Liver disease is the third leading cause of premature death in the UK, and the rate of death from chronic liver disease in the East Midlands has increased by over 60% in the last 20 years. The majority of liver disease results from lifestyle-related risk factors, and is therefore preventable. East Midlands AHSNs Scarred Liver Project is implementing a community-based liver pathway focused on risk factors, integrated care across primary and secondary care and novel diagnostic technologies using a non-invasive procedure.
Liver disease (cirrhosis) is the third leading cause of premature death in the UK, and the only one of the top five causes that is increasing. The majority of liver disease results from lifestyle-related risk factors (including excessive alcohol use, obesity and type 2 diabetes), and is therefore preventable. The rise in cirrhosis mortality in England and Wales is the steepest in Europe, with liver disease claiming 62,000 years of working life each year. Early diagnosis in primary care is vital, and current diagnostic algorithms are flawed in achieving this.
East Midlands Academic Health Science Network’s (EMAHSN) Scarred Liver Project is a diagnostic pathway which can detect significant chronic liver disease at a critical early stage, often with no apparent symptoms. Early detection means progress can be halted – or even reversed.
This pathway combines both the proactive identification of patients at risk of chronic liver disease. It uses proven non-invasive diagnostic tests (using a Fibroscan®) to detect liver disease earlier. It aims to provide an integrated pathway between primary and secondary care.
The pathway is picking up patients much earlier, with the ultimate aim of halting the condition or dramatically improving patient outcomes, as compared with current processes, which often lead to patients not being identified early enough for effective treatment. It has undergone a full health economic evaluation, and attracted interest from regional clinical commissioning groups (CCGs), which recently included the team facilitating the redesign of the liver disease pathway in one locality.
EMAHSN, working in partnership with the NIHR Nottingham Digestive Diseases Centre Biomedical Research Unit, has supported the pathway’s implementation at four sites across Nottingham, and one inner-city GP practice in Leicester.
EMAHSN has supported this project since 2013, in anticipation of expanding and replicating it across the East Midlands. The Scarred Liver Project won a 2013 NHS Innovation Challenge Prize which funded the pilot scheme, and has been awarded a fellowship as part of the NHS Innovation Accelerator programme.
EMAHSN funded the roll out of the pathway across multiple settings with differing socio-economic characteristics, and provided specialist expertise to support adoption and spread of the pathway into clinical practice. This includes health economics and translational research expertise which is informing the development of commissioning cases with local CCGs.
- Improving early diagnosis
- Care and Quality Gap
- Adoption and diffusion of innovation and research
- Spreading best practice.
In total, during implementation in Nottingham, diagnosis more than doubled for cirrhosis:
- 20,368 of the population analysed in Nottingham – 2,022 identified to be at risk.
- 6% (230) patients had signs of significant liver disease and 26 new cases of cirrhosis were identified – cases that would have otherwise gone undetected.
- Attendance rates for scans were 95% in the community versus 60% in hospital.
- More than 90% of patients stated that they would definitely recommend it to family and friends.
Inner-city Leicester results to date:
- 4,150 of the population analysed in inner-city Leicester.
- 1,320 identified to be at risk (in the Leicester phase, obesity was added as a risk factor alongside alcohol and diabetes, hence the higher risk identification rate in Leicester).
- 720 Leicester patients have been scanned so far, all of whom have received a brief lifestyle intervention to reduce their risk of developing liver disease (regardless of their scan result).
- 83 patients had signs of significant liver disease.
Overall summary and other impacts:
- A soon-to-be-published health economics report concludes that implementing this pathway provides better outcomes for patients with both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD), compared with standard care.
- Pathway costs are significantly within the NICE threshold of £20,000 per quality-adjusted life-year (QALY) at £2,138 per QALY for NAFDL and £6,537 per QALY for ALD.
- Currently supporting and working with one regional CCG in order to prepare a business case for implementing key elements of the pathway in their area.
- Dr Neil Guha was appointed an NHS Innovation Accelerator Fellowship in 2015.
- The project was a finalist in The University of Nottingham’s Knowledge Exchange and Impact Awards for Medicine 2016.
- Seek engagement early and help providers and commissioners understand the reasons for liver disease and associated costs.
- Trial the service in a small patch to start with and spread and embed with commissioners.
- Be flexible, certain elements of the pathway can be implemented, while others may not be.
- Working with NHS Nottingham City CCG and Nottingham University Hospitals NHS Trust to develop a commissioning case for the pathway.
- Securing primary and secondary care buy-in to implement the pathway in Chesterfield.
- Promoting the Scarred Liver Project diagnostic pathway to other East Midlands CCGs, and supporting the development of further commissioning cases where possible.
- Scoping a potential collaboration with Public Health England to deliver a media campaign designed to raise public awareness of liver disease.
- There are 12 million people nationally at risk – if scaled throughout England and Wales the pathway will identify these people. We would like to establish a road map to expanding the pathway from a regional to national service.
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2013 – present.