ABSTRACT
Background and Aim: The COVID-19 pandemic has led to significant disruption to the delivery of health care worldwide. The impact of the pandemic on liver transplant (LT) services in Australia and New Zealand has not yet been established. In March 2020, the Transplantation Society of Australia and New Zealand COVID-19 Taskforce raised the minimum eligibility for LT to patients with high short-term mortality (i.e. Model for End-Stage Liver Disease [MELD] score > 20). This directive was later removed, but services continued to be affected by broader government and hospital pandemic responses. This study aimed to examine the impact of the various responses to the pandemic on LT services in Australia and New Zealand. Method(s): We performed a retrospective analysis of all LT activity on the Australia and New Zealand Liver and Intestinal Transplant Registry from 2012 to 2021. The primary outcome was delisting from the LT waitlist (WL) due to disease progression or death. Outcomes were assessed at the end of each year and categorized as transplanted, died, or delisted. Delisted patients were defined as those who were removed and not relisted onto the WL within 180 days. Additional registrations onto the WL for retransplantation in the same patient were considered separate events. Annual trends in LT and WL activity were observed for the entire study period, using interrupted time series analysis. Differences between the pandemic cohort (1 January 2020 to 31 December 2021) and a corresponding pre-pandemic cohort (1 January 2018 to 31 December 2019), were then analyzed using chi2 and Mann-Whitney U tests as appropriate. Additionally, organ donation rates were obtained from the publicly accessible Australia and New Zealand Organ Donation (ANZOD) registry. Result(s): From 2012 to 2021, there were 3219 LTs performed, 3920 WL registrations, and 416 patients who died or were delisted due to disease progression. On interrupted time series analysis, there was a predicted annual increase of 17 LTs from 2012 to 2019 (95% CI, 12-22;P < 0.001);however, in 2020-2021, there was an annual reduction of 43 LTs (95% CI, 38-48;P < 0.001) compared with 2018-2019 (Fig. 1a). Concurrently, there was a predicted annual increase of 12 new WL registrations (95% CI, 7-17;P = 0.001) before the pandemic, which reduced by 18 new registrations annually in 2020-2021 (95% CI, 14-24;P < 0.001) (Fig. 1b). The number of patients remaining on the WL at year's end remained stable. ANZOD donor data found a corresponding predicted annual reduction of 86 actual/intended donors (95% CI, 80-93;P < 0.001) in 2020-2021 compared with before COVID-19 (Fig. 1c). Compared with the pre-pandemic cohort, the pandemic cohort had more severe liver disease at listing (median MELD score, 18 [12-24] vs 17 [11-22];P = 0.020) but no other baseline differences. The Australian pandemic cohort had a higher proportion of death or delisting due to disease progression (8.6% vs 6.0%, P = 0.043) and a corresponding lower proportion transplanted (66.9% vs 72.6%, P = 0.011) compared with the pre-pandemic cohort. In contrast, New Zealand transplant activity and outcomes were unchanged. Overall WL numbers and median days on the WL were unchanged before and after the pandemic in both nations. Conclusion(s): Despite low community rates of COVID-19, the effects on LT in Australia were similar to those seen in nations with high COVID-19 prevalence. Reduced Australian LT activity corresponded with reduced donor numbers and was associated with more severe disease at WL, as well as higher rates of disease progression. In New Zealand, LT activity was less disrupted and outcomes were unchanged.
ABSTRACT
Background and Aim: The rising burden of chronic disease in the developed world has resulted in an accumulation of patients requiring long-term specialist input in care, despite relatively stagnant capacity in tertiary hospital services. Newer models of care, incorporating specialist input while empowering and enabling community-based treatment in the more cost-effective primary care setting, are urgently needed. Digital health technologies have been proposed as one such novel model. The evolving digital technology paradigm shift instigated by the coronavirus 2019 pandemic has placed further emphasis on the need for evidence-based eHealth interventions. Chronic hepatitis C virus (HCV) represents a model disease in which rapid treatment advances have allowed care to shift from tertiary to community-based treatment models;however, barriers remain in achieving elimination targets and scaling up treatment to at-risk populations. We aimed to explore the efficacy, acceptability, and feasibility of an eHealth model to connect community and prison-based clinicians with specialist teams for HCV treatment. Methods: We conducted a multicenter quasi-experimental pre-post study using a hybrid effectiveness-implementation design with referring community and prison-based clinicians, in consultation with eight tertiary centers in Australia. The pre-intervention control group was treated through existing paper, fax, or remote consultation methods between 1 March 2016 and 28 February 2017. The eHealth model of care (using the HealthELink system) was prospectively implemented from 1 August 2017 to 30 April 2019. Key elements of the web-based eHealth model include HCV-specific clinical decision support, including University of Liverpool drug-drug interaction integration, secure electronic messaging, task management, email alerts, and an electronic patient portal. The primary outcome was sustained virological response at 12 weeks after treatment (SVR12), based on intention-to-treat analysis. Secondary outcomes included an implementation analysis comprising usability, acceptability, quality, safety, and uptake/utilization measures. Results: In total, 249 patients (180 community, 69 prison) were treated in the eHealth group, and 681 (588 community, 87 prison) in the control group. Sixty-one general practitioners, 12 specialists, 24 nurses, and four prison systems registered to use the eHealth system. In the community-based group, SVR12 was confirmed in 106/180 patients (59%), compared with 383/588 (65%) in the control group (P = 0.13), and 44/69 (64%) versus 61/87 (70%) in the prison-based group (P = 0.32). Completion of repeat liver biochemistry at the time of SVR12 testing (88% vs 51%, P = 0.01) and adherence to guideline-based treatment (100% vs 98%, P = 0.03) were higher in the eHealth group. Timeto specialist approval (median, 1 vs 7 days;P < 0.01) and SVR12 confirmation from the intention to treat when adjusted for treatment duration (175 vs 208 days, P = 0.05) were both significantly reduced in the eHealth group. Uptake of the eHealth model was greatest in nurse-led and prison-based cohorts. Low uptake was found among GP users, primarily due to few HCV patients encountered during the study. High levels of usability (median system usability score, 76) and acceptability were found among most users, with the clinical decision support features found to be most useful. Low technological failure rates were seen, with browser compatibility the most frequent issue encountered, in less than 5% of users. Conclusion: This eHealth model of care resulted in similar clinical outcomes to the current standard of care. However, treatment efficiency and adherence to guideline-based care were improved using eHealth. The model was acceptable and displayed good usability for most users. This study shows that a multifaceted eHealth system is a valuable and scalable model to manage HCVand serves as a blueprint for other chronic diseases.