Liver disease – examples of good practice in primary care
We recognise that every ICS/Health Board is at a different stage in developing and managing their liver disease pathways. Many local teams have led innovative and exciting developments in the prevention and management of liver disease in their areas across the UK. Below are some examples of possible approaches to help you implement full pathways for the early detection and management of liver disease. We have also listed some condition specific pathway exemplars as well as ideas for launching pro-active case finding of high risk individuals.
If you've been involved in innovative or best practice in the management of liver disease and you would like to share details of your project, please email: firstname.lastname@example.org
Areas of good practice for early detection include:
The intelligent Liver Function Testing pathway (iLFT) uses an automated, algorithm - based system to further investigate abnormal liver function test (LFT) results on initial blood samples from primary care.
GPs in Dundee can request an LFT via an electronic system, inputting information about a patients BMI, alcohol consumption and other risk factors. If an abnormal result is found in the laboratory, a series of additional tests on the same sample are automatically run to find the cause and stage of fibrosis. The information automatically identifies the diagnosis; highlights whether a referral to a specialist is required; and provides a management plan, which includes lifestyle advice for NAFLD patients. This can be made available to GPs instantaneously to enable them to take action and are also delivered electronically. [i] [ii]
The pathway, which was piloted from September 2015 to November 2016, saw a 43% increase in the number of liver disease patients diagnosed. It was found to save the NHS £3,216 per patient, per lifetime, proving cost-effective. [iii]
Since becoming fully operational across NHS Tayside's primary care services in August 2018, iLFT has identified that 70% of patients could continue to be managed in primary care. [iv] [v] The Scottish Government has identified the iLFT pathway as eligible for adoption across NHS Scotland through its Modern Outpatient Programme. The Tayside iLFT group are working with primary care services and laboratories to roll out the test. [vi]
iLFTs are also being piloted in Birmingham, and being worked on in Wolverhampton, Coventry, Liverpool, North London and Fife.
"The journey to date has been truly transformational, empowering primary care to have the confidence in managing low risk liver disease, expediting care for those with significant liver disease who truly need secondary care input and undoubtedly shortening the timescales in the assessment and management of liver disease across the health economy." – Dr Dennis Burke MD FRCP FRCPed, North Cumbria Integrated Care NHS Foundation Trust
In 2016, the Gwent AST Project (GAP) was commissioned as part of the Wales Liver Plan to pilot a pathway in primary care, aiming to improve the recognition of significant liver disease by automatically testing for the enzyme Aspartate transaminase (AST) as appropriate. The pathway automatically assesses and advises on whether to refer the patient for further assessment, which is done predominantly via FibroScan.
During the two-year pilot, 192 cases of advanced fibrosis were identified, and there has been an 81% increase in coded diagnoses of cirrhosis since its introduction. In addition, 50% of patients referred for FibroScan via the pathway has probable NAFLD as the final diagnosis.
Wales launched the All-Wales Liver Blood Test Pathway in October 2021 to improve the early detection and management of liver disease across all 7 Health Boards in Wales – the first UK nation to do so. We hope others in the devolved nations might look to Wales as an 'exemplar' and consider adopting a ‘National Pathway’ for the early detection and management of liver disease.
In South Nottinghamshire, an integrated pathway has been established within the community, as part of the Scarred Liver Project, to identify patients with risk factors for liver disease. GPs can opportunistically refer at-risk patients for a FibroScan to test for liver scarring.
Every patient, regardless of their test result, receives information on lifestyle interventions to maintain good liver health. Those with abnormal scan results are referred to a hepatologist for further review. [vii]
The pathway was piloted in 2014 and is now accessible to more than 100 GP practices serving a population of approximately 700,000 patients. The pathway is cost-effective, with the cost per quality-adjusted life-year (QALY) equating to £2,138 per patient diagnosed with NAFLD.
“The interesting aspect of the pathway is that we have targeted patients who have risk factors who may not know they already have liver disease, as they have no symptoms. Many of the tests GPs often use to detect liver disease come out as normal so they would not have been diagnosed in the usual circumstances”. – Professor Neil Guha, NIHR Nottingham BRC, University of Nottingham and NHS Innovation accelerator fellow (2015- 2018)[viii]
Proactive Case Finding
Below are some good practice exemplars for pro-active case finding of high risk individuals. They provide ideas of how pathways might work, however, to constitute a full pathway such practices would need to be rolled out across the whole Integrated Care System or Health Board.
In April 2019, West Hampshire CCG commissioned a Community FibroScan service to travel around 18 local GP surgeries in the Mid Hampshire area. This was the first study to make FibroScan available for GPs to use in Primary Care – its aim being to improve diagnosis of chronic liver disease in Primary Care using FibroScan.
By delivering this innovative practice using scanning in the community, it was hoped that it would improve liver health outcomes whilst simultaneously helping to risk stratify patients in Primary Care. The portability of the FibroScan machine meant that it could be in one GP practice in the morning and a different practice in the afternoon, ‘overcoming barriers to access’ and ‘bringing the service closer to patients’.
With FibroScan being based in Primary Care services, it’s a very simple straightforward referral from GPs and the FibroScan nurse then sees the patients and scans the liver with the FibroScan machine. Many patients from rural areas were having to travel a long way to hospital – undertaking the scan in a GP practice was much easier, greener on the environment and resulting in 98% positive feedback from patients.
The result of this service is that the FibroScan device is being used as much as possible and it ensures a quick triage. Patients at risk of liver disease, such as diabetics, when seen in the community diabetic clinic can then be booked in for a Fibroscan and referred if there is a raised result by the Fibroscan nurse. With real time results, any urgent cases are quickly diverted to secondary health care when necessary. Other patients are offered preventative measures including lifestyle advice, guidance and support to self-manage. The authors of the study estimated that prevention of progression to cirrhosis and ultimately transplantation represents a saving of at least £12,000 per patient, with an ICU bed priced at £1,328 per day and a general hospital bed at £195 per day at least.
This started as a 1 year pilot, however, due to its successful liver health outcomes has been extended to run ever since. They have recently trained up more people to run this service.
"This pilot demonstrates a scanning service can be portable, bringing the service closer to patients and overcoming barriers to access. It is low cost compared to hospital based alternative delivery models". (See BMJ Journal and Page 6 Lancet Review 2021).
“Feedback from Primary Care was that this was a seamless effective service, from patients that it was accessible and informative and we have found this has revolutionised our clinic.” – Mid Hants Liver Clinic
The St. Mary's Surgery in Southampton recognised that the patients in their large inner-city practice were likely to have a high prevalence of liver disease. Having been part of the 'Locate' project the practice worked with local liver specialists to improve their identification and management of liver disease through the development of local clinical pathways and through direct GP access to transient elastography (TE). They created a simple flagging system on their electronic patient records that identified those at risk so that they were routinely and systematically tested.
hepatoSIGHT is a unique tool that enables clinicians to rapidly and easily analyse existing test results, across a population, and identifies people with the subtle signs of early liver disease. When incorporated into a case-finding-led early diagnosis pathway, health systems can use hepatoSIGHT to identify patients before they require urgent care, and when treatments are more curative and cost-effective.
Case-finding using the hepatoSIGHT tool is complementary to other initiatives including the integration of liver pathways into EHR systems, reflexive testing, and targeted screening. It can also be customized with local search criteria, and deprivation indices to find the most at risk and hard-to-reach patients whilst still not overwhelming clinics.
Somerset NHS Foundation Trust has been trialling the new approach, with much success. As part of the trial, the hepatology department have found dozens of people with undiagnosed liver disease who are now on treatment that will slow its progression and hugely improve their outcomes. hepatoSIGHT is ready to be deployed to more regions and can form a vital part of the multi-dimensional approach needed to end the late diagnosis of liver disease[ix].
For details of the research study click here.
“At a time of intense pressure such as this, using technology that empowers clinicians to get ahead is critical.” – Prof. Daniel Meron, Chief Executive Officer, Somerset NHS Foundation Trust
Condition Specific Pathways- NAFLD
The Camden and Islington pathway consists of a two-step testing assessment for patients attending their GP with a new or established diagnosis of NAFLD to determine if the patient’s condition can be managed in primary or secondar care.
In the first step, all patients undergo a FIB-4 test. If the FIB-4 score falls below a certain level, patients are deemed to be at low risk of advanced fibrosis and are managed in primary care. If the FIB-4 score is considered high, patients are deemed to be at greater risk of advanced fibrosis and are referred to secondary care for specialist assessment. A further Enhanced Liver Fibrosis blood test can also be used to decide whether individuals can be managed in primary care or secondary care when it is not immediately clear from the FIB-4 test.
Patients managed in primary care receive treatment for cardiovascular risks and diabetes, receive annual liver function tests, and are re-assessed to gauge their risks of advanced fibrosis after three to five years. [x]
In 2016 - an 80% reduction in unnecessary referrals to secondary care was seen, saving £150,000. In addition, there was a 5-fold increase in the detection of advanced fibrosis and three-fold increase in the detection of cirrhosis. [xi] [xii]
The Pathway has been revised twice since its creation, most recently in 2019. [xiii]
At Newcastle Upon Tyne Hospitals NHS Foundation Trust a care bundle was developed by hepatologists, gastroenterologists, specialist dieticians and physiotherapists, to record key information on NAFLD follow-up patients. [xiv] The care bundle was developed following a regional baseline audit which found variation in documentation and practice.
The bundle was introduced at the Foundation Trust in November 2018 and provides a short and structured checklist to facilitate the recording of anthropometry, metabolic risk factors, stage of liver fibrosis, lifestyle advice and weight reduction targets, metabolic risk factor management and specific NAFLD treatment. It incorporates key recommendations from EASL and NICE and includes advice on routine investigations and an NAFLD management algorithm.
Overall, there was significantly better documentation and implementation of most aspects of patient management when the bundle was used. This led to better management of metabolic risk factors, documenting of lifestyle advice and provision of patient information booklets on NAFLD.
Condition Specific Pathways- Alcohol
Teams in Bolton have created the 'Bolton Alcohol Project'. They developed integrated and collaborative changes that led to:
- a primary care project that has been highly successful in identifying alcohol problems through screening with the AUDIT-C test and signposting patients to early interventions.
- the creation of a consultant-led hospital based alcohol care team that has improved the care and reduced admissions for alcohol-related conditions.
As part of the Sound the Alarm campaign, the British Liver Trust is calling for every NHS Trust to have an alcohol care team to support those who drink too much and to refer people who have alcohol related liver disease to specialised teams.
We are pleased to hear of new 'Alcohol Care Teams' being developed across the country and would be very happy to link you in with successful Alcohol Care Teams to help you in establishing this.
Please see this link for further information.
If you would like more information on any of the above initiatives or to be connected with clinicians leading these exemplars please contact email@example.com
[i] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19- Research-Article-iLFT.pdf
[ii] Royal College of General Practitioners, Recommendations for commissioning bodies to improve the early detection of chronic liver disease in UK primary care. Available at: https://www.rcgp.org.uk/clinical-and-research/resources/a-to-z-clinical-resources/recommendations-for-commissioning-bodies-to-improve-the-early-detection-of-chronic-liver-disease.aspx Accessed on: 8 March 2021
[iii] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19- Research-Article-iLFT.pdf
[iv] Dillon, J.F., Miller, M.H., Robinson, E.M., Donnan, P.T., Boyd, K.A., and Dow, E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care, Journal of Hepatology. June 2019. Available at: https://www.labs.scot.nhs.uk/wp-content/uploads/2019/12/Journal-of-Hepatology-Oct19- Research-Article-iLFT.pdf
[v] Scottish Government, Demand optimisation in laboratory medicine: phase two report. November 2019. Available at: https://www.gov.scot/publications/demand-optimisation-laboratory-medicine-phase-ii-report/pages/6/ [vi] Scottish Government, Demand optimisation in laboratory medicine: phase two report. November 2019. Available at: https://www.gov.scot/publications/demand-optimisation-laboratory-medicine-phase-ii-report/pages/6/
[vii] The Scarred Liver Project, Detecting liver disease in the community. Available at: https://www.scarredliverproject.org.uk
[ix] Wesley E, Matull W, Kitchin A, et al A cumulative liver damage index (CLDI) identifies patients at risk of significant liver disease Gut 2022;71:A4. Available at: https://gut.bmj.com/content/71/Suppl_3/A4
[x] Srivastava, A., Gailer, R., Tanwar, S., Trembling, P., Parkes, J., Rodger, A., Suri, D., Thorburn, D., Sennett, K., Morgan, S., Tsochatzis, E.A., Rosenberg, W., Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease, Journal of Hepatology. March 2019. Available at: https://discovery.ucl.ac.uk/id/eprint/10072675/1/1-s2.0-S0168827819302272-main.pdf
[xi] NHS Camden, NAFL Camden, June 2019. Available at: https://www.basl.org.uk/uploads/NAFLD%20SIG/NAFl%20Camden.pdf Accessed on: 9 March 2021
[xii] Srivastava, A., Gailer, R., Tanwar, S., Trembling, P., Parkes, J., Rodger, A., Suri, D., Thorburn, D., Sennett, K., Morgan, S., Tsochatzis, E.A., Rosenberg, W., Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease, Journal of Hepatology. March 2019. Available at: https://discovery.ucl.ac.uk/id/eprint/10072675/1/1-s2.0-S0168827819302272-main.pdf
[xiii] NHS North Central London, Adult Abnormal Liver Function Tests Guidance, February 2019. Available at: https://gps.northcentrallondonccg.nhs.uk/pathways/liver-function-tests-1 Accessed on: 9 March 2021
[xiv] Neilson, L., Macdougall, L., Lee, P., Hardy, T., Beaton, D., Chandrapalan, S., Ebraheem, A., Hussien, M., Galbraith, S., Looi, S., Oxenburgh, S., Phaw, N., Taylor, W., Haigh, L., Hallsworth, K., Mansour, D., Dyson, J., Masson, S., Anstee, Q. and McPherson, S. Implementation of a care bundle improves the management of patients with non-alcoholic fatty liver disease, Frontline Gastroenterology. January 2021. Available at: https://fg.bmj.com/content/early/2021/01/03/flgastro-2020-101480