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Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease

Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease
Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease

Background & Aims: the development of non-invasive liver fibrosis tests may enable earlier identification of patients with non-alcoholic fatty liver disease (NAFLD) requiring referral to secondary care. We developed and evaluated a pathway for the management of patients with NAFLD, aimed at improving the detection of cases of advanced fibrosis and cirrhosis, and avoiding unnecessary referrals. 

Methods: this was a prospective longitudinal cohort study, with analyses performed before and after introduction of the pathway, and comparisons made to unexposed controls. We used a 2-step algorithm combining the use of Fibrosis-4 score followed by the ELF™ test if required. 

Results: in total, 3,012 patients were analysed. Use of the pathway detected 5 times more cases of advanced fibrosis (Kleiner F3) and cirrhosis (odds ratio [OR] 5.18; 95% CI 2.97–9.04; p <0.0001), while reducing unnecessary referrals from primary care to secondary care by 81% (OR 0.193; 95% CI 0.111–0.337; p <0.0001). Although it was used for only 48% of referrals, significant benefits were observed in practices exposed to the pathway compared to those which were not, with unnecessary referrals falling by 77% (OR 0.23; 95% CI 0.658–0.082; p = 0.006) and a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR 4.32; 95% CI 1.52–12.25; p = 0.006). Compared to referrals made before the introduction of the pathway, unnecessary referrals fell from 79/83 referrals (95.2%) to 107/152 (70.4%), representing an 88% reduction in unnecessary referrals when the pathway was followed (OR 0.12; 95% CI 0.042–0.349; p <0.0001). 

Conclusions: the use of non-invasive blood tests for liver fibrosis improves the detection of advanced fibrosis and cirrhosis, while reducing unnecessary referrals in patients with NAFLD. This strategy improves resource use and benefits patients. Lay summary: Non-alcoholic fatty liver disease effects up to 30% of the population but only a minority of cases develop liver disease. Our study has shown that established blood tests can be used in primary care to stratify patients with fatty liver disease, leading to a reduction in unnecessary referrals by 80% and greatly improving the detection of cases of advanced fibrosis and cirrhosis.

Cirrhosis, Clinical management, Cost effectiveness, ELF, FIB-4, NAFLD, Non-invasive fibrosis test, Steatohepatitis
0168-8278
Srivastava, Ankur
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Gailer, Ruth
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Tanwar, Sudeep
61efeab7-e746-4a8f-9170-2e6d95278fcd
Trembling, Paul
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Parkes, Julie
59dc6de3-4018-415e-bb99-13552f97e984
Rodger, Alison
af928914-8be9-4009-99ed-20109b3b3d97
Suri, Deepak
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Thorburn, Douglas
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Sennett, Karen
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Morgan, Sarah
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Tsochatzis, Emmanuel A.
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Rosenberg, William
145ebec3-ffb6-45e7-8711-aa520ed42f55
Srivastava, Ankur
6c45ba97-4517-4f4e-992c-03e7d305ed47
Gailer, Ruth
82f6984a-c3af-400f-9cf6-0b03d651bfa7
Tanwar, Sudeep
61efeab7-e746-4a8f-9170-2e6d95278fcd
Trembling, Paul
28891cfb-fe47-4d3c-ab50-66966965551f
Parkes, Julie
59dc6de3-4018-415e-bb99-13552f97e984
Rodger, Alison
af928914-8be9-4009-99ed-20109b3b3d97
Suri, Deepak
f85f49f3-5afb-4cae-9a18-820bb29c3fcf
Thorburn, Douglas
3541a9b1-15f0-4577-83b3-3f6aaa3a5f8a
Sennett, Karen
d295e314-5a5e-4d01-8090-6738fc759443
Morgan, Sarah
2843f219-71cb-4748-bd79-6fa035330eac
Tsochatzis, Emmanuel A.
92ff645c-80b7-444d-bcdd-c21317cd6500
Rosenberg, William
145ebec3-ffb6-45e7-8711-aa520ed42f55

Srivastava, Ankur, Gailer, Ruth, Tanwar, Sudeep, Trembling, Paul, Parkes, Julie, Rodger, Alison, Suri, Deepak, Thorburn, Douglas, Sennett, Karen, Morgan, Sarah, Tsochatzis, Emmanuel A. and Rosenberg, William (2019) Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease. Journal of Hepatology. (doi:10.1016/j.jhep.2019.03.033).

Record type: Article

Abstract

Background & Aims: the development of non-invasive liver fibrosis tests may enable earlier identification of patients with non-alcoholic fatty liver disease (NAFLD) requiring referral to secondary care. We developed and evaluated a pathway for the management of patients with NAFLD, aimed at improving the detection of cases of advanced fibrosis and cirrhosis, and avoiding unnecessary referrals. 

Methods: this was a prospective longitudinal cohort study, with analyses performed before and after introduction of the pathway, and comparisons made to unexposed controls. We used a 2-step algorithm combining the use of Fibrosis-4 score followed by the ELF™ test if required. 

Results: in total, 3,012 patients were analysed. Use of the pathway detected 5 times more cases of advanced fibrosis (Kleiner F3) and cirrhosis (odds ratio [OR] 5.18; 95% CI 2.97–9.04; p <0.0001), while reducing unnecessary referrals from primary care to secondary care by 81% (OR 0.193; 95% CI 0.111–0.337; p <0.0001). Although it was used for only 48% of referrals, significant benefits were observed in practices exposed to the pathway compared to those which were not, with unnecessary referrals falling by 77% (OR 0.23; 95% CI 0.658–0.082; p = 0.006) and a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR 4.32; 95% CI 1.52–12.25; p = 0.006). Compared to referrals made before the introduction of the pathway, unnecessary referrals fell from 79/83 referrals (95.2%) to 107/152 (70.4%), representing an 88% reduction in unnecessary referrals when the pathway was followed (OR 0.12; 95% CI 0.042–0.349; p <0.0001). 

Conclusions: the use of non-invasive blood tests for liver fibrosis improves the detection of advanced fibrosis and cirrhosis, while reducing unnecessary referrals in patients with NAFLD. This strategy improves resource use and benefits patients. Lay summary: Non-alcoholic fatty liver disease effects up to 30% of the population but only a minority of cases develop liver disease. Our study has shown that established blood tests can be used in primary care to stratify patients with fatty liver disease, leading to a reduction in unnecessary referrals by 80% and greatly improving the detection of cases of advanced fibrosis and cirrhosis.

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Accepted/In Press date: 28 March 2019
e-pub ahead of print date: 6 April 2019
Keywords: Cirrhosis, Clinical management, Cost effectiveness, ELF, FIB-4, NAFLD, Non-invasive fibrosis test, Steatohepatitis

Identifiers

Local EPrints ID: 432284
URI: http://eprints.soton.ac.uk/id/eprint/432284
ISSN: 0168-8278
PURE UUID: 96779525-a641-4552-898d-6ecb2d6f3659
ORCID for Julie Parkes: ORCID iD orcid.org/0000-0002-6490-395X

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Date deposited: 08 Jul 2019 16:30
Last modified: 18 Feb 2021 16:51

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Contributors

Author: Ankur Srivastava
Author: Ruth Gailer
Author: Sudeep Tanwar
Author: Paul Trembling
Author: Julie Parkes ORCID iD
Author: Alison Rodger
Author: Deepak Suri
Author: Douglas Thorburn
Author: Karen Sennett
Author: Sarah Morgan
Author: Emmanuel A. Tsochatzis
Author: William Rosenberg

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