In Practice with Dr. Denver: Liver Disease, Deprivation & Late Diagnosis

Liver disease is one of the clearest examples of health inequality within the UK.

Unlike many other major diseases, liver-related mortality continues to rise, with the burden falling disproportionately on the most deprived communities (1). Across England, the prevalence of liver disease is estimated to be approximately five times higher in the most deprived populations compared with the least deprived (1).

This inequality is also reflected in mortality data. Premature liver-related mortality is approximately twice as high in the lowest deprivation deciles (Index of Multiple Deprivation (IMD) 1–2) compared with the least deprived populations (2).

Reducing these inequalities is now a stated NHS priority. The NHS Core20PLUS5 framework specifically identifies the most deprived 20% of the population as requiring targeted intervention to address widening health outcome disparities (3).

Understanding how deprivation influences liver disease presentation, diagnosis, and outcomes is therefore critical to improving population liver health.

Why Liver Disease Is Still Diagnosed Late

Chronic liver disease frequently develops silently over many years. Patients are often asymptomatic until advanced fibrosis, cirrhosis, hepatic decompensation, or hepatocellular carcinoma are already established.

Diagnosis is further complicated by the interpretive complexity of liver function tests, which may fluctuate over time and are often considered in isolation rather than longitudinally (see previous writings on cumulative liver damage index “CLDI”).

As a result, many patients continue to present late in the disease course, limiting opportunities for prevention and early intervention.

Importantly, this burden is not evenly distributed across society. Deprivation is recognised as an independent determinant of both late presentation and poorer liver-related outcomes (4).

This pattern reflects the continuing relevance of the Inverse Care Law, whereby those with the greatest healthcare need are often the least likely to access timely care (5). Patients from more deprived communities consistently demonstrate:

• Lower rates of routine health screening.
• Fewer primary care interactions.
• Reduced engagement with preventative healthcare.
• Delayed presentation with early or non-specific symptoms.

The consequence is that people from lower IMD groups have more advanced disease at diagnosis and poorer long-term outcomes.

How Deprivation Influences Liver Disease Outcomes

The impact of deprivation extends beyond presentation alone. Social determinants of health (SDoH) continue to influence outcomes throughout the liver disease care pathway.

A 2024 systematic review published in the American Journal of Gastroenterology demonstrated that social disadvantage significantly affects chronic liver disease outcomes, including mortality, hospitalisation rates, and readmission frequency (6).

Patients from disadvantaged backgrounds also face substantial barriers to specialist care, including within transplant pathways.

More recent evidence further reinforces this relationship. A 2026 study by Danpanichkul et al. evaluating cardiovascular and liver outcomes in alcohol-associated liver disease demonstrated significantly increased risks of acute complications among socially deprived patients, including:

• Major adverse cardiovascular events (MACE).
• Arrhythmia.
• Alcohol-associated hepatitis.
• Sepsis (7).

These findings highlight that deprivation is not only associated with liver disease prevalence but also influences severity, complications, and outcomes.

Can case-finding address the inequality gap and deliver early diagnosis?

Traditional approaches to liver disease diagnosis remain largely reactive and symptom-driven. This creates an inherent disadvantage for populations less likely to engage with healthcare systems early, and is particularly dangerous in asymptomatic conditions.

Predictive Health Intelligence‘s data-driven case-finding may offer an alternative approach.

In Somerset, a novel biomarker-based case-finding programme used routinely collected NHS laboratory data to identify individuals at risk of chronic liver disease.

Our hepatoSIGHT® platform applied mathematical algorithms to stratify risk in individuals aged 30–65 years using:

• Persistently raised ALT.
• FIB-4.
• Cumulative Liver Damage Index (CLDI™), representing the integral of ALT over time.

Index of Multiple Deprivation analyses compared individuals from IMD 1–2 populations with the wider Somerset population.

Importantly, individuals in IMD 1–2 communities had, on average, 19.5% more blood tests performed than individuals from less deprived areas (8).

While overall chronic liver disease prevalence appeared similar across the population, patients from deprived communities demonstrated significantly more biomarker patterns consistent with fibrosis and hepatic decompensation (8).

These findings are important for two reasons:

1. They demonstrate that deprived populations are already interacting with healthcare systems and generating clinically valuable biomarker data.
2. They suggest that biomarker-based case-finding does not exclude deprived populations, rather it may actively help identify them earlier.

Conclusion

Liver disease disproportionately affects deprived communities at every stage of the patient pathway, from access to early diagnosis through to long-term outcomes.

Current reactive approaches continue to identify many patients only once advanced disease is established.

Biomarker-driven case-finding represents a potential opportunity to shift towards earlier, more equitable identification of chronic liver disease using data that already exists within NHS systems.

Moving from reactive, symptom-driven diagnosis towards proactive, data-driven population health approaches may therefore represent an important step in narrowing the liver disease inequality gap within the communities most at risk.

References

1. British Liver Trust. “Liver Disease in Numbers – Key Facts and Statistics.” British Liver Trust, 2024, britishlivertrust.org.uk/information-and-support/statistics/.
2. Office. “Public Health Outcomes Framework: February 2026 Data Update.” GOV.UK, 3 Feb. 2026, www.gov.uk/government/statistics/public-health-outcomes-framework-february-2026-data-update.
3. NHS England. “Core20PLUS5 an Approach to Reducing Health Inequalities.” NHS England, 1 Nov. 2021, www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5/.
4. Vaz, Juan, et al. “Excess Mortality from Cirrhosis by Neighbourhood Deprivation, Aetiology, and Clinical Presentation: A Swedish Register-Based Cohort Study.” EClinicalMedicine, vol. 94, 2026, p. 103830. https://doi.org/10.1016/j.eclinm.2026.103830.
5. Watt, Graham. “The Inverse Care Law Revisited: A Continuing Blot on the Record of the National Health Service.” British Journal of General Practice, vol. 68, no. 677, 2018, pp. 562–563. https://doi.org/10.3399/bjgp18X699893.
6. Hasjim, Bima J, et al. “Social Disadvantage and Disparities in Chronic Liver Disease: A Systematic Review.” The American Journal of Gastroenterology, 2024. https://doi.org/10.14309/ajg.0000000000003171.
7. Danpanichkul, Pojsakorn, et al. “Liver, Cardiovascular and Infectious Outcomes in Alcohol-Associated Liver Disease with Cardiometabolic Risk Factors.” Liver International, vol. 46, no. 4, 2026, p. e70575. https://doi.org/10.1111/liv.70575.
8. Creamer, John, et al. “P95 a Novel Case Finding Database Can Be Utilised to Identify and Target Individuals in Areas of Deprivation at Risk of Advanced Liver Disease.” Poster Presentations, 2023. https://doi.org/10.1136/gutjnl-2023-basl.110.