Defining and evaluating care for liver disease in UK Primary Care

Abstract

Liver disease is an increasingly common cause of premature morbidity and mortality in the UK, primarily driven by alcohol (alcohol related liver disease (ALD)) and obesity (metabolic-dysfunction associated steatotic liver disease (MASLD), previously termed non-alcohol related fatty liver disease (NAFLD)). It is often diagnosed at the stage of decompensated cirrhosis, when interventions are less effective and mortality rates are very high. There are currently no standardised pathways of chronic disease management for patients with liver disease in UK primary care, limiting the potential for early detection and intervention. Using a step-wise approach, this programme of work aimed to determine how best to deliver detection strategies for liver disease in the primary care setting. The six publications described in this thesis focus on four objectives, which were to: a) Define who is at risk of common chronic liver disease in the unselected general population; b) i Review current, UK community pathways of care for chronic liver disease; c) Explore the experiences of primary care practitioners in managing liver disease and d) Contribute to designing and implementing a primary care strategy for detection and management of liver disease. A mix of methods were used to address these aims. Two systematic reviews of evidence from observational studies reported that most evidence on the metabolic risk factors for significant liver outcomes related to type two diabetes and obesity. Diabetes was found to more than double the risk of significant liver disease in MASLD. A narrative synthesis on the effect of moderate alcohol consumption in MASLD suggested that no safe level of alcohol could be recommended. An evidence review and national survey of current commissioning practice found stark inequalities in the provision of diagnostic tests and pathways of care for liver disease across the UK, with most areas having no pathways of care. Qualitative methods were used to explore the perceptions of general practitioners. They had little confidence in their own ability to manage liver disease, which they judged to be of low priority and high complexity. Further interviews with primary care practitioners guided by Normalisation Process Theory (NPT), elicited recommendations for implementation with incentivised, legitimate frameworks, and integration within other long term condition management. This research has contributed to a wider primary care strategy to detect and manage liver disease in practices in the North East of England. This is currently being piloted. Quantifying and researching the implementation outcomes of this strategy using a validated survey and interviews with health care practitioners and patients to guide national implementation will form the basis of my post-doctoral research.