Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community

Abstract

ObjectiveTo 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.DesignA referral pathway between primary and secondary care for the detection and risk stratification of liver disease.SettingFour Nottinghamshire clinical commissioning groups (700 000 population).PatientsPatients 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).InterventionsWe 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 measuresPathway uptake, patient characteristics, liver disease stratification results and stakeholder feedback.ResultsOver 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.ConclusionsTargeting 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.

Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK

“…The forward focus is on developing the brief lifestyle advice provided to all patients into a more supportive and sustainable behaviour change intervention. https://www.scarredliverproject.org.uk/ (76) Each of the successful local schemes for earlier diagnosis have led to a reduction in unnecessary referrals to hospital-based consultant clinics with consequent cost savings. Demonstrating the effects on survival and state of health will require larger cohorts and longer periods of follow-up.…”

Health related quality of life in individuals at high risk of chronic liver disease: Impact of a community diagnostic pathway

“…The at-risk and assessed populations are described in detail in prior publications. In brief, from detailed piloting we determined that approximately 10% of the adult population in the area had a GP record of either type 2 diabetes or alcohol excess and that when offered the referral opportunity approximately 50% agreed [ 6 , 7 ].…”

“…This study utilises The Nottingham Adult Liver Disease Stratification Pathway, a community-based healthcare pathway in Nottingham, UK [ 6 ], which aims to support the diagnosis of early and later stage CLD in individuals deemed to be at high risk within general practice. We aimed to determine the impact of a diagnosis of CLD on HRQoL in the short (three month) and medium (12 month) term in individuals at high risk of CLD in the community and how this differed by diagnosed liver disease severity.…”

On the path to detecting significant liver disease

“…On the path to detecting significant liver disease Rohit Gupta, 1 James O'Beirne 1,2 COmmentaRy doi:10.1136/flgastro-2019-101282…”

“…In Frontline Gastroenterology, Chalmers et al present findings from a commissioned referral pathway designed to focus on risk factors for NAFLD or ARLD rather than abnormal liver enzymes alone. 2 Under the pathway, general practitioners (GPs) were encouraged to identify patients at risk of significant liver disease and to refer these patients for assessment with transient elastography (TE). Patients with a TE reading suggesting significant liver fibrosis (TE >8 kPA) were recommended to be referred for assessment in secondary care, whereas those with lower readings underwent a brief intervention regarding lifestyle by a dedicated nurse in the TE clinic and were referred back to primary care.…”