Elsevier

Journal of Hepatology

Volume 71, Issue 2, August 2019, Pages 371-378
Journal of Hepatology

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

https://doi.org/10.1016/j.jhep.2019.03.033Get rights and content
Under a Creative Commons license
open access

Highlights

  • Established blood tests can be used in primary care to stratify patients with fatty liver disease.

  • A 2-step pathway (FIB-4 followed by ELF™ if required) reduced unnecessary referrals by 80%.

  • This pathway also improved the detection of cases of advanced fibrosis 5-fold and cirrhosis 3-fold.

  • This pathway can be used in primary care to identify patients who might benefit from referral to liver specialists.

  • This should reduce unnecessary referrals while at the same time improving the detection of 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% 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.

Keywords

FIB-4
ELF
Steatohepatitis
Non-invasive fibrosis test
Cirrhosis
Cost effectiveness
Clinical management
NAFLD

Cited by (0)

Joint senior authors.