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Original research
Development and implementation of a commissioned pathway for the identification and stratification of liver disease in the community
  1. Jane Chalmers1,2,
  2. Emilie Wilkes1,2,
  3. Rebecca Harris1,2,
  4. Lucy Kent3,
  5. Sonali Kinra1,4,
  6. Guru Aithal1,2,
  7. Mary Holmes1,
  8. Jeanette Johnson1,
  9. Joanne Morling1,5,
  10. Indra Neil Guha1,2
  1. 1 NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
  2. 2 Nottingham Digestive Diseases Centre, Nottingham, UK
  3. 3 Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Grimsby, Lincolnshire, UK
  4. 4 Greater Nottingham Clinical Commissioning Group, Nottingham, UK
  5. 5 Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr Indra Neil Guha, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK; neil.guha{at}


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.

  • liver function test
  • fatty liver
  • alcoholic liver disease

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  • JC and EW are joint first authors.

  • JM and ING are joint senior authors.

  • Contributors NG, EW, SK and GA were involved in the conceptual design of the pathway. Data collection was done by MH, JJ, JC, RH and LK. JC, JM and NG analysed and interpreted the data for this evaluation. JC, JM and NG developed the concept for the manuscript and produced the first draft, with critical review and revision from EW, SK, GA, MH, RH and JJ.

  • Funding JC, EW, RH, GA and NG are supported by the Gastrointestinal and Liver Disorder theme of the NIHR Nottingham Biomedical Research Centre (reference no: BRC-1215-20003). JM is supported by a 4-year MRC Clinician Scientist Fellowship and as such this work was supported by the Medical Research Council [grant number MR/P008348/1]. Funding for the Nottingham liver disease stratification pathway has also been received from the East Midlands Academic Health Science Network.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethical approval This body of work is written as a service evaluation piece, and as such ethical approval was not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data from this work are only relevant to the local trust and as such will not be available to others. Information and resources related to the Nottingham liver disease stratification pathway can be found at

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