Transforming Liver Care: Integrated Care Models, Real-World Evidence and Digital Health

The management of chronic liver disease increasingly requires coordinated, multidisciplinary care involving hepatologists, gastroenterologists, transplant physicians, primary care providers, radiologists, surgeons, nutritionists, specialist nurses, pharmacists, and allied health professionals. Yet translating clinical trial evidence into routine practice remains difficult: healthcare delivery is fragmented, access to specialist care varies, guideline implementation is inconsistent, and these gaps in coordination are compounded by limited real-world data on how integrated care actually performs outside the trial setting.

This Research Topic focuses on a specific, underexplored intersection: how integrated, multidisciplinary care models can be evaluated and improved using real-world evidence and digital health tools. Registries, electronic health records, national databases, and observational cohorts are increasingly able to capture treatment effectiveness, long-term safety, healthcare utilization, and patient outcomes at a scale and in populations that trials cannot reach. At the same time, digital medicine, remote monitoring, telemedicine, and AI-based clinical decision support are changing how multidisciplinary teams coordinate care and how that care can be measured. What remains missing is a rigorous, implementation-science lens connecting these three elements — coordinated care delivery, real-world data, and digital tools — into evidence-based, scalable care pathways. This is the specific gap this collection addresses, distinguishing it from broader collection's on liver disease therapeutics or single-technology digital health topics.

We welcome studies that evaluate integrated or multidisciplinary care pathways using real-world data, assess the implementation, scalability, and impact of digital health and AI-supported tools within coordinated liver care, and apply implementation science and health services research frameworks to explain why these models succeed or fail across different healthcare systems. Contributions may span the disease spectrum where integrated care is most consequential — including MASLD/MASH, cirrhosis and its complications, hepatocellular carcinoma, and liver transplantation pathways — but should center on the care-delivery, real-world evidence, or digital-implementation angle rather than disease-specific therapeutics alone.

Topics of interest include, but are not limited to:

· Multidisciplinary and integrated care pathways, and their real-world evaluation
· Implementation science and health services research applied to liver care delivery
· Registry-based and observational studies of care delivery models
· Digital health, telemedicine, and remote monitoring within integrated care
· AI-based clinical decision support for care coordination and outcome prediction
· Patient-reported outcomes and quality of life in integrated care settings
· Health economics and cost-effectiveness of integrated care models
· Healthcare disparities and access within multidisciplinary care pathways
· Liver transplantation care pathways and coordination
· Integrated care in cirrhosis, portal hypertension, hepatocellular carcinoma, and MASLD/MASH

We welcome Original Research Articles, Systematic Reviews, Meta-analyses, Brief Research Reports, Clinical Reviews, Perspectives, and Opinion articles. Contributions from multidisciplinary teams and international collaborations using robust real-world datasets are particularly encouraged, especially those that make explicit use of implementation science frameworks or AI-driven methods to strengthen the conceptual link between care coordination and measurable outcomes.

Article types and fees

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Community Case Study
• Curriculum, Instruction, and Pedagogy
• Data Report
• Editorial
• FAIR² Data
• ... View all formats

Articles that are accepted for publication by our external editors following rigorous peer review incur a publishing fee charged to Authors, institutions, or funders.

Article types

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Community Case Study
• Curriculum, Instruction, and Pedagogy
• Data Report
• Editorial
• FAIR² Data
• General Commentary
• Hypothesis and Theory
• Methods
• Mini Review
• Opinion
• Original Research
• Perspective
• Policy and Practice Reviews
• Policy Brief
• Review
• Study Protocol
• Systematic Review
• Technology and Code

Keywords: Liver Disease, Integrated Care, Real-World Evidence, Digital Health, Multidisciplinary Care, Patient-reported Outcomes, AI, Precision Medicine, Health Services Research, Implementation Science

Important note: All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.