Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community
Open Access
- 26 June 2019
- journal article
- research article
- Published by BMJ in Frontline Gastroenterology
- Vol. 11 (2), 86-92
- https://doi.org/10.1136/flgastro-2019-101177
Abstract
Objective To describe the development of the Nottingham liver disease stratification pathway, present a 12-month evaluation of uptake and stratification results, and compare the pathway with current British Society of Gastroenterology (BSG) guidelines. Design A referral pathway between primary and secondary care for the detection and risk stratification of liver disease. Setting Four Nottinghamshire clinical commissioning groups (700 000 population). Patients Patients are referred to the pathway with (1) raised aspartate aminotransferase to alanine aminotransferase (AST:ALT) ratio, (2) harmful alcohol use or (3) risk or presence of non-alcoholic fatty liver disease (NAFLD). Interventions We report on clinic attendance within secondary care for transient elastography (TE) and brief lifestyle intervention. The TE result is reported back to the general practitioner with advice on interpretation and referral guidance. Main outcome measures Pathway uptake, patient characteristics, liver disease stratification results and stakeholder feedback. Results Over the first 12 months 968 patients attended a TE clinic appointment, with raised AST:ALT ratio being the most common single reason for referral (36.9%). Of the total, 222 (22.9%) patients had an elevated liver stiffness (≥8 kPa), in whom 57 (25.7%) had a liver stiffness which was indicative of advanced chronic liver disease. If a traditional approach based on raised liver enzymes (BSG guidance) had been followed, 38.7% of those with significant liver disease (≥8 kPa) would have gone undetected among those referred for either NAFLD or raised AST:ALT ratio. Conclusions Targeting patients with risk factors for chronic liver disease and stratifying them using TE can detect significant chronic liver disease above and beyond the approach based on liver enzyme elevation.Keywords
Funding Information
- Health Services and Delivery Research Programme (BRC-1215-20003)
This publication has 14 references indexed in Scilit:
- Guidelines on the management of abnormal liver blood testsGut, 2018
- Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility studyBMJ Open, 2017
- Direct targeting of risk factors significantly increases the detection of liver cirrhosis in primary care: a cross-sectional diagnostic study utilising transient elastographyBMJ Open, 2015
- Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitisThe Lancet, 2014
- Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non-alcoholic fatty liver diseaseGut, 2010
- Health outcomes following liver function testing in primary care: a retrospective cohort studyFamily Practice, 2009
- Metabolic and histological features of non‐alcoholic fatty liver disease patients with different serum alanine aminotransferase levelsAlimentary Pharmacology & Therapeutics, 2009
- Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: A role for insulin resistance and diabetesHepatology, 2008
- The Fatty Liver Index: a simple and accurate predictor of hepatic steatosis in the general populationBMC Gastroenterology, 2006
- Clinical and histologic spectrum of nonalcoholic fatty liver disease associated with normal ALT valuesHepatology, 2003