The coronavirus disease 2019 (COVID-19) pandemic has shattered the processes meticulously developed over years by which physicians delivered quality care for patients with cirrhosis. COVID-19 has exposed deep flaws in the structural and process measures developed to follow patients, evaluate disease status and response to therapy, and screen for complications, each of which depends upon frequent physical patient-physician interaction.
The impact of the pandemic on cirrhosis care may unfold in three waves. The first wave has been an intense period with high-acuity care given priority with delayed elective procedures and routine care for “stable” patients during physical distancing to mitigate spread of disease. Screening for varices and hepatocellular carcinoma (HCC) was deferred. Relevant therapeutic procedures such as living donor liver transplants were placed on hold until a safe pathway for surgery was developed to mitigate the risk as much as possible for donors and recipients.
“In the United States, deceased donor liver transplantations also declined due to limited assurance of the availability of intensive care beds and ventilators, blood products and/or renal replacement therapy in the context of COVID-19 care. In this atmosphere, accepting organs for waitlisted patients was tenuous,”says Sumeet Asrani, MD, MSc, a transplant hepatologist on the medical staff at Baylor University Medical Center and co-author of a paper on the impact of the pandemic on cirrhosis care published April 13 in the Journal of Hepatology. “Programs may risk stratify their waitlisted patients, deferring both evaluations and transplant offers. Uncertainty about coronaviral test-accuracy and transmission challenges donor assessments, and quarantine travel restrictions hampered donor procurement.”
Fortunately, at Baylor University Medical Center and Baylor Scott & White All Saints Medical Center – Fort Worth, the deceased donor program was not put on hold due to resource constraints because a priority was set on continuing transplantation. However, the number of liver transplants did decline as a result of the 40 percent decrease in donors throughout the country.
The second wave of the pandemic’s impact occurs when normal clinic operations resume. For some institutions, clinics have reopened and are beginning to welcome patients in person again, but the massive backlog of routine visits may overwhelm pre-crisis capacities for months. A higher incidence and increased overall acuity of second wave encounters are expected because of delayed care, lapsed prescriptions, fear of seeking medical attention and the additional stress that isolation and social distancing has put on patients.
Complications from the pandemic are expected for years in the third wave due to missed diagnoses and haphazard follow up or tracking mechanisms. These may include failure to diagnose HCC at earlier stages, complications of medical therapy for lack of timely labwork and delayed surveillance procedures. Furthermore, any postponed appointment may be accompanied by unintended loss to follow up. Also, what will likely be a protracted economic crisis will impact many patients’ insurance coverage and the ability to travel or take leave from work for care.
Given the uncertain path ahead both with regard to severity and duration of the pandemic, there is a crucial need to adapt to preserve the outcomes patients deserve. Four factors must be integrated into how physicians care for patients in the future. These include:
- An intensification of the preventative care provided to patients with compensated cirrhosis
- Proactive chronic disease management
- Robust telehealth programs
- A reorganization of care delivery to provide the full spectrum of care with flexible clinical staffing
“The second and third waves worry us equally as the first wave because all of these patients with chronic disease we are used to seeing frequently are now deferring their care,” Dr. Asrani says. “We are trying to be very innovative so there is no lapse in care because of the importance of keeping the care of these patients on track. We are using new ways to reach out to patients, including telehealth. We are thinking of alternate ways to keep patients out of the ER by implementing procedures such as outpatient infusions or outpatient paracentesis. In addition, we have restarted living donation in a safe and controlled manner and continued deceased donor liver transplantation with meticulous analysis of each step in the process, from patient safety, donor testing, ensuring adequate resources and appropriate staff protection. We also have reopened our clinics for all liver transplant evaluations.”
Dr. Asrani says it will be critically important to keep track of what necessary care is being deferred to a later date. One consideration is to have a coordinator in all clinics whose only job is to manage the list of “to do” items for patients. As patients lose insurance due to job loss, the challenge will be how to provide care to patients who need it.
“On the other hand, not everything is doom and gloom,” Dr. Asrani says. “This has opened our eyes to the potential of alternate ways to reach patients. In one week alone, telemedicine has helped prevent an admission in a post liver transplant patient, saved a four-hour drive, allowed a cirrhotic patient to proudly share the ‘view from my porch’ in rural Texas, an ascites patient to tour his stocked pantry and another to showcase the facemasks she was making for our team. We have restarted procedures with protocol testing for asymptomatic carriers and redesigned patient flow.
“At the same time, we need checks and balances,” he continues. “We need to ensure that the way forward is patient centric and physician/healthcare provider driven and not simply a byproduct of market forces. The goal of telemedicine is not seeing more patients in less time, but providing quality care that enhances our interactions.”