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. 2020 Feb 10;11(2):86-92.
doi: 10.1136/flgastro-2019-101177. Epub 2019 Jun 26.

The Development and Implementation of a Commissioned Pathway for the Identification and Stratification of Liver Disease in the Community

J Chalmers  1   2 , E Wilkes  1   2 , R Harris  1   2 , L Kent  3 , S Kinra  1   4 , G P Aithal  1   2 , M Holmes  1 , J Johnson  1 , J R Morling  1   5 , I N Guha  1   2
Affiliations

The Development and Implementation of a Commissioned Pathway for the Identification and Stratification of Liver Disease in the Community

J Chalmers et al. Frontline Gastroenterol. .

Abstract

Objective: To describe the development of the Nottingham liver disease stratification pathway, present a 12-month evaluation of uptake, stratification results and compare the pathway to 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 i) raised AST/ALT ratio ii) harmful alcohol use or iii) risk or presence of non-alcoholic fatty liver disease (NAFLD).

Interventions: Clinic attendance within secondary care for transient elastography (TE) and brief lifestyle intervention. The TE result is reported back to the GP 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 (≥8kPa) and in 60 (27.0%) liver stiffness 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 (≥8kPa) would have gone undetected among those referred for either NAFLD or raised AST:ALT.

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.

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Conflict of interest statement

Competing Interests None declared

Figures

Figure 1
Figure 1
Nottingham liver disease stratification referral pathway. ALT, alanine aminotransferase; AST, aspartate aminotransferase; FLI, fatty liver index; MetS, metabolic syndrome; NAFLD, non-alcoholic fatty liver disease; T2DM, type 2 diabetes mellitus; USS, ultrasound.
Figure 2
Figure 2
(A) Distribution of referral criteria to Nottingham liver disease stratification pathway (excluding those who did not meet the criteria). (B) Transient elastography results of these patients according to the referral criteria. ALT, alanine aminotransferase; AST, aspartate aminotransferase; NAFLD, non-alcoholic fatty liver disease.
Figure 3
Figure 3
Stratification of patients through the Nottingham liver disease stratification pathway compared with standard stratification using the BSG guidelines (numbers in brackets ≥15 kPa). ALT, alanine aminotransferase; BSG, British Society of Gastroenterology; TE, transient elastography.
See this image and copyright information in PMC

Comment in

  • On the path to detecting significant liver disease.
    Gupta R, O'Beirne J. Gupta R, et al. Frontline Gastroenterol. 2019 Sep 21;11(2):84-85. doi: 10.1136/flgastro-2019-101282. eCollection 2020 Mar. Frontline Gastroenterol. 2019. PMID: 32133107 Free PMC article. No abstract available.

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