Multidisciplinary Integrated Continuous Care in Patients with Liver Cirrhosis

Summary

This study demonstrates that multidisciplinary integrated continuous care improves negative emotions, self-care ability, and quality of life in liver cirrhosis patients compared to routine care.

Abstract

This study aimed to observe the influence of multidisciplinary integrated continuous care on negative emotions, quality of life, and self-care ability in 80 patients with liver cirrhosis (LC) from January 2023 to January 2024. Patients were randomly assigned to group A (n=40, routine care) or group B (n=40, multidisciplinary care). The latter was intervened through the formation of an interdisciplinary team including nutritionists and psychologists, combined with online guidance on the WeChat platform and monthly offline health sharing meetings. Negative emotions (Self-Rating Anxiety Scale [SAS], Self-Rating Depression Scale [SDS]), self-care ability (ESCA), compliance behavior, quality of life (QOL-35), and nursing satisfaction were compared between groups. Results showed that group B had significantly greater reductions in SAS/SDS scores, improved self-care ability, compliance, quality of life, and nursing satisfaction (all P<0.05). Results show that this model can effectively alleviate patients' negative emotions, improve self-management ability and quality of life, and provide an innovative path for the comprehensive care of patients with cirrhosis.

Introduction

Clinically, it is generally considered that the occurrence and progression of liver cirrhosis (LC) are the results of repeated episodes of chronic hepatitis, as well as the liver cell injury, degeneration, and necrosis caused by continuous replication of hepatitis virus-DNA and induction of immune mechanisms in patients. The pathological process will lead to liver cell regeneration, proliferation of fibrous connective tissue, and formation of liver fibrosis, which will eventually develop into LC^1,2. Recent studies indicate that only 50-60% of cirrhosis patients adhere to medication regimens during home care³.

LC is a long-term and recurrent chronic liver damage disease with persistent and incurable disease, a long course of disease, and many complications, which seriously affect patients' daily lives. Especially when the disease progresses to the decompensated stage, ascites, gastrointestinal bleeding, and other symptoms occur in sequence, aggravating the patient's condition and greatly reducing the survival probability, which leads to a decrease in compliance with medicine and low self-care ability in these patients to varying degrees. Many patients choose home-based treatment due to various factors, and the compliance behavior of patients outside the hospital is significantly decreased, so it is particularly necessary to strengthen the out-of-hospital care for patients with LC^3,4. Continuous care is a nursing mode that provides scientific and healthy health protection services to patients receiving home treatment. It has achieved ideal nursing effects in some clinical patients and is an extension of in-hospital care, with high acceptance among many patients. However, previous studies have shown that due to the existence of physiological and psychological adverse phenomena induced by disease factors in patients with LC, single-subject continuous care alone cannot fully meet the needs of patient care^2,4.

Recent studies highlight the challenges of managing LC patients' self-care and compliance, underscoring the need for innovative nursing models^1,5. Unlike single-subject continuous care, which focuses on isolated medical interventions, multidisciplinary integrated care combines expertise from nursing, psychology, and nutrition to address holistic patient needs, potentially improving compliance and psychological outcomes. To investigate the implementation of a multidisciplinary, integrated, and continuous care model in the treatment of patients with liver cirrhosis (LC), aiming to improve the quality, continuity, and outcomes of patient care^5,6. The intervention involved a team of nurses, dietitians, and psychologists providing 12-month follow-ups, including monthly in-person meetings and weekly online guidance. Therefore through observing the application of multidisciplinary integrated continuous care in patients with LC, and analyzing the impact of this model on the negative emotions, quality of life, and self-care ability of patients with LC, this study aims to provide a reference model for the care of patients with LC and related diseases, and improve the overall benefit level of patients.

Protocol

The Institutional Review Board of Tangdu Hospital of the Fourth Military Medical University approved this study (Approval Number: K202405-27). All participants voluntarily participated in the study with full knowledge and signed an informed consent form before the start of the study. The research team explained in detail to the participants the purpose, content, potential risks, and benefits of the study, and clearly informed them that they could choose to withdraw from the study at any stage, and that withdrawal would not have any negative impact on their treatment and medical services.

Included subjects
The study timeline was between January 2023 and January 2024 and included 80 patients with LC. A sample size of 80 (40 per group) was selected based on prior studies⁷ to ensure sufficient statistical power to detect meaningful differences. The subjects were randomly assigned to group A (n = 40) and group B (n = 40). Patients were randomly assigned using a computer-generated random number table. The balance of two groups of baseline information is ideal (P > 0.05; Table 1).

Entry criteria
Inclusion criteria: The study included patients who met the diagnostic criteria as per the Chinese guidelines on the management of liver cirrhosis⁸ and confirmed through serological examination, B ultrasonography, and CT. All participants had a clear understanding of the research content.

Exclusion criteria: This study excluded patients with previous autoimmune liver diseases and organic liver diseases, patients with malignant diseases such as liver cancer, patients with diseases of the blood system, heart, brain, and other important organs, and patients with cognitive abnormality or low compliance who failed to cooperate with the research.

Methods
Group A (Conventional nursing): Patients received routine nursing care in the hospital, including disease-related health education, medication management, and dietary guidance. Although the fundamental care procedures were standardized, minor adjustments were made depending on individual patient conditions, such as comorbidities, functional status, or personal preferences. Upon discharge, patients were instructed to attend regular follow-up visits according to their clinical progress and physician recommendations. This care was provided by the hospital's standard nursing team, which consisted of registered nurses (RNs), junior nurses, and health educators. The team was supervised by a senior head nurse with over 10 years of clinical experience. Responsibilities were clearly divided, with RNs primarily handling medication and monitoring, junior nurses assisting with daily care, and educators focusing on patient instructions. All team members had received uniform training in routine liver disease care protocols prior to the start of the study.

Group B (Multidisciplinary integrated continuous care):
Team establishment and clear division of labor: The director of the nursing department took the lead, including a dietician, a psychologist and a specialist nurse: The nursing director served as the group leader, who was responsible for clarifying the responsibilities, process development, standard assessment, supervision, and implementation and evaluation of various work plans for quality control of each member; The nursing members were responsible for the management of WeChat group, establishing two-way relations, and building a continuous nursing platform. The dietician was responsible for nutrition assessment and formulation of nutrition intervention plans, and the psychologist was responsible for assessment and formulation of psychological intervention plans.

Multidisciplinary integrated continuous care plan:
Evaluation: The patients were followed up in the outpatient department on the day of discharge and at 3 months after discharge, and their records were reviewed. The responsible nurse conducts monthly telephone follow-up to evaluate patients' self-concept, health knowledge, and the other four dimensions using the ESCA scale, with each follow-up lasting at least 30 min. An official WeChat account was established, and two popular science articles (including an animated demonstration of the medication process) were shared every week, and a video question and answer (Q&A) meeting was held every month.

Group entry: Patients were assisted in entering the established WeChat group, and its function was explained to them when they were discharged from the hospital.

Online guidance: A public announcement was issued every week in the WeChat group, together with video conferences, time for answering questions and solving new problems on time, and team members were required to evaluate the nutritional status and psychological status of patients in a timely manner.

Health propaganda and education: The patients were handed a printed copy of the general hospital cirrhosis nursing propaganda manual, diet precautions, and daily activities points for attention.

Offline sharing: A monthly gathering of patients in the hospital was organized. A summarizing meeting was held to analyze and summarize the psychological, nutritional, and disease status of patients, and formulate targeted interventions. A schematic diagram of the study design is shown in Figure 1.

Outcome indicators
Negative emotions: The Zung Self Rating Anxiety Scale (SAS)⁹, Zung Self-Rating Depression Scale (SDS)¹⁰ covered 20 items, each item was scored according to no or very little time (1 point), a small part of time (2 points), most of time (3 points), and most or all time (4 points). SDS ≥ 53 points and SAS ≥ 50 points indicated the existence of depression and anxiety. The score was positively correlated with the degree of depression and anxiety of patients.

Self-care ability: The exercise of the self-care agency scale (ESCA)¹¹ included 43 items, including four dimensions of self-concept, health knowledge level, self-care responsibility, and self-care skill, with 172 points. The scores were positively correlated with patients' self-care ability.

Compliance behavior: The self-made assessment scale for compliance behavior included a reasonable diet, control of tobacco and alcohol, correct medication, punctual return visit, and rest activities. The full score of each item was 5 points. The scores were positively correlated with patients' compliance behavior. Compliance behavior was assessed using a self-developed scale, including adherence to diet, medication, and follow-up visits.

Quality of life: The quality-of-life scale (QOL-35)¹² included the social activities and daily living ability, with 0-4 points for each item. The score was negatively correlated with patients' quality of life.

Nursing satisfaction: The self-made nursing satisfaction scale included nursing attitude, nursing skill, and nursing effect. The full score was 100 points, with scores ≥ 90 as very satisfactory, 75-89 as satisfactory, and ≤ 74 as unsatisfactory. Total satisfaction = (Very satisfactory cases + Satisfactory cases) /40 100%. The evaluation time was before and after the intervention (3 months after).

Statistical methods
All data are expressed as mean ± standard deviation (Mean ± SD) and are suitable for continuous variables. The categorical variables are expressed in frequency and percentage. An independent sample t-test was used for intergroup comparisons, while a paired t-test was used for intra-group comparisons. For each data set, the normal distribution was tested, and only variables that conform to the normal distribution were subjected to a t-test. If the data does not follow a normal distribution, non-parametric tests such as the Mann Whitney U test should be used. In addition, all count data in the study (such as gender, nursing satisfaction, etc.) were analyzed using chi square test (chi square test). For chi square test, continuity-corrected chi-square test, and Fisher's exact test were used to ensure accurate results when the sample size is small or the frequency is low. All data analyses were conducted using a two-sided test, and P < 0.05 was considered statistically significant. Small p-values <0.001 are reported as "<0.001" for clarity.

Results

Comparison of negative emotions
As shown in Table 2, there was no significant difference in SAS and SDS scores between the two groups before nursing (P > 0.05). After nursing, the SAS and SDS scores of Group A significantly decreased (P < 0.001), but the SAS and SDS scores of Group B decreased more significantly and were significantly lower than those of Group A (P < 0.001). The emotional improvement effect of Group B is significantly better than t...

Discussion

Liver cirrhosis (LC) is a chronic, irreversible liver disease. Progression to the decompensated stage causes severe symptoms, multi-organ involvement, and significant physical and psychological burden on patients. In addition, we are aware of the importance of patients' self-care ability and compliance behavior, which in essence lies in the patients' knowledge about health and active mobilization of subjective initiative. These results align with a study by Zhang et al.¹³, who found multid...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Exercise of Self-care Agency Scale (ESCA)	Kearney & Fleischer	https://psycnet.apa.org/doi/10.1037/t33571-000	43-item scale assessing self-concept, health knowledge, responsibility, and skills.
Quality of Life Scale (QOL-35)	Zhao et al.	10.3969/j.issn.1671-7562.2020.10.026	35-item scale assessing social activities and daily living abilities.
Self-made Assessment Scale for Compliance Behavior	Self-developed	N/A	Assesses diet, tobacco/alcohol control, medication, follow-up, and rest activities.
Self-made Nursing Satisfaction Scale	Self-developed	N/A	Evaluates nursing attitude, skills, and effects (score ≥90: very satisfied).
SPSS 24.0	IBM	Version 24.0	Statistical software for data analysis (t-tests, chi-square tests, etc.).
WeChat	Tencent	https://www.wechat.com/	Online platform for communication and follow-up.
Zung Self-Rating Anxiety Scale (SAS)	Zung	10.1016/S0033-3182(71)71479-0	20-item scale for anxiety assessment (score ≥50 indicates anxiety).
Zung Self-Rating Depression Scale (SDS)	Zung	10.1001/archpsyc.1965.01720310065008.	20-item scale for depression assessment (score ≥53 indicates depression).