Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage

Abstract

BACKGROUND & AIMS: Q8Missed or inappropriate referrals of potential candidates for liver transplantation (LT) are common and traditional referral methods (tRs) do not allow for efficient triage. We investigated the effects of these issues on a website developed for electronic outpatient referral to LT (eRW-LT). METHODS:We prospectively collected data on all consecutive outpatient referrals to 2 Italian LT centers from January 2015 to December 2019. In the second half of the study, starting from July 2017, referring physicians had the option of using eRW-LT, quickly obtaining the judgment on the appropriateness and urgency of the visit from a transplant hepatologist. RESULTS:In the second half of the study, there were 99 eRW-LTs and 96 traditional referrals (new tRs), representing a 17.4% increase over the 161 traditional referrals (old tRs) of the first half. With eRW-LT, 11.1% of referrals were judged inappropriate online without booking a visit. Appropriateness, judged at the time of the first visit, was 59.6%, 56.2%, and 94.3% with old tRs, new tRs, and eRW-LT, respectively. Considering the appropriate visits, the median waiting time in days between referral date and first visit appointment was significantly shorter for urgent visits referred with eRW-LT (5.0; 95% CI, 4.8-9.3) compared with nonurgent visits sent with the same system (17.0; 95% CI, 11.5-25.0; P < .0001), those referred with old tRs (14.0; 95% CI, 8.0-23.0; P < .001) and with new tRs (16.0; 95% CI, 10.0-23.0; P < .001). CONCLUSIONS:eRW-LT allows an increase in the number of referrals for LT, ensuring effective triage and better appropriateness of visits.

Telehealth interventions in patients with chronic liver diseases: A systematic review

“…Two studies evaluated electronic transplant referrals. Ferri et al 45 found no difference in the number of patients listed or transplanted. Delman et al 47 found a decrease in the number of monthly referrals without a difference in transplant volume, possibly because of decreased competition for liver transplants during the COVID pandemic.…”

“…Consequently, greater distance from a liver transplant center is associated with a lower likelihood of listing, transplantation, and increased mortality 60,61 . TH can close this gap with video consultations and telemedicine to expedite the evaluation of referrals and transplant listing 45,46 . We also think that the use of TH in the initial transplant evaluation can shorten or substitute some of the inperson consultations, such as the transplant hepatology visit for stable chronic liver disease suffering from HCC, the psychosocial evaluation and, if a handgrip dynamometer or measurement tape is available on prior remote consultations, the nutritional assessment.…”

“…[60,61] TH can close this gap with video consultations and telemedicine to expedite the evaluation of referrals and transplant listing. [45,46] We also think that the use of TH in the initial transplant evaluation can shorten or substitute some of the inperson consultations, such as the transplant hepatology visit for stable chronic liver disease suffering from HCC, the psychosocial evaluation and, if a handgrip dynamometer or measurement tape is available on prior remote consultations, the nutritional assessment. Moreover, in the posttransplant setting, telemedicine offers an equally effective option for close follow-up, without differences in pertinent outcomes such as rates of graft rejection, hospital readmission, and overall mortality.…”

The role of an integrated referral program for patients with liver disease: A network between hub and spoke centers

“…To our knowledge, this was the first experience of an integrated referral program for out-and in-patients with acute or chronic liver diseases in Italy. As for many other conditions, the institution of this dedicated program may theoretically improve patient's outcomes, rebalance potential inequities, spare healthcare resources, and reduce barriers to LT. [21][22][23] Recently, an electronic referral system was developed in Italy, but it was dedicated only to the outpatient evaluation of potential candidates for LT. 24 During a 4-year study, 281 patients were referred to the Multivisceral Transplant Unit (Padua University Hospital) for the first time.…”

“…Median (IQR) Child-Pugh and MELD scores were 11 [9][10][11][12] and 24, [18][19][20][21][22][23][24][25][26][27][28] respectively, with no significant differences in terms of liver disease severity between pre-and post-referral eras (Table 4). Notably, in the referral period, patients were admitted with significantly different indications than before, with an evaluation for TIPS placement having a significant increase over time (5.6% vs. 1%) and LT evaluation having a less significant rising trend (84.5% vs. 81%).…”