CirrhoCare in COVID-19: A Pilot, Remote, Home Monitoring Study in Advanced Cirrhosis

The current Covid Pandemic has necessitated an unusual allocation of healthcare resources which inevitably negatively impacts on resources available to care for patients with chronic diseases including liver disease. This is most marked in those with acute 'decompensation' of cirrhosis, namely the significant subset of patients who develop a rapid decline in liver function and numerous complications including, fluid overload, confusion (encephalopathy), kidney dysfunction and gastrointestinal bleeding.[Jalan et al, J Hepatol 2015; Moreau R et al, Gastroenterology 2013] These patients normally require a regular clinical assessment (every 1-2 weeks) and even when discharged following a recent admission to hospital, have re-admission rates approaching 40% in 8 weeks.[Moranda et al, J Hepatol, 2013] The current unmet need is to institute regular contact with the patient, to avoid further new complications from cirrhosis developing and hospital admission, whilst also avoiding nosocomial (health care setting related) infection with Covid 19 through standard outpatient, scheduled contact. [Tapper EB et al, J Hepatol 2020]

We propose to provide a remote management system for cirrhosis care, which will include remote acquisition of important vital signs such as heart rate, heart rate variability, blood pressure, physical activity and sleep status (through wearable technology), weight, and assessment of higher mental function (smartphone app based tools), all of which are key metrics that are perturbed as cirrhosis decompensation ensues. By efficiently collating this data and linking this to an effective clinical workflow stream based on a platform created for smartphone and clinical user application interfaces, will facilitate improved telemedicine 'consultations' by healthcare providers. This is a novel approach that in this patient cohort, which will allow early detection of signs of complications and rapid triaging of patients who need early direct clinical review, at a time when this is a limited resource. Our solution will help prioritize care whilst limiting risk of COVID-19 infection exposure, and also personalizing this to an individual patient's needs and disease, making this more acceptable and convenient for patients. In the longer term, costs savings will arise through more efficient and streamlined outpatient direct contacts, whilst all patients will receive the priority and regular care input they need.

This is a single centre study at the Royal Free London trust. This is a tertiary liver unit with significant experience in running clinical trials in decompensated cirrhosis. This pilot study has already recruited 20 cirrhosis patients with a known history of decompensation and 20 contemporaneous controls. Potential participants were identified by the PI and/or clinical fellows on the study log, using existing clinic lists and inpatient and discharge lists. The individuals have been monitored using a wrist-watch wearable device, with associated smart weighing scales and blood pressure cuff, along with a smartphone application (including economic smartphone in those patients if not available), to facilitate home monitoring. Currently an interim analysis is being performed on the data collected to assess safety and engagement.

Routine laboratory data was collected in the previous 7 days as part of standard clinical assessment prior to recruitment. Data included liver and kidney function tests and full blood count. The data is logged within the patient historical data on the Cirrhocare App.

All study specific procedures that the participant has undertaken at home were relayed in person during a first study visit meeting, to ensure all the equipment was functional, had been sync'd to work appropriately, and that the participant could operate both the wearables and the Cirrhocare App. The Investigator also provided the participant (and any carer) with written instructions but also a recorded User Guide video on the App. Following patient consent, App set-up, and Cirrhocare Healthkit sync to the patient's (or study provided) phone, and the subsequent patient education steps, the participant, under supervision, performed the baseline App based tests detailed below.

Following the baseline Visit (Visit 1) listed above, the participants were educated with regards to use of their Wearable devices, the use of the Cirrhocare App and the notifications they should expect to receive, such as reminders for the daily measurements required.

Each day, Monday-Friday, between 9am-11am, participants were expected to perform the following measurements:

HRV- as instructed at the baseline visit, and after a brief period of rest when sitting still. This was performed on the Withings move ECG watch after a prompt within the App, which captured their ECG and communicated this to a dedicated Cloud storing daily recordings. The ECG capture was repeated as steps to record 5 minutes of total ECG readings, needed for thorough evaluation of daily HRV. If the participant failed or was unable to complete the task each day after being prompted by the App, they received reminder notifications on their watch and phone to the need for this important data capture. If the participant was unwell and hence felt unable to perform the test, they received a further prompt to enter any symptoms to be communicated to the Investigator team.

BP measurement- participants followed the App prompt to start BP recordings using the supplied Withings cuff. They followed a guide (video clip on the App) that showed placement of the BP cuff on the left arm and when to begin measurement. The recording of BP is automatic through the App and the readings similar to HRV, stored on a Cloud after they are integrated in the App.

Weight measurement - Following the above, the participant was prompted to assess their weight on the supplied Withings scales. They weighed themselves applying bare feet to the scales and with ideally limited loose-fitting clothing so as to standardize daily measurements.

Well-being information: The participants were then prompted to enter their sense of well-being, with drop-down menu prompts (tired, well, unwell, etc.) and the opportunity to input specific symptoms and to request an additional contact.

If the participants had completed the above tasks, they were then next prompted at 8pm to record their daily food and fluid intake through drop-down menus as prompted by the App for simplicity.

The participant was also prompted after the morning measurements, to apply the Stroop Test for encephalopathy as shown to them on visit 1. The App guides them through the completion of the task, which involves naming animals, and then sends the information upon completion of the task to the Cloud.

For all measurements and the Stroop test, the participant received acknowledgement form the App to confirm their data had been logged correctly.

In addition to the tasks requiring direct participant engagement, the Withings Move watch also recorded daily activity as steps, including whether this included vertical climb (stairs) and also sleep patterns (day/night/REM sleep, etc.). This data was collected automatically, which the participant is aware of at the time of consent and helps inform of functional status as well as the development of signs of encephalopathy (i.e increased daytime sleep or inactivity).

Based on daily inputs form participants including measured data as well as food/fluid/sleep and activity data, the physician investigator may have requested a phone call or prompt the participant for further information. For example, if the participant reported new symptoms of a cough or urinary symptoms and has a decrease in HRV or blood pressure, the physician may have prompted the participant to check their temperature with a forehead strip thermometer (also supplied to participants). Another such example might include a check on encephalopathy based on reduced daytime activity or increased sleep or poor Stroop test performance, prompting an additional tele consult.

Physicians also used the outputs that were collated by the App from each participant to gauge the need for additional contact via text messages or phone in addition to the standard scheduled visits, below.

Tele consults were routinely scheduled at week 4, and at week 8 (+/- 5 days), which would historically have been face-to-face appointments pre-COVID 19.

They included assessments of the patient's symptoms, state of encephalopathy (based on conversation and animal naming tests), and assessment of diet and functional status. In addition, routine scheduled blood tests were performed within the week prior to the telephone clinic to inform changes in routine clinical care/treatment. These included, full blood count, liver and kidney function tests, and prothrombin time/INR; C-reactive protein and N-terminal BNP.

Participants also populated their usability questionnaire on the Cirrhocare App at the time of these telephone contacts, and this information was added to any clinician entry on patients' quality of life as discerned by questions during the consultation.

Week 12 involved a face-to-face consultation to assess clinical status by history and clinical examination (i.e. HE, assessment of ascites and oedema, Jaundice, etc) and general symptoms as part of a routine clinical visit for such patients. Patient's HRV, heart rate, BP and weight were re-assessed in the clinic and recorded as the study-end measured variables. Patients were also sent for routine blood test after the appointment and this included; full blood count, liver and kidney function tests, and prothrombin time/INR; C-reactive protein and N-terminal BNP. The results from these routine bloods will be used for assessment of their clinical scores at that time, to reflect their liver decompensation status, namely MELD and EF-CLIF AD scores, as necessary for standard clinical assessment.

During this clinic appointment, a participant Cirrhocare App usability questionnaire was also completed and also a quality-of-life questionnaire.

If the patient requires their routine liver cancer screening ultrasound in the 3-4 month time period when they are participating in the study (done once every 6 months as standard), then this too will be booked routinely. Similarly, most patients undergo routine endoscopic examination for oesophageal varices every year if they have advanced disease. If their screening endoscopy falls within the time frame of their study inclusion, then this too will be booked in routinely. The data from these tests are not specifically required for the study.

As participants are monitored, it is foreseen that some will have events such as increased hepatic encephalopathy (HE), or new infection, as these are expected events in any patient with decompensated cirrhosis. If their monitoring suggests an event may be more likely by for example, changes in activity status (onset of HE) or Increased heart rate and falling blood pressure (potential sepsis), then the Investigator may elect to contact the participant for more information and suggest some advice by an additional telephone call. The outcome of such a contact might trigger a need for further blood tests or even hospital face-to-face assessment, as indicated by the clinical need and individual patient circumstances.

This COVID-19 funded pilot study seeks to evaluate early assessment of usability and feasibility of home monitoring in this advanced cirrhosis population. We are not planning to have further study related visits after 3 months, though patient data on mortality at 3 months and 6 months will be captured for subsequent reporting purposes.

After the last study visit at 12 weeks, patients will return to routine scheduled tele clinic follow-up or face-to-face reviews based on clinical indications (e.g. requirement for ascites drainage), at intervals of around 4-8 weeks.