Editorial: Timely Follow-Up in Cirrhosis—How Does It Work? Authors' Reply

We are grateful for the interest in our study by Kimer et al. [1] and Tan et al. [2] In a population-based cohort of 8852 patients with a first diagnosis of cirrhosis in a hospital setting in Sweden, we found that only 42% had outpatient follow-up within 90 days of discharge. We also showed that patients obtaining follow-up were more likely to have higher levels of education, have decompensation or hepatocellular carcinoma and have less other medical comorbidities such as cardiovascular disease and diabetes. This research also suggests that obtaining follow-up may be associated with a reduced risk of mortality within 1 year, highlighting the importance of the topic [3]. Both the editorial by Kimer and Gluud and the letter to the editor by Tan et al. focus on the need for more detailed data.

Using a nationwide cohort design based on register data, we had coverage of a full country, limiting selection bias and allowing for in principle no loss to follow up. However, this methodology is always limited by the lack of granular data that may be available in smaller cohorts based on, for example, patient chart data. Kimer et al. mention the importance of family support, frailty and social factors in the determinants of receiving follow-up care after a hospital discharge [1]. Frailty which is in itself mediated by many different social determinants of health, has been shown to have a strong impact on mortality and may be a confounder in registry-based research as these patients are more likely to have rehospitalisations [4]. Future research into outpatient follow-up that stratifies patients by severity of frailty can shine more light into the most appropriate follow-up for this especially vulnerable population.

Tan et al. also suggest that clinical care may have changed during the long study period (2002–2020), including advancements in treatment for hepatitis C and imaging techniques allowing for earlier detection of complications from cirrhosis such as HCC [2]. Indeed, we found that patients diagnosed later in the study period were more likely to receive 90-day outpatient follow-up, hence these data are already presented in the paper.

We agree with Tan et al. that there are likely other factors which may affect who receives proper follow-up. Data on factors like smoking and physical activity cannot, however, be addressed using register-based data since such factors are not reported. Future research into personalised interventions for those diagnosed with cirrhosis is vital to ensuring that follow-up is tailored to each patient. Patients diagnosed with cirrhosis deserve timely and proper post-discharge care, yet this remains an understudied topic.

Max S. Schechter: writing – original draft, writing – review and editing. Hannes Hagström: writing – original draft, writing – review and editing, supervision.

This article is linked to Schechter et al papers. To view these articles, visit https://doi.org/10.1111/apt.18309 and https://doi.org/10.1111/apt.18365 and https://doi.org/10.1111/apt.18367.