The health economics and service process of management of chronic liver disease

Hepatic encephalopathy is associated with a poor prognosis and increased health resource utilisation, and until the advent of rifaxamin there had been no new treatment modality for many years. A real world study of resource use following initiation of rifaximin in 13 hospitals in the UK is reported in this edition of the journal. Published data to date has tended to come from specialist institutions, so this is an important study. Patients with hepatic encephalopathy can present in a variety of ways, so a comprehensive analysis needs to look at planned and unplanned admissions as well as liver-specific resource use. The data from this study should help provide data in negotiating clinical pathways with commissioners and service reimbursement officers, with a direct impact on patient care.

Another liver study in this edition of the journal by Sheridan et al1 uncovers the picture of the patient pathway in patients with suspected non-alcoholic fatty liver disease. It reveals that there is under-recognition of the condition even in high-risk populations (type II diabetes, overweight). The deficiencies are both in primary care investigation, but also secondary care utilisation of conservative therapies for the condition. The authors provide recommendations that may help to improve the standard of care for these patients.

It’s not so easy to ‘Be clear on cancer’

The Department of Health 2015 campaign to tackle oesophageal and gastric cancer, ‘Be Clear On Cancer’ targeted early diagnosis for these all too common cancers which are associated with a poor prognosis. The emphasis was on identifying dysphagia and – more challengingly – having heartburn most days, for three weeks or more. In this edition of Frontline Gastroenterology we include two papers evaluating the effect of the campaign in four local regions of the UK.2 3 While of course national level data is needed before deciding on the utility and practicality of widespread implementation of this initiative, this level of data from across different Trusts is of value. Rates of new diagnosis of cancer varied across regions, but as yet there is no data as yet on survival (rather than just diagnosis). In addition, it appears that there was an increase in routine waiting times for elective gastroscopies. The message of these data is that understanding of local populations and current endoscopy unit utilisation is essential in deciding whether to implement the “Be clear on cancer” campaign in one’s local area.

Managing nutrition and upper gastrointestinal dysfunction after cancer therapy

No institution is more associated with managing any one condition than the gastroenterology unit at the Royal Marsden for managing the gut complications of cncer therapy. In this edition of Frontline Gastroenterology we are delighted to complement our previous manuscript on management of lower gut symptoms by including a pathway of care by Andreyev et al4 on the topic of nutrition and upper gastrointestinal symptoms. This manuscript will prove highly useful for all in practice as it is set in the form of realistic clinic practice according to presenting symptom. There is a particular focus on the issue of nutrition which is often and variably compromised by chemo- and radio-therapy. The utility of questionnaires and objective assessment is emphasised in light of the proven poor value of symptom burden in identifying at-risk individuals. This patient group warrant investigation to identify reversible causes of dysfunction, and the stepwise, timely use of such investigation is emphasised. This manuscript is open access and we invite readers to download and print off these charts and tables to complement their practice.

Patient self-management of IBD: the use of the ‘flare card’

Patient self-care is an established core strategy in the management of irritable bowel syndrome, and is an area of increasing interest in inflammatory bowel disease (IBD). Squires et al5 report in the implementation of a strategy of a patient-held alert ‘flare’ card and cessation of follow-up appointments for IBD patients. In a selected group of patients the protocol was implemented and compared with a time and case matched cohort. The extraordinary data suggests that not only is there reduced serviced usage but also improved clinical outcomes. The case for developing local self-management protocols and prospectively studying outcomes could not be stronger. We would welcome such manuscripts – the challenge is careful patient selection, but the potential benefits warrant the effort.