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

Chalmers, Jane; Wilkes, Emilie; Harris, Rebecca; Kent, Lucy; Kinra, Sonali; Aithal, Guruprasad; Holmes, Mary; Johnson, Jeanette; Morling, Joanne; Guha, Indra Neil


Jane Chalmers

Emilie Wilkes

Lucy Kent

Sonali Kinra

Mary Holmes

Jeanette Johnson

Clinician Scientist Fellowin Public Health

Professor of Hepatology


© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. 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.


Chalmers, J., Wilkes, E., Harris, R., Kent, L., Kinra, S., Aithal, G., …Guha, I. N. (2020). Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community. Frontline Gastroenterology, 11(2), 86-92.

Journal Article Type Article
Acceptance Date Jun 4, 2019
Online Publication Date Jun 26, 2019
Publication Date 2020-03
Deposit Date Jun 11, 2019
Publicly Available Date Jul 10, 2019
Journal Frontline Gastroenterology
Print ISSN 2041-4137
Electronic ISSN 2041-4145
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 11
Issue 2
Pages 86-92
Public URL
Publisher URL


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