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An intervention with financial incentives and text-based nudges may help patients who are frail and inactive awaiting liver transplant be better prepared for surgery.

A home-based intervention with financial incentives and text-based nudges may help frail and functionally impaired people on the liver transplant (LT) waitlist become more physically active and better prepared for surgery, according to findings from a pilot study published in Liver Transplantation.

“The behavioral rehabilitation intervention was found to be feasible and safe, and it had high retention and patient satisfaction among LT candidates and effectively increased physical activity among highly sedentary LT candidates,” Marina Serper, MD, MS, and colleagues wrote.

Although frailty and impaired function are linked with adverse outcomes while on the LT waitlist and after transplantation, prehabilitation, or improving a patient’s physical health in preparation for surgery, has rarely been tested, the authors wrote.

In the Prehabilitation Intervention to Maximize Early Recovery (PRIMER) study, Dr. Serper and colleagues recruited 30 adult patients between February and December 2018 at one hepatology clinic at the University of Pennsylvania. Participants who were either undergoing LT evaluation, waitlisted for LT or had completed LT evaluation but were not yet waitlisted due to clinical issues used smartphones.

Participants averaged 61 years of age; 53% were male, and the median Model for End-stage Liver Disease sodium (MELD-Na) score was 13. One-third were frail or prefrail according to the liver frailty index, 40% had impaired mobility according to the short physical performance battery, almost 40% had sarcopenia by bioimpedance phase angle, 23% had prior falls, and 53% had diabetes. 

After 2 weeks of baseline assessments, participants began the 12-week active intervention. The study was unblinded to the study staff but blinded to the investigators. 

Personal Attention, Tech, Money: Effective Incentives

The researchers randomly assigned 20 patients to the intervention group and 10 to the control group. Both groups received usual care, a personal fitness tracker, personalized nutrition, and physical activity recommendations from a physical therapist and registered dietitian.

The intervention group received text reminders linked to wearable fitness trackers and financial incentives for meeting daily step goals, which were increased by 15% every two weeks. The researchers paid $3,621 for meeting walking goals and participating in weekly check-ins with staff to assess barriers to physical activity. People reported adhering to exercise during check-ins about 50% of the time, and the most common barriers were fatigue, weather, and liver-related symptoms. The intervention group also received text messages to promote medication adherence and regular consultations with allied health professionals, including clinical dieticians and physical therapists, as needed.

After 14 weeks, with 27 (90%) of patients completing the study, the intervention group walked almost 1,000 more steps than the controls (adjusted difference 997; 95% CI, 147-1847; P=.02), and they reached their daily step targets 51% of the time, on average.

Looking Ahead to Future Research

“Our study serves as a good proof of concept for future, larger studies,” Dr. Serper notes. “We know that frailty and functional impairment predict adverse outcomes while on the liver transplant waitlist, such as dropping off the list due to being too ill, debilitated, or dying while on the list after transplantation. Getting patients to rehabilitate and to move more can improve their health on the waitlist.”

The authors recommend pairing physical activity and protein supplementation in larger, multicenter cohorts investigating outcomes after LT, including length of stay, readmissions, muscle mass, frailty, and physical function.

“We need more data,” Dr. Serper says. “We are planning larger studies and targeting nutrition because it is a major area that can impact frailty and sarcopenia due to cirrhosis.

“If ultimately we show that improving physical activity improves waitlist and post-transplant outcomes, transplant centers can institute home-based remote monitoring programs for waitlist candidates and recipients,” she explains. “Patients who are motivated—such as those on the transplant waitlist, for example—can achieve behavior change. They need monitoring, advice, encouragement, and some of these features can be automated.”