Primary care-based triage of steatotic liver diseases

Objective Non-invasive staging of fibrosis in steatotic liver disease (SLD) is an important step in identifying individuals most at risk. We developed and evaluated a pathway using the enhanced liver fibrosis (ELF) test to guide referrals to community hepatology (C-HEP) clinical review with a specialist hepatologist. Method This retrospective longitudinal cohort study compared the C-HEP pathway with the previously established referral pathway for suspected SLD. Individuals with ELF above a certain threshold went on to have liver stiffness measurement (LSM). LSM ≥12.5 kPa was considered to indicate advanced fibrosis and ≥20 kPa cirrhosis. In uncertain cases, patients were referred for liver biopsy and for these, the histological stage was used. Results In total, 882 patients were referred via the C-HEP pathway in 18 months and 571 met the threshold for clinical review. Of these, 421 (73.7%%) were deemed low risk, 77 (13.4%) had advanced fibrosis and 39 (6.8%) had cirrhosis. The cost per patient assessed on this pathway was £173.23 and the cost per case of advanced disease found was £1984.22. By comparison, in the standard referral pathway, 23.1% of patients were found to have advanced fibrosis and 15.9% had cirrhosis. The cost per patient seen was £457.36 and £1560.40 per case of advanced disease. Conclusion The Leeds Community Hepatology Pathway is a simple-to-use pathway to guide referral of patients with suspected SLD. Use of the ELF test with a threshold of 9.5 can triage appropriate referrals in a cost-effective manner. Further data regarding referral pathways will help to guide recommendations for effective management of the large number of individuals with SLD.