Emerging digital technologies to help patients with cirrhosis (2024)

INTRODUCTION

A patient-centered approach to the management of cirrhosis relies on high-quality clinical monitoring and shared decision-making between patients and providers. Self-care is challenging as it requires medication adherence and titration, strict dietary and weight monitoring, and frequent testing, in addition to performing actions to address the disease etiology. Digital health interventions are key in extending clinical monitoring beyond the walls of the clinic room and in promoting patient engagement in the treatment plan. Herein, we review the emerging landscape of digital health tools in cirrhosis, with a focus on smartphone applications and patient-facing biometric tools (Figure ​(Figure11).

SMARTPHONE APPLICATIONS

Smartphone ownership in persons with cirrhosis is high, making the use of smartphone applications a promising tool to facilitate remote patient monitoring and disease management.¹ In HE, symptom control depends on the careful titration of lactulose therapy to achieve bowel movement goals. To assist patients in stool assessments and lactulose adjustments, an artificial intelligence-based smartphone application used patient-obtained stool photos to provide feedback based on stool features.^2,3 Patients using the application experienced improved self-efficacy in lactulose titration and subjective control of HE symptoms. In a more comprehensive smartphone application with a focus on HE, Ganapathy et al enrolled patients to use the Patient Buddy smartphone application. Within the platform, patients engaged in multiple functionalities including medication adherence tracking and cognitive assessments with the EncephalApp Stroop test. Patients viewed the application favorably, and 8 HE-related hospitalizations were potentially prevented due to the use of the application.⁴ Similarly, smartphone application use in the management of ascites has also shown encouraging results. In providing patients with a Bluetooth-enabled weight scale, Bloom et al provide convincing evidence that smartphone-based remote monitoring tools are feasible and the information collected can be directly acted upon with timely medication changes or arrangement of paracenteses.⁵

While monitoring and preventing cirrhosis-related complications is important, addressing the disease etiology is critical to reducing the risk of disease progression and decompensation. The use of behavior change interventions delivered through smartphone applications is growing. In metabolic dysfunction–associated liver disease, patients using a smartphone application that combined dietary and exercise monitoring with behavioral change coaching achieved significantly higher weight loss than those in the standard care arm.⁶ Smartphone applications that leverage behavioral change are also emerging in alcohol-associated liver disease (ALD). Mellinger et al piloted a smartphone application created to facilitate engagement in alcohol use disorder (AUD) treatment in patients with ALD.⁷ Modules within the application identified and corrected patient misconceptions regarding AUD and ALD, and gathered patient-centered treatment preferences to link patients to AUD treatment. Patients in the intervention group had trends towards increased engagement in AUD treatment and reduction in drinking risk levels. A larger study by Mehta et al used principles of behavior change techniques and self-monitoring (cravings, smartphone-compatible breathalyzer) tools embedded in a smartphone application (AlcoChange) for patients with ALD and hazardous drinking. Patients completing the intervention, particularly with higher engagement, had reductions in alcohol use.⁸

Lastly, smartphone application-based behavioral interventions have also been applied to the management of frailty. The EL-FIT application incorporates exercise video regimens, goal-oriented coaching, and physical activity tracking to modify frailty measures. In a 3-month study, the intervention led to improved frailty measures (liver frailty index, 6-minute walk test), including a third of patients transitioning from the frail to nonfrail state.⁹

BIOMETRIC DATA

The collection and interpretation of physiological and behavioral biometric data extends digital monitoring beyond simple, yet important, patient engagement with smartphone applications. Biometric tools leverage real-time information passively collected from sensors contained within everyday devices (smartphones, wearable devices) to inform and predict health states.¹⁰ Technological advances have increased the ability to gather precise, continuous health information within the comfort of patients’ homes and daily routines. Recent studies have demonstrated feasibility and proof of concept in understanding the potential role of biometric data in the clinical monitoring of cirrhosis.

Sensors within smartphones harbor immense amounts of information, from hardware measures of usage and individual activity to software applications of communication and social networking. Using a patient-facing smartphone application, a recent study that enrolled 24 patients with ALD demonstrated the feasibility of smartphone sensor data as surrogate markers of alcohol craving and mood. Additionally, specific location and accelerometer sensor features were associated with alcohol craving in individual-level analyses.¹¹ Smartphone-captured images have also been evaluated as a proxy measure of biochemical data. In a study of 46 patients with alcohol-associated hepatitis, scleral images showed a strong correlation with serum bilirubin at baseline and over time. Given the inclusion of serum bilirubin in clinical scoring systems for acute hepatic deterioration, scleral images taken from smartphones may serve as useful biomarkers for clinical parameters of disease severity.¹²

Commercially available fitness and sleep trackers have also been studied in patients with cirrhosis to assess for covert HE. Buckholz et al collected sleep data from 25 patients using a multi-sensor device validated for 4-stage sleep detection. Covert HE was associated with worse sleep factors, including sleep cycles, rapid eye movement sleep, and restorative sleep. Additionally, a model combining sleep measures and biochemical data showed good discrimination for covert HE (AUROC 0.79).¹³

Furthermore, biometric speech data in patients with cirrhosis can predict HE. In 1 study, patients with low psychometric test scores or a history of overt HE were found to have slower speech and longer word duration, even after adjusting for age, gender, and education.¹⁴ Another study by Moon et al also showed that impaired speech rate, precision of articulation, and a combined speech severity metric were more pronounced among patients with overt HE. As patients experienced clinical improvement, their speech rate improved.¹⁵ Extending biometric speech data collection and interpretation to the at-home setting for the remote monitoring of HE is eagerly awaited.

CONCLUSION

Digital technologies are revolutionizing the delivery of health care for patients with cirrhosis. Such platforms improve remote monitoring, build self-efficacy, and promote effective and timely clinical interventions. Previous studies have demonstrated the potential to achieve these benefits. However, caution is needed to ensure that these digital interventions do not further exacerbate disparities through their use of tools and technologies that require high digital literacy or devices that are not readily accessible by patient populations.¹⁶ Additionally, transparency and standardized consent procedures will be needed to ensure data collection is safeguarded and limited to appropriate clinical use. Further research is needed to validate preliminary findings, demonstrate efficacy in larger cohorts, and advance technology for precise data collection and intelligent delivery of care. Digital technologies will have an increasing role in cirrhosis management and have the potential to assist in clinical care in exciting and unprecedented ways.

AUTHOR CONTRIBUTIONS

Footnotes

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