Improving access to liver health nurses in primary care - can we improve the early detection of liver disease? Findings from the LOCATE study.

Problem

Chronic liver disease is an escalating problem both in the United Kingdom and worldwide. In the UK mortality rates have risen sharply over the previous 50 years predominantly due to alcohol, however the increasing prevalence of non-alcohol related fatty liver disease (NAFLD) both in the UK and elsewhere is also of concern. Liver disease develops silently hence early detection of fibrosis is essential to prevent progression. Primary care presents an opportunity to identify at risk populations, however assessment largely comprises of indirect markers of fibrosis such as liver function tests which have little prognostic value. We hypothesised that setting up nurse-led primary care based liver clinics using additional non-invasive testing would increase the number of new diagnoses of liver disease compared to usual care.

Approach

This was a prospective, cluster randomised feasibility trial based in urban primary care in the South of England. 10 GP practices were randomised to either intervention (liver health nurse) or control (care as usual.) Pre recruitment audits were carried out in each practice to ascertain baseline prevalence of liver disease. Participants were subsequently recruited in intervention practices from July 2014-March 2016 via one of 3 pathways: GP referral, nurse led case finding or random AUDIT questionnaire mailouts. Liver assessment included the Southampton Traffic Light test (serum fibrosis markers HA and P3NP) and transient elastography (FibroScan). Cases were ascribed as ‘no fibrosis’, ‘liver warning’, ‘progressive fibrosis’ or ‘cirrhosis’. Post recruitment audits were repeated and incident liver diagnoses captured from July 2014-September 2016. Each new diagnosis was reviewed in a virtual clinic by a consultant hepatologist and GP.

Findings

910 participants were seen in the nurse led clinic - 44 (4.8%) cirrhosis, 141 (15.5%) progressive fibrosis, 220 (24.2%) liver warning and 505 (55.5%) no evidence of liver fibrosis. 450 (49.5%) cases were due to NAFLD with 356 (39.1%) from alcohol. Nurse led case finding and GP referrals were most effective compared to AUDIT questionnaire mailouts in an urban population in identifying unknown disease: in the 405 with a liver disease diagnosis, 136 (33.6%) were referred by GP, 218 (53.8%) from nurse led case finding and 51 (12.6%) from the AUDIT mailout. 544 incident cases were identified overall in the intervention arm compared to 221 in the control arm in the period July 2014-September 2016 (OR 2.4, 95% CI 2.1 to 2.8).

Consequences

This study has shown that providing primary care clinical staff with access to additional technologies can greatly increase the number of early liver disease diagnoses. This can allow time for lifestyle modification, preventing the complications of advanced liver disease and associated healthcare costs. Additionally this study suggests that progressive liver disease may be safely excluded in primary care, potentially saving costs in onward referral and unnecessary further investigation.