Altus R, Sandford J, Wigg A. Improving management of oesophageal varices in patients with cirrhosis. Qual Saf Health Care. 2010;19(6):536–41. https://doi.org/10.1136/qshc.2009.036525.

    Article  PubMed  Google Scholar 

  34. Farrell C, Halpen A, Cross TJ, Richardson PD, Johnson P, Joekes EC. Ultrasound surveillance for hepatocellular carcinoma: service evaluation of a radiology-led recall system in a tertiary-referral centre for liver diseases in the UK. Clin Radiol. 2017;72(4):338 e11–7. https://doi.org/10.1016/j.crad.2016.10.019.

    Article  Google Scholar 

  35. Walling AM, Schreibeis-Baum H, Pimstone N, Asch SM, Robinson L, Korlekar S, et al. Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. J Palliat Med. 2015;18(4):378–81. https://doi.org/10.1089/jpm.2014.0265.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Sclair SN, Carrasquillo O, Czul F, Trivella JP, Li H, Jeffers L, et al. Quality of care provided by hepatologists to patients with cirrhosis at three parallel health systems. Dig Dis Sci. 2016;61(10):2857–67. https://doi.org/10.1007/s10620-016-4221-3.

    Article  PubMed  Google Scholar 

  37. • Bajaj JS, Reddy KR, Tandon P, Wong F, Kamath PS, Garcia-Tsao G, et al. The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology. 2016;64(1):200–8. https://doi.org/10.1002/hep.28414. One of several recent studies outlining a population of patients at high risk for readmission and subsequent care fragmentation.

    Article  PubMed  Google Scholar 

  38. Desai AP, Reau N. The burden of rehospitalization for patients with liver cirrhosis. Hosp Pract (1995). 2016;44(1):60–9. https://doi.org/10.1080/21548331.2016.1142828.

    Article  Google Scholar 

  39. Tapper EB. Building effective quality improvement programs for liver disease: a systematic review of quality improvement initiatives. Clin Gastroenterol Hepatol. 2016;14(9):1256–65 e3. https://doi.org/10.1016/j.cgh.2016.04.020.

    Article  PubMed  Google Scholar 

  40. Kanwal F, Tansel A, Kramer JR, Feng H, Asch SM, El-Serag HB. Trends in 30-day and 1-year mortality among patients hospitalized with cirrhosis from 2004 to 2013. Am J Gastroenterol. 2017;112(8):1287–97. https://doi.org/10.1038/ajg.2017.175.

    Article  PubMed  Google Scholar 

  41. Beste LA, Leipertz SL, Green PK, Dominitz JA, Ross D, Ioannou GN. Trends in burden of cirrhosis and hepatocellular carcinoma by underlying liver disease in US veterans, 2001–2013. Gastroenterology. 2015;149(6):1471–82 e5; quiz e17–8. https://doi.org/10.1053/j.gastro.2015.07.056.

    Article  PubMed  Google Scholar 

  42. Doycheva I, Issa D, Watt KD, Lopez R, Rifai G, Alkhouri N. Nonalcoholic steatohepatitis is the most rapidly increasing indication for liver transplantation in young adults in the United States. J Clin Gastroenterol. 2017. https://doi.org/10.1097/MCG.0000000000000925.

  43. Allen AM, Kim WR, Moriarty JP, Shah ND, Larson JJ, Kamath PS. Time trends in the health care burden and mortality of acute on chronic liver failure in the United States. Hepatology. 2016;64(6):2165–72. https://doi.org/10.1002/hep.28812.

    Article  PubMed  Google Scholar 

  44. Volk ML. The role of value-based care in patients with cirrhosis. Semin Liver Dis. 2017;37(1):56–9. https://doi.org/10.1055/s-0037-1599840.

    Article  PubMed  Google Scholar 

  45. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44((3):Suppl):166–206.

    Article  Google Scholar 

  46. Volk ML, Tocco RS, Bazick J, Rakoski MO, Lok AS. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2012;107(2):247–52. https://doi.org/10.1038/ajg.2011.314.

    Article  PubMed  Google Scholar 

  47. • Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M, Lai M. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(5):753–9. https://doi.org/10.1016/j.cgh.2015.08.041. An interventional study demonstrating the impact of including a care checklist into routine clincial care through an automated order system.

    Article  PubMed  Google Scholar 

  48. Mayorga CA, Rockey DC. Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11(10):1342–8. https://doi.org/10.1016/j.cgh.2013.04.021.

    Article  PubMed  Google Scholar 

  49. Rawson TM, Bouri S, Allen C, Ferreira-Martins J, Yusuf A, Stafford N, et al. Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors. Clin Med (Lond). 2015;15(5):426–30. https://doi.org/10.7861/clinmedicine.15-5-426.

    Article  Google Scholar 

  50. Morando F, Maresio G, Piano S, Fasolato S, Cavallin M, Romano A, et al. How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. J Hepatol. 2013;59(2):257–64. https://doi.org/10.1016/j.jhep.2013.03.010.

    Article  PubMed  Google Scholar 

  51. Ganapathy D, Acharya C, Lachar J, Patidar K, Sterling RK, White MB, et al. The patient buddy app can potentially prevent hepatic encephalopathy-related readmissions. Liver Int. 2017;37(12):1843–51. https://doi.org/10.1111/liv.13494.

    Article  PubMed  Google Scholar 

  52. Tan M, Menon S, Black D. The impact on patients of a nurse-led clinical service in gastroenterology. Br J Nurs. 2017;26(13):734–8. https://doi.org/10.12968/bjon.2017.26.13.734.

    Article  PubMed  Google Scholar 

  53. • Kanwal F, Asch SM, Kramer JR, Cao Y, Asrani S, El-Serag HB. Early outpatient follow-up and 30-day outcomes in patients hospitalized with cirrhosis. Hepatology. 2016;64(2):569–81. https://doi.org/10.1002/hep.28558. A large retrospective study highlighting the importance of early post-discharge physician follow-up in improving mortality and the associated increase in rehospitalization.

    Article  PubMed  Google Scholar 

  54. Seraj SM, Campbell EJ, Argyropoulos SK, Wegermann K, Chung RT, Richter JM. Hospital readmissions in decompensated cirrhotics: factors pointing toward a prevention strategy. World J Gastroenterol. 2017;23(37):6868–76. https://doi.org/10.3748/wjg.v23.i37.6868.

    Article  PubMed  PubMed Central  Google Scholar 

  55. • Tapper EB, Volk M. Strategies to reduce 30-day readmissions in patients with cirrhosis. Curr Gastroenterol Rep. 2017;19(1):1. https://doi.org/10.1007/s11894-017-0543-3. A review on the impact of various interventions on 30-day readmissions.

    Article  PubMed  Google Scholar 

  56. Thomson M, Volk M, Kim HM, Piette JD. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60(12):3563–9. https://doi.org/10.1007/s10620-015-3744-3.

    Article  PubMed  Google Scholar 

  57. Singal AG, Rahimi RS, Clark C, Ma Y, Cuthbert JA, Rockey DC, et al. An automated model using electronic medical record data identifies patients with cirrhosis at high risk for readmission. Clin Gastroenterol Hepatol. 2013;11(10):1335–41 e1. https://doi.org/10.1016/j.cgh.2013.03.022.

    Article  PubMed  Google Scholar 

  58. Poonja Z, Brisebois A, van Zanten SV, Tandon P, Meeberg G, Karvellas CJ. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management. Clin Gastroenterol Hepatol. 2014;12(4):692–8. https://doi.org/10.1016/j.cgh.2013.08.027.

    Article  PubMed  Google Scholar 

  59. Potosek J, Curry M, Buss M, Chittenden E. Integration of palliative care in end-stage liver disease and liver transplantation. J Palliat Med. 2014;17(11):1271–7. https://doi.org/10.1089/jpm.2013.0167.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Brisebois AJ, Tandon P. Working with palliative care services. Clin Liver Dis. 2015;6(2):37–40. https://doi.org/10.1002/cld.493.

    Article  Google Scholar 

  61. Choi Y. Care coordination and transitions of care. Med Clin North Am. 2017;101(6):1041–51. https://doi.org/10.1016/j.mcna.2017.06.001.

    Article  PubMed  Google Scholar 

  62. Burt J, Rick J, Blakeman T, Protheroe J, Roland M, Bower P. Care plans and care planning in long-term conditions: a conceptual model. Prim Health Care Res Dev. 2014;15(4):342–54. https://doi.org/10.1017/S1463423613000327.

    Article  PubMed  Google Scholar 

  63. Li DJ, Park Y, Vachharajani N, Aung WY, Garonzik-Wang J, Chapman WC. Physician-patient communication is associated with hepatocellular carcinoma screening in chronic liver disease patients. J Clin Gastroenterol. 2016; https://doi.org/10.1097/MCG.0000000000000747.

  64. Wigg AJ, McCormick R, Wundke R, Woodman RJ. Efficacy of a chronic disease management model for patients with chronic liver failure. Clin Gastroenterol Hepatol. 2013;11(7):850–8 e1–4. https://doi.org/10.1016/j.cgh.2013.01.014.

    Article  PubMed  Google Scholar 

  65. Hayward KL, Horsfall LU, Ruffin BJ, Cottrell WN, Chachay VS, Irvine KM, et al. Optimising care of patients with chronic disease: patient-oriented education may improve disease knowledge and self-management. Intern Med J. 2017;47(8):952–5. https://doi.org/10.1111/imj.13505.

    Article  PubMed  Google Scholar 

  66. Mansouri PM, Ghadami MM, SSM N, Yektatalab SP. The effect of self-management training on self-efficacy of cirrhotic patients referring to transplantation Center of Nemazee Hospital: a randomized controlled clinical trial. Int J Community Based Nurs Midwifery. 2017;5(3):256–63.

    Google Scholar 

  67. Ow TW, Ralton L, Tse E. Saving costs through a coordinated care model for patients with hepatocellular cancer. Intern Med J. 2017;47(9):1005–11. https://doi.org/10.1111/imj.13465.

    Article  PubMed  Google Scholar 

  68. Nutt M, Hungerford C. Nurse care coordinators: definitions and scope of practice. Contemp Nurse. 2010;36(1–2):71–81. https://doi.org/10.5172/conu.2010.36.1-2.071.

    Article  PubMed  Google Scholar 

  69. Conway A, O’Donnell C, Yates P. The effectiveness of the nurse care coordinator role on patient-reported and health service outcomes: a systematic review. Eval Health Prof. 2017; https://doi.org/10.1177/0163278717734610.

  70. Mathur AK, Chakrabarti AK, Mellinger JL, Volk ML, Day R, Singer AL, et al. Hospital resource intensity and cirrhosis mortality in United States. World J Gastroenterol. 2017;23(10):1857–65. https://doi.org/10.3748/wjg.v23.i10.1857.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Addolorato G, Mirijello A, Leggio L, Ferrulli A, D’Angelo C, Vassallo G, et al. Liver transplantation in alcoholic patients: impact of an alcohol addiction unit within a liver transplant center. Alcohol Clin Exp Res. 2013;37(9):1601–8. https://doi.org/10.1111/acer.12117.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Tapper EB, Halbert B, Mellinger J. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study. Clin Gastroenterol Hepatol. 2016;14(8):1181–8 e2. https://doi.org/10.1016/j.cgh.2016.04.009.

    Article  PubMed  Google Scholar 

  73. Andersen MM, Aunt S, Jensen NM, Homann C, Manniche J, Svendsen S, et al. Rehabilitation for cirrhotic patients discharged after hepatic encephalopathy improves survival. Dan Med J. 2013;60(8):A4683.

    PubMed  Google Scholar 

  74. Arend J, Tsang-Quinn J, Levine C, Thomas D. The patient-centered medical home: history, components, and review of the evidence. Mt Sinai J Med. 2012;79(4):433–50. https://doi.org/10.1002/msj.21326.

    Article  PubMed  Google Scholar 

  75. Ward L, Powell RE, Scharf ML, Chapman A, Kavuru M. Patient-centered specialty practice: defining the role of specialists in value-based health care. Chest. 2017;151(4):930–5. https://doi.org/10.1016/j.chest.2017.01.006.

    Article  PubMed  Google Scholar 

  76. Huang X, Rosenthal MB. Transforming specialty practice—the patient-centered medical neighborhood. N Engl J Med. 2014;370(15):1376–9. https://doi.org/10.1056/NEJMp1315416.

    Article  PubMed  CAS  Google Scholar 

  77. Meier SK, Shah ND, Talwalkar JA. Adapting the patient-centered specialty practice model for populations with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(4):492–6. https://doi.org/10.1016/j.cgh.2015.12.034.

    Article  PubMed  Google Scholar 

  78. McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V et al. Care Coordination Atlas Version 3 (Prepared by Stanford University under subcontract to Battelle on Contract No. 290–04-0020). Rockville, MD: Agency for Healthcare Research and Quality. 2010;November(AHRQ Publication No. 11–0023-EF).

  79. Singal AG, Tiro JA, Marrero JA, McCallister K, Mejias C, Adamson B, et al. Mailed outreach program increases ultrasound screening of patients with cirrhosis for hepatocellular carcinoma. Gastroenterology. 2017;152(3):608–15 e4. https://doi.org/10.1053/j.gastro.2016.10.042.

    Article  PubMed  Google Scholar 

  80. Le S, Spelman T, Chong CP, Ha P, Sahhar L, Lim J, et al. Could adherence to quality of care indicators for hospitalized patients with cirrhosis-related ascites improve clinical outcomes? Am J Gastroenterol. 2016;111(1):87–92. https://doi.org/10.1038/ajg.2015.402.

    Article  PubMed  Google Scholar 

  81. Beg S, Curtis S, Shariff M. Patient education and its effect on self-management in cirrhosis: a pilot study. Eur J Gastroenterol Hepatol. 2016;28(5):582–7. https://doi.org/10.1097/MEG.0000000000000579.

    Article  PubMed  Google Scholar 

  82. Roman E, Garcia-Galceran C, Torrades T, Herrera S, Marin A, Donate M, et al. Effects of an exercise programme on functional capacity, body composition and risk of falls in patients with cirrhosis: a randomized clinical trial. PLoS One. 2016;11(3):e0151652. https://doi.org/10.1371/journal.pone.0151652.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  83. Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015;62(2):584–90. https://doi.org/10.1002/hep.27830.

    Article  PubMed  Google Scholar 

  84. Group KDIGO. KDIGO clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(1):1–150.

    Article  Google Scholar 

  85. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Rev Esp Cardiol (Engl Ed). 2016;69(12):1167. https://doi.org/10.1016/j.rec.2016.11.005.

    Article  Google Scholar 

  86. DeVore AD, Allen LA, Eapen ZJ. Thinking outside the box: treating acute heart failure outside the hospital to improve care and reduce admissions. J Card Fail. 2015;21(8):667–73. https://doi.org/10.1016/j.cardfail.2015.05.009.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Cirrhosis Care Clinic, 8540 112 Street, Zeidler Ledcor Centre, Edmonton, AB, T6G 2X8, Canada

    Michelle Carbonneau & Puneeta Tandon

  2. Alberta Health Services, 8440 112 Street, Zeidler Ledcor Centre, Edmonton, AB, T6G 2B7, Canada

    Michelle Carbonneau & Tracy Davyduke

  3. Faculty of Medicine & Dentistry, University of Alberta, 2J2.00 Walter C Mackenzie Health Sciences Centre, 8440 112 St, Edmonton, AB, T6G 2R7, Canada

    Puneeta Tandon

Authors
  1. Michelle Carbonneau
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  2. Tracy Davyduke
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  3. Puneeta Tandon
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Correspondence to Michelle Carbonneau.

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Michelle Carbonneau, Tracy Davyduke, and Puneeta Tandon each declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors

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This article is part of the Topical Collection on Management of Cirrhotic Patient

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Carbonneau, M., Davyduke, T. & Tandon, P. Care Coordination in Cirrhosis. Curr Hepatology Rep 17, 33–41 (2018). https://doi.org/10.1007/s11901-018-0388-8

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  • DOI: https://doi.org/10.1007/s11901-018-0388-8

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