CirrhoCare- Using Smart-phone Technology to Enhance Care and Access to Treatment for Cirrhosis (CirrhoCare)

CirrhoCare, A Real-world, Randomised Controlled Study, to Determine the Clinical and Cost-effectiveness of CirrhoCare Digital Home Monitoring and Management in Patients With Decompensated Cirrhosis

The CirrhoCare trial is a multi-centre, open label randomised controlled trial in patients with decompensated cirrhosis. The trial aims to investigate the clinical and cost-effectiveness of CirrhoCare digital home monitoring and management with current standard of care in these patients.

Study Overview

• Status: Recruiting
• Conditions: Decompensated Cirrhosis
• Intervention / Treatment: Device: CirrhoCare management system

Detailed Description

Cirrhosis, progressive scaring of the liver- has many causes, principally, excessive alcohol intake, fatty-liver and viral infections. Unlike many chronic diseases, cirrhosis deaths are increasing rapidly year-on-year. It is the third commonest cause of premature, UK working-age deaths, with 62,000 years of working-life lost each year and NHS care costs of £4.53bn annually. One quarter of all UK cirrhosis patients are at-risk of acute decompensation, whereby complications such as fluid-overload, confusion and infections arise, requiring hospital-emergency treatment.

Currently, decompensated cirrhosis patients require regular hospital clinical assessments to detect these new complications. Even following hospital discharge, readmission with new decompensating complications approaches 37% in 4 weeks. This disease burden, compounded by increasing alcohol and obesity-driven liver disease, means demand for specialist liver services outweighs current capacity in a resource-stretched healthcare system. Moreover, regional variation of specialist liver services also impacts on illness and deaths, leading to a postcode lottery of care access and geographical inequity.

The CirrhoCare trial, addresses this urgent clinical-need through an innovative cirrhosis management system, including home-monitoring of decompensated cirrhosis patients, measuring vital signs such as heart rate and blood pressure (using low cost, sensing technology), assessing weight (smart-scale) and mental ability (smartphone app), all of which are impacted as cirrhosis progresses. By efficiently and securely collecting data on CyberLiver's management-system (platform), CirrhoCare provides a decision-facilitating tool, incorporating individual-patient data, helping liver-physicians to optimise and personalise treatment in the community.

The CirrhoCare trial investigators also plan to assess clinical and cost effectiveness of CirrhoCare management and seek regulatory approvals. This innovative aspect of cirrhosis management will be more acceptable and convenient for patients. It will also deliver community care with environmental, sustainable benefits, through reduced hospital visits, despite increasing service demands. The cost- effectiveness analysis will generate value-for-money evidence of CirrhoCare management, and the clinical evidence needed to inform future adoption into the NHS.

• Study Type: Interventional
• Enrollment (Estimated): 214
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Jenny Philip; Phone Number: 54175 0203 108 4175; Email: cctu.cirrhocare@ucl.ac.uk

Study Locations

• United Kingdom
  • Coventry, United Kingdom, CV2 2DX
    • Not yet recruiting
    • Walsgrave General Hospital, University Hospital Coventry & Warwickshire NHS Trust
    • Contact: Sophia Than; Email: sophia.than@uhcw.nhs.uk
    • Principal Investigator: Sophia Than
  • Liverpool, United Kingdom, L7 8YE
    • Not yet recruiting
    • Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust
    • Contact: Omar Elshaarawy; Email: Omar.Elshaarawy@liverpoolft.nhs.uk
    • Principal Investigator: Omar Elshaarawy
  • London, United Kingdom, NW3 2QG
    • Recruiting
    • Royal Free Hospital, Royal Free London NHS Foundation Trust
    • Contact: Rajeshwar Mookerjee; Email: r.mookerjee@ucl.ac.uk
    • Principal Investigator: Rajeshwar Mookerjee
  • London, United Kingdom, SE1 7EH
    • Not yet recruiting
    • St Thomas Hospital, Liverpool University Hospitals NHS Foundation Trust
    • Contact: Giovanni Tritto; Email: Giovanni.Tritto@gstt.nhs.uk
    • Principal Investigator: Giovanni Tritto
  • London, United Kingdom, SE5 9RS
    • Not yet recruiting
    • King's College Hospital, King's College Hospital NHS Foundation Trust
    • Contact: Vishal Patel; Email: vishal.patel@researchinliver.org.uk
    • Principal Investigator: Vishal Patel
  • London, United Kingdom, SW17 0QT
    • Not yet recruiting
    • St George's Hospital, St George's University Hospital NHS Foundation Trust
    • Contact: Daniel Fortan; Email: daniel.forton@nhs.net
    • Principal Investigator: Daniel Fortan, Prof
  • Oxford, United Kingdom, OX3 9DU
    • Not yet recruiting
    • John Radcliff Hospital, Oxford University Hospitals NHS Foundation Trust
    • Principal Investigator: Jeremy Cobbold
    • Contact: Jeremy Cobbold; Email: Jeremy.Cobbold@ouh.nhs.uk
  • Plymouth, United Kingdom, PL6 8DH
    • Not yet recruiting
    • Derriford Hospital, University Hospitals Plymouth NHS Trust
    • Contact: Ashwin Dhanda; Email: ashwin.dhanda@nhs.net
    • Principal Investigator: Ashwin Dhanda
  • Southampton, United Kingdom, SO16 6YD
    • Not yet recruiting
    • Southampton General Hospital, University Hospital Southampton NHS Foundation Trust
    • Contact: Mark Wright; Email: mark.wright@uhs.nhs.uk
    • Principal Investigator: Mark Wright

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

1. Adults ≥ 18 years and diagnosed with cirrhosis of any aetiology.
2. Cirrhosis defined by standard clinical criteria, ultrasonographic findings and/or histology. Cirrhosis of any aetiology may be included. However, participants with cirrhosis due to autoimmune hepatitis must be on stable corticosteroid dose for ≥3-month period before study inclusion.
3. Cirrhosis severity-risk defined by European-Foundation Consortium Liver Failure - Acute Decompensation score (CLIF-C AD score) ≥45 but <60 points at the time of screening.
4. Hospitalisation for acute decompensation (determined as one or more of the following: increasing ascites, portal hypertensive-related bleeding, overt hepatic encephalopathy, new infection).
5. Participants able to give informed consent.

Exclusion Criteria:

1. Participants with ACLF grade 2 and above according to the criteria published by Moreau 1
2. Participants with CLIF-C AD score ≥ 60, who have a high mortality similar to ACLF ≥2 participants. 2
3. Current overt hepatic encephalopathy, defined as grade II-IV hepatic encephalopathy according to the West-Haven classification 3, unable to give consent.
4. Participants with active hepatocellular carcinoma (HCC) or history of HCC that is in remission for less than six months for uninodular HCC or for less than 12 months for multinodular HCC within Milan criteria.
5. Participants with a history of significant extra hepatic disease with impaired short-term prognosis, including congestive heart failure New York Heart Association Grade III/IV 4, COPD GOLD >2, chronic kidney disease with serum creatinine >2mg/dL or under renal replacement therapy.
6. Participants with documented refractory ascites, and who are being considered for liver transplantation listing.
7. Participants with current extra hepatic malignancies including solid tumours and hematologic disorders.
8. Participants with mental incapacity, language barrier, or any other reason considered by the investigator precluding adequate understanding, cooperation or compliance in the study (e.g., severe addiction and relapse history).
9. Participants with active viral infections, or yet to achieve clear response to anti-viral therapy.
10. Any disorders likely to impact on study engagement, including severe frailty, severe addiction history (including opioids) with evidence of multiple relapses.
11. Any other reason that the PI considers would make the participant unsuitable to enter CirrhoCare (e.g., participants on an end-of-life palliative care pathway).
12. Refusal or inability to give informed consent.
13. Participants enrolled in other interventional trials.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Standard of Care
Other: CirrhoCare management system	Device: CirrhoCare management system; This is a UKCA-marked, digital-therapeutic system consisting of: clinical-grade, cirrhosis monitoring sensors and a smartphone app,; a clinical team-facing, decision-facilitating dashboard, and; CyberLiver's platform incorporating hepatic algorithms. The CirrhoCare kit consists of: - Apple watch - iPhone with an in-built CirrhoCare app - a digital Bluetooth-linked system comprised of: ~Wellue BP monitor, ~Wellue weighing scale ~Bluetooth thermometer. The CirrhoCare management system also includes: The clinician dashboard: All participant data collected through the app will be reviewed by the clinical team via the clinician dashboard.; The CirrhoCare algorithm: This algorithm will advise the clinical team if the participant is at high, medium, or low risk of developing a particular outcome event, based on monitoring data collected each day from the participant which is compared to the baseline values and average values collected over the first week of monitoring.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of hospital interventions from new-liver related complications	The CirrhoCare trial will investigate whether the CirrhoCare management system leads to a reduction in the requirement for hospital intervention from new-liver related complications over 12 weeks from randomisation.	12 weeks from randomisation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effects on CLIF-C AD score	To determine the effects of the CirrhoCare management system on the Chronic Liver Failure Consortium Acute Decompensation (CLIF-C AD) score. [Minimum score is 0 and there is no upper limit. The higher the score the worse the outcome)	12 weeks from randomisation
Effects on MELD score	To determine the effects of the CirrhoCare management system on the Model for End-Stage Liver Disease score ( MELD). [Score ranges from 6-40. The higher the score the worse the outcome]	12 weeks from randomisation
To determine the effects of the CirrhoCare management system on the number of liver-related deaths at 12 weeks.	To determine the effects of the CirrhoCare management system on the number of liver-related deaths at 12 weeks.	12 weeks from randomisation
Healthcare resource use analysis	To assess healthcare resource use through analysis of the number of healthcare appointments during the study period	12 weeks from randomisation
Healthcare cost analysis	To assess the financial costs associated with healthcare interventions during the study period (measured in British Pound Sterling).	12 weeks from randomisation
User experience and engagement	To assess user experience and engagement through questionnaires and interviews : The questionnaires will be graded from 1-10 for each question, with 0 is extremely negative as a response, and 10 very highly positive response.	12 weeks from randomisation
Quality of Life (EQ-5D-5L) assessment	To assess health-related quality of Life through the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire. The score ranges from -0.59 to 1, with a score of 1 representing the best possible health status.	12 weeks from randomisation
Frailty assessment	To assess frailty using the Liver Frailty Index. The score ranges from 1.0 to 7.0 with higher scores representing increased levels of frailty.	12 weeks from randomisation
Mortality	To assess mortality (overall survival)	12 weeks from randomisation
Number of hospital readmissions	To assess the overall number of readmissions to hospital	12 weeks from randomisation
Effects of the individual components making up the primary outcome	Assessment of the effects of the individual components making up the primary outcome. Each complication of cirrhosis will be individually assessed between CirrhoCare and standard of care groups. [Ascites based on Gr 1-3 and HE based on West Haven criteria 1-4; Infection Positive or Negative culture]	12 weeks from randomisation
Longitudinal effects of all secondary outcomes	The longitudinal effects of all secondary outcomes will be investigated by using an appropriate model that incorporates the week 4 and week 8 visits in addition to the week 12	Week 4, week 8 and week 12
Length of hospital readmissions	Assessment of the length of stay for each hospital readmission for a given participant recorded in days.	12 weeks from randomisation

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Nutritional impact analysis	To assess whether there is a change in nutritional status using the Royal Free Hospital Nutrition Prioritizing Tool (RFH-NPT). The score ranges from 0-7, with higher scores being associated with an increased risk of malnutrition.	12 weeks from randomisation

Collaborators and Investigators

• Sponsor: University College, London
• Collaborators: London School of Hygiene and Tropical Medicine; CyberLiver Ltd
• Investigators: Study Chair: Rajeshwar Mookerjee, UCL

Study record dates

Study Major Dates

• Study Start (Actual): November 24, 2023
• Primary Completion (Estimated): May 1, 2025
• Study Completion (Estimated): May 1, 2025

Study Registration Dates

• First Submitted: October 31, 2023
• First Submitted That Met QC Criteria: January 16, 2024
• First Posted (Estimated): January 25, 2024

Study Record Updates

• Last Update Posted (Estimated): January 25, 2024
• Last Update Submitted That Met QC Criteria: January 16, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Liver Diseases; Fibrosis; Liver Cirrhosis
• Other Study ID Numbers: 151197

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No