We received 15 excellent entries for the first BSG Service Prize in 2019. The winning submission was from Dr Jane Chalmers and colleagues on behalf of the NIHR Nottingham Biomedical Research Centre for the development of a new diagnostic pathway to detect chronic liver disease across primary and secondary care.

Dr Jane Chalmers receiving her award from President Dr Cathryn Edwards and CSSC Chair Dr Tony Tham at the BSG Annual Conference 2019
Dr Jane Chalmers receiving her award from President Dr Cathryn Edwards and CSSC Chair Dr Tony Tham at the BSG Annual Conference 2019

The Development of a New Diagnostic Pathway to Detect Chronic Liver Disease across Primary and Secondary Care

Dr Jane Chalmers, on behalf of the NIHR Nottingham Biomedical Research Centre

This application outlines the development of a new diagnostic pathway to detect chronic liver disease across primary and secondary care. Since it was commissioned in 2016 over 3000 patients at risk of liver disease have been assessed and stratified through this pathway, increasing detection of significant liver disease within the community.

 

Authors and Institution (listed with their role)
  • Dr Jane Chalmers on behalf of NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham
  • Hepatologists
    • Dr Neil Guha, Dr Emilie Wilkes, Prof Guru Aithal, Prof Stephen Ryder, Dr Martin James
  • Clinical Research Fellows
    • Dr Jane Chalmers, Dr Rebecca Harris, Dr Dave Harman
  • CCG/GP collaborators
    • Dr Sonali Kinra (GP), Dr Hugh Porter (Chair of CCG)
  • EMAHSN
    • Karen Glover, Fiona Kilpatrick, Nick Hamilton
  • Nursing staff
    • Mary Holmes, Andrea Bennett, Tracey Wildsmith
  • Public Health collaborators
    • Dr Joanne Morling, Dr Tim Card

Summary of the service story

Deaths from chronic liver disease (CLD) in the UK continue to rise. In contrast to cardiovascular disease and cancer the incidence in patients under the age of 55 is rising. Liver disease is asymptomatic until a late stage and subsequently 50% of patients receive their initial diagnosis after presenting as an emergency admission [1]. The need for early detection in order to allow intervention and to change the course of disease has been highlighted by three independent reports [2-4]. However, with no nationally agreed guidance, the approach used by GPs to identify patients varies widely. Current diagnostic pathways are based on liver enzymes tests which have a low sensitivity/ specificity [5] and may lead to expensive and invasive tests in secondary care.
 

Challenges

Our aim was to develop a pathway to detect significant but asymptomatic CLD at a critical stage. This pathway incorporates a targeted stratification of patients with risk factors for CLD e.g. hazardous alcohol intake, diabetes and obesity alongside traditional referral parameters such as raised liver enzymes. Secondly, it allows GPs direct access to non-invasive tests of liver fibrosis, utilising the ability of transient elastography (Fibroscan®) to give an immediate result and enabling prompt brief lifestyle intervention.

  • The feasibility of the pathway was initially piloted through 4 GP practices in Nottingham in which 20,000 patients were screened and 2000 patients were identified to have a predefined risk factor. Of the ̴900 patients who were risk stratified, 20% had evidence of significant liver disease, and detection of advanced liver disease/ cirrhosis was increased by 140%. Approximately 70% of the patients diagnosed with significant liver disease had normal liver enzymes.
  • Through engagement with the East Midlands Academic Health Science Network (EMAHSN), funding was secured to enable further iterations of the pathway to be tested within different socio-economic areas including inner city Nottingham and Leicester.
  • An economic evaluation of the pathway demonstrated the pathway was cost effective with an ICER of £2,138 per extra QALY, well below the NICE threshold of £20,000.
  • Patient engagement within the pilot studies was high with 95% attendance rates and 94% stating they would recommend the service to family and friends.

 

Evaluation and Outcomes
  • Using this evidence, a co-produced bespoke pathway was designed with four local CCGs and the Nottingham Liver Disease Stratification Pathway was commissioned and commenced in September 2016. This pathway is accessible to 108 GP practices serving a population of ̴ 700,000 people.
  • To date over 3000 patients have been assessed and received brief intervention.
  • In the first year, 968 patients were assessed of which 222 had elevated liver stiffness indicating disease, and 60 with evidence of advanced liver disease.
  • Non-attendance is less than 15% (previously identified to be 40% for specialist tests) and feedback using the friends and family test is excellent (>95% in all domains).
  • Further development of the pathway is underway, adapting the pathway to suit local need. This includes implementation amongst alcohol and drug users in Chesterfield hospital.
  • The pathway has been highlighted by the British Liver Trust and the Royal College of General Practitioners as an example of best practice and by NICE as an exemplar of implementation of its cirrhosis guideline through its Shared Learning programme.

 

Learning Points
  • Pathway development is complex and challenging. Early involvement of key stakeholders including patients, consultant hepatologists, GPs and commissioners was critical to enable adoption.
  • Face to face training events with local GPs improved understanding of the pathways aims and allowed feedback on how the pathway could be implemented more effectively.
  • Collaboration with the East Midlands Academic Health Science Network (EMAHSN) provided not just funding but helped facilitate evaluation of the service as well as adoption and spread nationally.

 

Supporting information:
  • Flow diagram/algorithm to illustrate how you did it
    • Figure 1. is a flow diagram depicting the development of the pathway from early feasibility work to the commissioned pathway and includes pivotal awards and papers resulting from the work.
    • Figure 2. outlines the current referral pathway used by GPs for the stratification of liver disease in patients at risk.
    • A bespoke website was created to consolidate implementation learning materials and other literature from the different iterations of the pathway. It is purposely designed to integrate new knowledge and evidence and to enable others to adopt and adapt the pathway within their own health care setting.

Tools: www.scarredliver.org.uk



References

  1. Ratib, S., et al., 1- and 5-year survival estimates for people with cirrhosis of the liver in England, 1998-2009: a large population study. J Hepatol, 2014. 60(2): p. 282-9.
  2. Davies, S., Chief Medical Officer annual report. 2011. p. p. 163.
  3. The all-party parliamentary hepatology group, Liver disease: Today's complacency, tomorrow's catastrophe. 2014.
  4. Williams, R., et al., Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. The Lancet. 384(9958): p. 1953-1997.
  5. Fracanzani, A.L., et al., Risk of severe liver disease in non-alcoholic fatty liver disease with normal aminotransferase levels: a role for insulin resistance and diabetes. Hepatology, 2008. 48(3): p. 792-8.

Contact details for members interested in getting more information

NIHR Nottingham Biomedical Research Centre
E Floor, West Block
Queen’s Medical Centre
Derby Road
Nottingham, NG7 2UH

jane.chalmers@nottingham.ac.uk