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Nobes J, Leith D, Handjiev S, Dillon JF, Dow E. Intelligent Liver Function Testing (iLFT): An Intelligent Laboratory Approach to Identifying Chronic Liver Disease. Diagnostics (Basel) 2024; 14:960. [PMID: 38732374 PMCID: PMC11083526 DOI: 10.3390/diagnostics14090960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The intelligent Liver Function Testing (iLFT) pathway is a novel, algorithm-based system which provides automated laboratory investigations and clinical feedback on abnormal liver function test (LFT) results from primary care. iLFT was introduced to NHS Tayside, Scotland, in August 2018 in response to vast numbers of abnormal LFTs, many of which were not appropriately investigated, coupled with rising mortality from chronic liver disease. Here, we outline the development and implementation of the iLFT pathway, considering the implications for the diagnostic laboratories, primary care services and specialist hepatology clinics. Additionally, we describe the utility, outcomes and evolution of iLFT, which was used over 11,000 times in its first three years alone. Finally, we will consider the future of iLFT and propose areas where similar 'intelligent' approaches could be used to add value to laboratory investigations.
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Affiliation(s)
- Jennifer Nobes
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - Damien Leith
- Department of Gastroenterology and Hepatology, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK
- Gut Group, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - Sava Handjiev
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK
- Gut Group, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - John F. Dillon
- Department of Gastroenterology and Hepatology, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK
- Gut Group, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - Ellie Dow
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK
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Li W, Sheridan D, McPherson S, Alazawi W. National study of NAFLD management identifies variation in delivery of care in the UK between 2019 to 2022. JHEP Rep 2023; 5:100897. [PMID: 38023607 PMCID: PMC10654022 DOI: 10.1016/j.jhepr.2023.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background & Aims Non-alcoholic fatty liver disease (NAFLD) is associated with liver and cardiovascular morbidity and mortality. Recently published NAFLD Quality Standards include 11 key performance indicators (KPIs) of good clinical care. This national study, endorsed by British Association for the Study of the Liver (BASL) and British Society of Gastroenterology (BSG), aimed to benchmark NAFLD care in UK hospitals against these KPIs. Methods This study included all new patients with NAFLD reviewed in the outpatient clinic in the months of March 2019 and March 2022. Participating UK hospitals self-registered for the study through BASL/BSG. KPI outcomes were compared using Fisher's exact or Chi-square tests. Results Data from 776 patients with NAFLD attending 34 hospitals (England [25], Scotland [four], Wales [three], Northern Ireland [two]) were collected. A total of 85.3% of hospitals reported established local liver disease assessment pathways, yet only 27.9% of patients with suspected NAFLD had non-invasive fibrosis assessment documented at the point of referral to secondary care. In secondary care, 79.1% of patients had fibrosis assessment. Assessment of cardiometabolic risk factors including obesity, type 2 diabetes, hypertension, and smoking were conducted in 73.2%, 33.0%, 19.3%, and 54.9% of all patients, respectively. There was limited documentation of diet (35.7%) and exercise advice (55.1%). Excluding those on statins, only 9.1% of patients with NAFLD at increased cardiovascular risk (T2DM and/or QRISK-3 >10%) had documented discussion of statin treatment. Significant KPI improvements from 2019 to 2022 were evident in use of non-invasive fibrosis assessment before secondary care referral, statin recommendations, and diet and exercise recommendations. Conclusions This national study identified substantial variation in NAFLD management in the UK with clear areas for improvement, particularly fibrosis risk assessment before secondary care referral and management of associated cardiometabolic risk factors. Impact and implications This study identified significant variation in the management of NAFLD in the UK. Only 27.9% of patients with suspected NAFLD had non-invasive fibrosis assessment performed to identify those at greater risk of advanced liver disease before specialist referral. Greater emphasis is needed on the management of associated cardiometabolic risk factors in individuals with NAFLD. Hospitals with multidisciplinary NAFLD service provision had higher rates of fibrosis evaluation and assessment and management of cardiometabolic risk than hospitals without multidisciplinary services. Further work is needed to align guideline recommendations and real-world practice in NAFLD care.
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Affiliation(s)
- Wenhao Li
- Barts Liver Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - David Sheridan
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Hepatology Research Group, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Stuart McPherson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
- the Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - William Alazawi
- Barts Liver Centre, Blizard Institute, Queen Mary University of London, London, UK
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McPherson S, Shearer J. Moving forward with the detection of chronic liver disease. Frontline Gastroenterol 2023; 14:449-450. [PMID: 37854777 PMCID: PMC10579543 DOI: 10.1136/flgastro-2023-102470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/29/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Stuart McPherson
- Liver Unit and NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jessica Shearer
- Liver Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Abeysekera KWM, Srivastava A, Rowe I, Jarvis H, Ryder SD, Yeoman A, Dillon JF, Rosenberg W. Exploring changing attitudes to non-invasive liver fibrosis tests in secondary care pathways: comparison of two national surveys. Frontline Gastroenterol 2023; 14:483-490. [PMID: 37854785 PMCID: PMC10579552 DOI: 10.1136/flgastro-2023-102415] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction The increasing availability of non-invasive tests (NITs) has created the opportunity to explore their use in improving risk stratification of advanced liver disease. The study aimed to determine the attitudes and practices among UK secondary care specialists, focusing primarily on attitudes to fibrosis assessment and the use of NITs. Methods Two web-based surveys were circulated, first between 2014 and 2015 (survey 1), and again in 2021 (survey 2). The surveys were promoted via the British Society of Gastroenterology, the British Association for the Study of the Liver and using Twitter. Results In survey 1, 215 healthcare professionals (HCPs) completed the online survey. 112 HCPs completed survey 2. 71 acute UK trusts were represented in survey 1 compared with 60 trusts in survey 2. Between the two surveys, the proportion of HCPs performing fibrosis assessment in all or nearly all cases rose from 45.1% to 74.1% (χ2=25.01; p<0.0001). 46.5% (n=33/71) respondents in acute services reported the use of NITs in clinical pathways in survey 1, rising to 70.0% (n=42/60) in survey 2 (χ2=7.35; p=0.007). Availability of tests has increased but is not universal. The proportion reporting availability as a barrier to uptake fell from 57.2% of responses in survey 1 to 38.4% in 2021 χ2=11.01; p=0.0009). Conclusion Between 2014 and 2021, the role of NITs in fibrosis assessment has risen substantially, as has the proportion of clinicians using NITs in clinical pathways to assess risk of liver disease. Poor access to NITs remains the predominant barrier.
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Affiliation(s)
- Kushala W M Abeysekera
- Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Ankur Srivastava
- Gastrointestinal and Liver Services, North Bristol NHS Trust, Bristol, UK
| | - Ian Rowe
- Leeds Liver Unit, University of Leeds & St James's University Hospital, Leeds, UK
| | - Helen Jarvis
- Population Health Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Yeoman
- Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - William Rosenberg
- Institute for Liver and Digestive Health, University College London Division of Medicine, London, UK
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Time to focus on chronic liver diseases in the community: A review of primary care hepatology tools, pathways of care and reimbursement mechanisms. J Hepatol 2023; 78:663-671. [PMID: 36283499 DOI: 10.1016/j.jhep.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/25/2022] [Accepted: 10/15/2022] [Indexed: 12/04/2022]
Abstract
Addressing primary care's low confidence in detecting and managing chronic liver disease is becoming increasingly important owing to the escalating prevalence of its common lifestyle-related metabolic risk factors - obesity, physical inactivity, smoking and alcohol consumption. Whilst liver blood testing is frequently carried out in the management of long-term conditions, its interpretation is not typically focused on specific liver disease risk. Educational steps for primary care should outline how liver fibrosis is the flag of pathological concern, encourage use of pragmatic algorithms such as fibrosis-4 index to differentiate between those requiring referral for further fibrosis risk assessment and those who can be managed in the community, and emphasise that isolated minor liver function test abnormalities are unreliable for estimating the risk of fibrosis progression. Measures to increase primary care's interest and engagement should make use of existing frameworks for the management of long-term conditions, so that liver disease is considered alongside other metabolic disorders, including type 2 diabetes, cardiovascular disease, chronic kidney disease etc. Selling points when considering the required investment in developing local fibrosis assessment pathways include reduced repeat testing of minor abnormalities and improved secondary care referrals, plus improvements in the patient's journey through long-term multimorbidity care. A focus on improving chronic liver disease is likely to have wide-ranging benefits across co-existing metabolic disorders, particularly when pathways are aligned with community lifestyle support services. The important message for primary care is to increase the value of existing monitoring rather than to generate more work.
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Abeysekera KWM, Macpherson I, Glyn-Owen K, McPherson S, Parker R, Harris R, Yeoman A, Rowe IA, Dillon JF. Community pathways for the early detection and risk stratification of chronic liver disease: a narrative systematic review. Lancet Gastroenterol Hepatol 2022; 7:770-780. [PMID: 35525248 DOI: 10.1016/s2468-1253(22)00020-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
Patients with chronic liver disease are often diagnosed during an index presentation to hospital with decompensated cirrhosis or liver-related events, and these presentations are associated with high mortality. However, there is often a long asymptomatic phase, in which there is an opportunity for earlier diagnosis and interventions to prevent progression to advanced disease. Therefore, strategies for early diagnosis and interventions (including behavioural changes and pharmacological treatments) that prevent patients progressing to cirrhosis and its associated complications probably have substantial benefits for patients and health-care services. Many community pathways have been generated. Some pathways focus on abnormal liver function tests as a starting point to diagnose liver disease. Other pathways target groups at greater risk of chronic liver disease-particularly people with harmful alcohol consumption, type 2 diabetes, and obesity. This systematic review summarises the existing strategies available for the early detection or risk stratification of liver disease, focusing primarily on alcohol-related liver disease and non-alcoholic fatty liver disease. Conducting randomised clinical trials that compare different strategies will be essential to elucidate which pathways are acceptable to patients, feasible, provide high diagnostic accuracy for the detection of liver disease, improve liver-related outcomes, and are most cost-effective at the population level.
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Affiliation(s)
| | - Iain Macpherson
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Kate Glyn-Owen
- School of Primary Care, Population Science and Medical Education (PPM), Faculty of Medicine, University of Southampton, University Hospital Southampton, UK
| | - Stuart McPherson
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Liver Unit, Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Rebecca Harris
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Andrew Yeoman
- Aneurin Bevan University Health Board, Hepatology, Newport, UK
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, UK; Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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