Ankur Srivastava1, Ruth Gailer1, Sudeep Tanwar1, Paul Trembling1, Julie Parkes2, Alison Rodger3, Deepak Suri4, Douglas Thorburn1, Karen Sennett5, Sarah Morgan6, Emmanuel A Tsochatzis7, William Rosenberg8. 1. UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom; Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom. 2. UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom; Public Health Sciences and Medical Statistics, University of Southampton, University Hospital Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom. 3. Department of Public Health, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom; Infection and Population Health, Institute for Global Health, Faculty of Population Health Sciences, UCL Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom. 4. Department of Gastroenterology, The Whittington Hospital NHS Trust, Magdala Avenue, London N19 5NF, United Kingdom. 5. Killick Street Practice, Islington Clinical Commissioning Group, 75 Killick Street, King's Cross, London N1 9RH, United Kingdom. 6. Hampstead Group Practice, Camden Clinical Commissioning Group, 75 Fleet Road, Hampstead, London NW3 2QU, United Kingdom. 7. UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom; Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom. Electronic address: e.tsochatzis@ucl.ac.uk. 8. UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom; Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom. Electronic address: w.rosenberg@ucl.ac.uk.
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%CI2.97-9.04; p <0.0001), while reducing unnecessary referrals from primary care to secondary care by 81% (OR0.193; 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% (OR0.23; 95% CI0.658-0.082; p = 0.006) and a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR4.32; 95% CI1.52-12.25; 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 (OR0.12; 95%CI0.042-0.349; 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.
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%CI2.97-9.04; p <0.0001), while reducing unnecessary referrals from primary care to secondary care by 81% (OR0.193; 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% (OR0.23; 95% CI0.658-0.082; p = 0.006) and a 4-fold improvement in detection of cases of advanced fibrosis and cirrhosis (OR4.32; 95% CI1.52-12.25; 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 (OR0.12; 95%CI0.042-0.349; 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.
Authors: Manuel Romero-Gómez; Jörn M Schattenberg; Jeffrey V Lazarus; Quentin M Anstee; Hannes Hagström; Kenneth Cusi; Helena Cortez-Pinto; Henry E Mark; Michael Roden; Emmanuel A Tsochatzis; Vincent Wai-Sun Wong; Zobair M Younossi; Shira Zelber-Sagi Journal: Nat Rev Gastroenterol Hepatol Date: 2021-06-25 Impact factor: 46.802
Authors: Abdel Aziz Shaheen; Kiarash Riazi; Alexandra Medellin; Deepak Bhayana; Gilaad G Kaplan; Jason Jiang; Roy Park; Wendy Schaufert; Kelly W Burak; Monica Sargious; Mark G Swain Journal: CMAJ Open Date: 2020-05-15
Authors: James B Maurice; Robert Goldin; Andrew Hall; Jennifer C Price; Giada Sebastiani; Caryn G Morse; Laura Iogna Prat; Hugo Perazzo; Lucy Garvey; Patrick Ingiliz; Giovanni Guaraldi; Emmanouil Tsochatzis; Maud Lemoine Journal: Clin Infect Dis Date: 2021-10-05 Impact factor: 9.079
Authors: Andrew D Schreiner; Sherry Livingston; Jingwen Zhang; Mulugeta Gebregziabher; Justin Marsden; David G Koch; Chelsey A Petz; Valerie L Durkalski-Mauldin; Patrick D Mauldin; William P Moran Journal: J Clin Gastroenterol Date: 2021-07-22 Impact factor: 3.062