Caroline Tallis

Cost and time savings from a rapid access model of care using transient elastography to screen and triage patients with chronic Hepatitis C infection

Abstract Background: Treatment uptake amongst patients with chronic Hepatitis C virus (HCV) in Australia is relatively low. New approaches to assessment have the potential to reduce public waiting lists, improve access to treatment, and to reduce healthcare costs. Aim: To describe the costs to the public hospital system and waiting time associated with a novel integrated rapid access to assessment and treatment (RAAT) model of care that utilizes Transient Elastography (TE) as a specialist outpatient-based approach for a streamlined assessment of patients with chronic HCV, compared to conventional outpatient management with liver biopsy (LB). Methods: Time from first medical review to treatment plan and costs associated with detection of fibrosis were recorded for patients receiving RAAT during a 3-month period, and for a similar historical cohort managed conventionally with LB. Costs related to medical and multidisciplinary team reviews and the TE/LB test itself were included. Results: Patients receiving RAAT had lower costs (n = 27, median AU

Medication beliefs predict medication adherence in ambulatory patients with decompensated cirrhosis

2716) and shorter time to treatment (median = 194 days) than for conventional management (n = 13, median

Discrepancies in the use of medications in patients with cirrhosis

5005, 420 days; p < 0.01). Differences related to the lower TE test costs and the lower cost of consults between first medical review and establishment of a treatment plan. Conclusions: Based on real world audit data, this evaluation suggests TE, used as part of a new RAAT model of care, is cost saving to the health system in the short-term and reduces waiting times. The analysis reported here was intended to assess the costs related to detection of fibrosis, and is limited by the small sample size and potential selection bias. Future research should undertake a full economic evaluation at a whole of service level, to consider a more comprehensive and longer-term assessment of the costs and benefits associated with HCV management.

Medication adherence in outpatients with decompensated cirrhosis

AIM To investigate the impact of medication beliefs, illness perceptions and quality of life on medication adherence in people with decompensated cirrhosis. METHODS One hundred adults with decompensated cirrhosis completed a structured questionnaire when they attended for routine outpatient hepatology review. Measures of self-reported medication adherence (Morisky Medication Adherence Scale), beliefs surrounding medications (Beliefs about Medicines Questionnaire), perceptions of illness and medicines (Brief Illness Perception Questionnaire), and quality of life (Chronic Liver Disease Questionnaire) were examined. Clinical data were obtained via patient history and review of medical records. Least absolute shrinkage and selection operator and stepwise backwards regression techniques were used to construct the multivariable logistic regression model. Statistical significance was set at alpha = 0.05. RESULTS Medication adherence was “High” in 42% of participants, “Medium” in 37%, and “Low” in 21%. Compared to patients with “High” adherence, those with “Medium” or “Low” adherence were more likely to report difficulty affording their medications (P < 0.001), lower perception of treatment helpfulness (P = 0.003) and stronger medication concerns relative to medication necessity beliefs (P = 0.003). People with “Low” adherence also experienced greater symptom burden and poorer quality of life, including more frequent abdominal pain (P = 0.023), shortness of breath (P = 0.030), and emotional disturbances (P = 0.050). Multivariable analysis identified having stronger medication concerns relative to necessity beliefs (Necessity-Concerns Differential ≤ 5, OR = 3.66, 95%CI: 1.18-11.40) and more frequent shortness of breath (shortness of breath score ≤ 3, OR = 3.87, 95%CI: 1.22-12.25) as independent predictors of “Low”adherence. CONCLUSION The association between “Low” adherence and patients having strong concerns or doubting the necessity or helpfulness of their medications should be explored further given the clinical relevance.

Prevalence of medication discrepancies in patients with cirrhosis: A pilot study

Individuals with decompensated cirrhosis and ascites requiring paracentesis utilize exceptionally high levels of hospital resources. Consequently, potential modifications to existing models of healthcare to assist patients in the management of their liver disease and reduce the need for hospital encounters have potential to improve patients’ health and reduce demand on acute hospital services. However, there is a paucity of data examining how much healthcare resources could be re-directed to interventions that prevent hospitalizations without net annual budgetary disadvantage (from the hospital’s perspective). The purpose of this study was to probabilistically examine how much healthcare resourcing could be saved per hospital presentation avoided among this clinical population.

Medication beliefs predict low medication adherence in people with decompensated cirrhosis

Background: Interferon gamma release assay (IGRA) is the most widely used test for screening of latent tuberculosis (TB). However, indeterminate IGRA tests may occur, reducing the utility of the test, and have been associated with impaired immune status. The performance of the IGRA in patients with end stage liver disease, a disease state with known, multifaceted immune dysfunction, has not been well studied. The aim of this study was therefore to evaluate the prevalence and predictors of indeterminate IGRAs in patients with end stage liver disease being assessed for liver transplantation. Methods: Prospective study of 49 consecutive patients undergoing liver transplantation assessment who underwent IGRA (Quantiferon-TB Gold) to exclude latent TB. Groups (indeterminate versus determinate) were compared and tested for association with clinically relevant variables (age, aetiology of liver disease, MELD score, Child–Pugh score and absolute lymphocyte count). Groups were compared using the Mann–Whitney U-test. Testing for independent associations with an indeterminate test was performed using multivariate logistic regression. An ROC curve was also created to define the optimum probability cut off. Results: Of the 49 IGRAs performed, 12 (24%) were indeterminate and 37 (76%) were determinate. Of the determinate IGRAs, three (6 %) were positive and 34 (70%) were negative. Patients who had an indeterminate test were significantly older than those with determinate tests (57.3 vs. 50.5, p = 0.03). There were no other statistically significant differences between the indeterminate versus determinate group: mean MELD score (16.1 vs. 15.8, p = 0.43), mean Child–Pugh score (9.8 vs. 8.8, p = 0.21), mean absolute lymphocyte count (1.03 vs. 0.95, p = 0.30). Multivariate logistic regression testing for independent associations with an indeterminate test, together with changes in the area under the ROC curve, are shown in Table 1. The combination of these variables could provide a high degree of accuracy for predicting an indeterminate test with a c statistic of 0.80 for the ROC curve (Fig. 1). Conclusions: Patients with advanced liver disease had a high rate of indeterminate IGRA in this study relative to other groups described in the literature, which may limit the utility of this test in this population. Indeterminate tests could be predicted with moderate to high accuracy using five routinely collected clinical variables. The reason for the high prevalence of indeterminate tests may relate to immune dysfunction associated with advanced liver disease but results require validation in larger studies.