Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community

OBJECTIVE: To describe the development of the Nottingham liver disease stratification pathway, present a 12-month evaluation of uptake and stratification results, and compare the pathway with current British Society of Gastroenterology (BSG) guidelines. DESIGN: A referral pathway between primary and secondary care for the detection and risk stratification of liver disease. SETTING: Four Nottinghamshire clinical commissioning groups (700 000 population). PATIENTS: Patients are referred to the pathway with (1) raised aspartate aminotransferase to alanine aminotransferase (AST:ALT) ratio, (2) harmful alcohol use or (3) risk or presence of non-alcoholic fatty liver disease (NAFLD). INTERVENTIONS: We report on clinic attendance within secondary care for transient elastography (TE) and brief lifestyle intervention. The TE result is reported back to the general practitioner with advice on interpretation and referral guidance. MAIN OUTCOME MEASURES: Pathway uptake, patient characteristics, liver disease stratification results and stakeholder feedback. RESULTS: Over the first 12 months 968 patients attended a TE clinic appointment, with raised AST:ALT ratio being the most common single reason for referral (36.9%). Of the total, 222 (22.9%) patients had an elevated liver stiffness (≥8 kPa), in whom 57 (25.7%) had a liver stiffness which was indicative of advanced chronic liver disease. If a traditional approach based on raised liver enzymes (BSG guidance) had been followed, 38.7% of those with significant liver disease (≥8 kPa) would have gone undetected among those referred for either NAFLD or raised AST:ALT ratio. CONCLUSIONS: Targeting patients with risk factors for chronic liver disease and stratifying them using TE can detect significant chronic liver disease above and beyond the approach based on liver enzyme elevation.