Liver disease – examples of best practice in primary care
Many local teams have led innovative and exciting developments in the prevention and management of liver disease in their areas across the UK, some of these are listed below.
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 complete the pro forma and email it to firstname.lastname@example.org
Areas of good practice for early detection include:
Camden and Islington
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. 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 risk of advanced fibrosis after three to five years.[i]
2016 – an 80% reduction in unnecessary referrals to secondary care was seen, saving £150,000. In addition, there was a five-fold increase in the detection of advanced fibrosis and three-fold increase in the detection of cirrhosis.[ii],[iii]
The pathway has been revised twice since its creation, most recently in 2019.[iv]
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 patient’s BMI, alcohol consumption and other risk factors. If an abnormal LFT 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.[v],[vi]
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.[vii] 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.[viii],[ix] 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.[x]
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.[xi]
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.
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.
North East England
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.[xii] 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.
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
Middlesbrough has developed a 'Live Well Centre'. The centre is a one-stop shop to support people in changing their lives for the better across a full spectrum of life issues. The project is specifically building in the identification of risk factors for liver disease together with signposting to further interventions as part of an opportunistic screening programme.
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.
Recognising higher than average liver disease mortality in the region, together with high levels of health inequality, local PHE leads have brought together services and organisations to address the human and financial costs arising from this. Through local workshops and the creation of a local network, the region has put in place strategies to improve the early detection of liver disease and improve the patient experience.
The 'Liver Matters' project has worked across the Birmingham South Central CCG to enhance the quality of life for people with alcohol related liver disease and their carer(s) and families, providing information and advice, liaising with treatment services, expanding social networks, and supporting end of life care.
[i] 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
[ii] NHS Camden, NAFL Camden, June 2019. Available at: https://www.basl.org.uk/uploads/NAFLD%20SIG/NAFl%20Camden.pdf Accessed on: 9 March 2021
[iii] 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
[iv] 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
[v] 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
[vi] 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
[vii] 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
[viii] 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
[ix] 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/
[x] 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/
[xii] 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