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Original research
Evaluation of a primary to secondary care referral pathway and novel nurse-led one-stop clinic for patients with suspected non-alcoholic fatty liver disease
  1. Andrew J Fowell1,
  2. Kirsty Fancey1,
  3. Karen Gamble1,
  4. Kelly Bicknell2,
  5. Joanna K Dowman1,
  6. Paul Howden3,
  7. Richard J Aspinall1
  1. 1 Department of Gastroenterology and Hepatology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
  2. 2 Department of Microbiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
  3. 3 NHS Fareham and Gosport Clinical Commissioning Group, Fareham, Hampshire, UK
  1. Correspondence to Dr Andrew J Fowell, Department of Gastroenterology and Hepatology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth PO6 3LY, UK; andrew.fowell{at}


Objective Non-alcoholic fatty liver disease (NAFLD) affects approximately one in four adults of the general population, with an important minority of cases at high risk of developing cirrhosis. We evaluated the utility of a primary care NAFLD pathway incorporating a specialist nurse-led NAFLD clinic and a two-step testing approach for advanced liver fibrosis.

Design/Method We performed a retrospective evaluation of prospectively collected demographic and clinical data on all patients diagnosed with NAFLD and intermediate NAFLD fibrosis score seen in our nurse-led NAFLD clinic between 1 May 2014 and 30 April 2017. Patients were assessed using a specific clerking pro forma and transient elastography (TE). Discharge to primary care with lifestyle advice was considered where TE<7.9 kPa.

Results 904 patients were identified, 114 (12.6%) of whom did not meet NAFLD criteria. Among the NAFLD population (n=790 (87.4%)), TE<7.9 kPa was present in 558 patients (70.6%), 519 of whom were discharged to primary care. Selected patients were followed up in secondary care despite TE<7.9 kPa or discharged with TE≥7.9 kPa. TE was unreliable in 22 patients (2.7%). Overall, 559 (70.8%) of patients with confirmed NAFLD were discharged from the nurse-led clinic. Introduction of the new pathway was associated with increased screening for hepatitis B and C viruses in primary care, and 17 new cases of alpha-1-antitrypsin deficiency were identified.

Conclusion An integrated primary/secondary care NAFLD pathway, including a specialist nurse-led clinic may be a useful way of managing increasing demand on secondary care hepatology services.

  • fatty liver
  • fibrosis
  • chronic liver disease
  • primary care
  • non-alcoholic steatohepatitis

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  • Contributors AJF, KF, KG, JKD, PH and RJA contributed to the design and implementation of the care pathway. AJF, KF, KG, KB, JKD and RJA contributed to the design of the service evaluation, the analysis of the results and the writing of the manuscript. PH reviewed and commented on the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved as a quality improvement project by the Portsmouth Hospitals NHS Trust Clincial Audit Department (approval ID 4241).

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

  • Data availability statement No data are available. Due to institutional restrictions, there are no data that can be shared. However, further information can be obtained from the corresponding author.