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COVID-19 pandemic will have a long-lasting
impact on the quality of cirrhosis care
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How will COVID-19 negatively impact quality care
We are only beginning to understand the impact of the pandemic on care quality. Our response is likely to unfold in 3 waves.[10]
COVID-19 brought into sharp relief the trade-offs inherent in our daily clinical decision making. Care has been transformed by the crisis, but enduring lessons have been learned. Novel quality metrics are needed to emphasize the importance of team-based care and telehealth. In addition, a definition of quality that depends on processes and procedures that are not tenable in the context of pandemics and, particularly where a non-procedural alternative exists, highlight inefficient resource utilization. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic will be difficult. Change will be needed. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm.
April 13 2020 Jnl of Hepatology - Elliot B. Tapper, Sumeet K. Asrani
1. Division of Gastroenterology and Hepatology, University of Michigan
2. Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor
3. Baylor University Medical Center, Dallas Texas
Summary
The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging ‘return to normal’ following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.
Introduction
Cirrhosis is common and its prevalence is increasing.[1] Its course is characterized by life-limiting complications such as variceal hemorrhage, ascites, hepatic encephalopathy and hepatocellular carcinoma (HCC). Globally, it causes 2 million deaths per year.[2] Evidence-based interventions directed at each liver-related complication can improve patient outcomes. Examples include imaging-based screening for HCC,[3] endoscopic screening for varices, [4] immunization against viral hepatitis, and optimal therapy for hepatic encephalopathy.[5] Reproducible evidence of improved patient outcomes where care is concordant with quality indicators has validated each measure.[6,7] Guidelines, therefore, have codified these practices as process measures that serve to define quality care in clinical practice.[8,9] Where access to care is limited such as in response to pandemics (i.e. coronavirus disease 2019 [COVID-19]) or natural disasters, priorities change. Indeed, the COVID-19 pandemic shattered the processes, often meticulously developed over years, by which we delivered quality care. COVID-19 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. Given the uncertain path ahead both with regards to severity and duration, there is a crucial need to adapt to preserve the outcomes our patients deserve. Herein, we review the specific ways that COVID-19 will impact on our approach to delivering quality care.
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