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BLOG: A Smartphone App to Identify At-Risk Cirrhosis Patients in 5 Minutes

Issue: July 2015

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In today’s researcher blog from DDW, Jasmohan S. Bajaj, MBBS, MD, MS, offers insight into his new smartphone application that can quickly identify patients at risk for hepatic encephalopathy.

If  clinicians could use a free app to predict whether a patient with end-stage liver disease or cirrhosis is likely to develop overt hepatic encephalopathy, the neurocognitive complication that leads to prolonged hospitalizations and costs the health care system untold billions of dollars could be caught early.

Towards this goal, we developed the EncephalApp-Stroop Test. Our research shows that this app-based test can predict the risk as accurately as current methods, with less complication and inconvenience for patients and providers — and can do it in 5 minutes.

Jasmohan S. Bajaj

We shared the results of our study on 387 cirrhosis patients at Digestive Disease Week 2015, the world’s largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Our work gives clinicians an easy-to-use smartphone screening tool that they can administer themselves. The two current testing options are more problematic: the psychometric hepatic encephalopathy score (PHES) can only be administered by a psychologist, and the inhibitory control test (ICT) can be difficult on patients. Both of these can take as long as 20 minutes.

Up to 50% of cirrhosis patients are at risk for — or may already have — covert hepatic encephalopathy, whose symptoms are particularly hard to diagnose using a routine physical examination. And a significant percentage of covert hepatic encephalopathy cases develop into overt hepatic encephalopathy, which, if left untreated, causes more significant complications and leads to hospitalization, which results in billions of dollars of care annually.

Hepatic encephalopathy begins with the subtle cognitive impairments of covert hepatic encephalopathy that can get progressively worse. The Stroop Test measures the extent of damage by asking patients to perform two tasks: identify the color of hashtags that appear on the screen, and then identify the color of the text of words written on the screen. The second task is more challenging because each word spells a color, but the words are in differing colors, for example: RED, BLUE, GREEN.

The new Stroop Test immediately provides clinicians with the total time patients took to successfully complete each task five times. This total time, we have shown, can identify patients who already have covert hepatic encephalopathy or are at risk. We administered the Stroop Test, along with the ICT and PHES, to 387 patients at three centers in Virginia, Ohio and Arkansas. Using the two standard tests for comparison, the Stroop Test identified from 150 to 209 patients as already having covert hepatic encephalopathy because their total times exceeded certain thresholds. Specifics on the comparisons and time thresholds can be found here.

We followed up with these patients almost a year later and found that 50 of the cirrhotic patients, or 13%, had deteriorated to develop overt hepatic encephalopathy. The initial Stroop Test had flagged most of these 50 patients as already having covert hepatic encephalopathy, accurately labeling them at risk for developing overt hepatic encephalopathy.

These findings confirmed that the EncephalApp–Stroop Test performs as well as the other tests — but can do it in just 5 minutes. Using this app, all providers — primary care physicians, nurses, medical assistants — would be able to rapidly administer an effective screening test. When these covert hepatic encephalopathy patients are identified, clinicians will be able to decide if proactive interventions are warranted to prevent a highly debilitating and costly disorder. – Jasmohan S. Bajaj, MBBS, MD, MS 

Screenshots from the EncephalApp – Stroop Test (Left: Task 1, Right: Task 2)

Jasmohan S. Bajaj, MBBS, MD, MS, is an associate professor of medicine, division of gastroenterology, hepatology, and nutrition at Virginia Commonwealth University and McGuire VA Medical Center in Richmond, VA. He is a fellow of the American Gastroenterological Association and American College of Gastroenterology. Active in research, Dr. Bajaj has served as a principal investigator or co-investigator for numerous clinical trials in areas such as hepatic encephalopathy, chronic liver disease and gut microbiome. 

For more information:

Bajaj JS, et al. Abstract 229. Presented at: Digestive Disease Week; May 15-19, 2015; Washington, D.C.