When interventional radiologists talk about treating portal hypertension and liver disease, it sounds simple—but it’s actually very complex. These diseases require regular attention and frequent labs and procedures, so patients are at the hospital on a weekly basis. Often, the ultimate goal is to secure a transplant, which means referring the patient to a tertiary center that is typically farther away. Standard treatment of liver diseases results in a lot of travel for the patient, and eventually removes IRs and the community hospital from the process.
My dream was to take this complex, multistep process and bring it to one location—the local community hospital. The concept was to allow the patient to begin and manage their treatment in their local community hospital. Through my practice, VIR Chicago, we have done just this, creating a Multidisciplinary Portal Hypertension Clinic which brings the tertiary center to the community hospital, resulting in patient retention and better care.
Photo courtesy of Dr. Behrens
Structure
The clinic provides a full assessment and care team for the patient in one location—nurses, APPs and coordinators, the IR who has been managing their case, a hepatologist, a nutritionist, an oncologist, and even a transplant surgeon. As a team we meet with the patient and identify a treatment plan. As a result, the patient can manage their disease through our community hospital, which is closer, often more affordable and more comfortable for them.
Patients get referred to the clinic through our multihospital IR practice, where we see patients every day for treatment of liver disease. In general, the spectrum of liver diseases casts a wide net of stages and treatments options that span a long period of time. It can take 15 years for a patient to transition from the earliest stages of liver disease to cirrhosis, hepatocellular carcinoma (HCC) or portal hypertension (PHT). By focusing our clinic on PHT, we are able to refer patients who need a higher level of care and expertise and include 100% of the patients, whether they have simple ascites, HCC or are in need of a transplant.
In its current form, the clinic has been operating for 2 years with rapid expansion. We started with one clinic a month where we would see three or four patients and have grown to two clinics a month with 14 or 15 patients per clinic. We’ve recently begun discussions to set up a monthly clinic at another one of our satellite offices at St. Anthony’s Hospital.
Challenges
Turning the clinic into today’s thriving, successful model has been a long road. One of the biggest hurdles was finding a tertiary center to partner with, who understood what we were trying to accomplish and was willing to drive to us. It took almost 3 years and three failed partnerships until we partnered with the University of Chicago. They saw the value in our idea and, due to their location, they often experience transportation issues with their clients. Partnering with us removes those barriers and brings more patients into their pipeline.
There were also economics to consider and administrators to convince. The idea wasn’t just to bring physicians to us—the goal was to centralize the process and create a multidisciplinary approach. I was often asked, “if the other physicians come and use our facility, what is the value to the local hospital?” The value is in the long-term reward of keeping the patient. The tertiary center experts will order work-ups that can be done at the community hospital and, instead of shifting the care to a new facility, that patient stays with us. Any upfront loss is made up for in maintaining the long-standing relationship with the patient.
The lasting value for IR
My passion has always been PHT. I remember when I joined my group, and my oldest partner told me I’d forget about PHT and TIPS and focus on the “cooler” things that IR can do—but I haven’t. I feel that when it comes to liver disease IR offers more comprehensive care than any other single specialty. We provide the imaging, diagnosis and follow up care. IR offers so many therapy options, from ascites care and shunt placement to embolization of the spleen, to TIPS. We have the ability to take ownership of this field and manage our patients all the way through, and there’s no need to lose them once they’re referred for transplant.
There is always talk about the value of collaboration and creating relationships with other fields, and this clinic is a clear example of those partnerships in action. To me, PHT is an obvious area for IR to take ownership and foster collaboration, but because IR spans so many disease processes across the body, the sky is the limit in terms of possible multidisciplinary paths. In fact, we have already launched a pulmonary nodule clinic in conjunction with pulmonologists and surgeons as well as a vascular clinic. COVID-19 showed us that the way we provide care can easily change, and telehealth is a viable possibility that can bridge the space between community and tertiary centers. Consider that, given the restrictions of practicing this year, many specialists are now comfortable with telemedicine, such as cardiologists. Physicians have grown familiar with doing telemedicine consults between local and tertiary centers, which throws the gates wide open for future possible collaboration.
Multidisciplinary clinics and partnerships are the future of the field. Not only will they provide better patient care and comfort, but they will create lasting relationships with other disciplines and cement IR’s value and expertise in these areas. It requires persistence, though; persistence and the right team. But with enough people dedicated to the cause, the sky is the limit.
In this Kinked Wire episode, originally published on May 8, 2020, host Warren Krackov, MD, FSIR, speaks with George Behrens, MD, about the COVID-19 impact on Chicago, changes his practice has made in response, and how his native Venezuela has been faring during the pandemic.
