The Somerset Liver Improvement Programme (SLIP) was brought into being to tackle problems in the treatment of chronic (long term) liver disease. One of these was the sheer size of the problem of liver disease – 2000 patients per month having an abnormal liver blood test in our local area. In order to manage these patients, we had agreed protocols (including a pathway or flowchart for all doctors to follow if a patient had abnormal blood tests suggesting liver disease), but these were not being followed in many cases.
In addition to this we were all seeing patients who were both presenting late (that is with advanced, and often untreatable problems) and who had previously had multiple blood tests which could have led to an earlier diagnosis. Patients would say in clinic “but my GP has told me for years I have abnormal liver tests but ‘not to worry’” or patients would ask “could this have been diagnosed sooner” and a quick look back through our results system would lead to the answer “yes”! For some patients this was a major concern. For others this delay could turn out to be fatal, with opportunities for earlier treatment being missed. There was often a familiar pattern: blood tests were done for other health related reasons; these included liver tests as part of a routine panel of tests; and minor abnormalities on liver blood tests were not followed up on as the healthcare professional probably deemed (correctly) that there was no ‘immediate’ problem requiring attention. This pattern would then be repeated, over and over, for the same patient. Each time there would be a minor abnormality, but the existence of a chronic, underlying problem was not picked up on. GPs were not making bad decisions on the individual tests they received, it was only by putting these tests together when we saw the patient, often looking at blood tests going back 10-15 years, that the diagnosis became clearer.
At the same time, a new approach to diagnosis and treatment known as ‘case finding’ was being promoted nationally for one subset of liver patients – those with Hepatitis C virus. This chronic infection is often overlooked, but leads to long term liver damage. At the time the case finding approach was being promoted, newer and better treatments were becoming available, and it was increasingly worthwhile seeking out potential treatment candidates.
The idea was simple. Patients with Hepatitis C were all known to the Public Health databases. In addition, patients who had been treated were known within specialist pharmacy databases (in particular because the drugs are expensive, and all need to be logged on a patient by patient basis). So it was possible for NHS analysts to identify patients likely to have the condition but who hadn’t yet been treated. Whilst some of the identified patients would potentially have had treatment that was not recorded (e.g. other drugs used previously, or elsewhere) the list of potential patients could be refined and used by local teams to track down people and offer them treatment. So by using existing and available information, clinical teams were finding cases where they could make a positive intervention. All we did was suggest using this approach for the other chronic liver diseases which show up on routine blood tests!
Finally, the team agreed that the large number of people with abnormal blood tests was telling us important information about population health overall. Most of the ‘2000 per month’ identified as having abnormal tests probably didn’t need specialist treatment. Much research the world over has shown that these people (1:10 or thereabouts of the population) often have a condition known as NAFLD (non-alcoholic fatty liver disease). This needs a brief explanation. When a sample of liver (a biopsy) from a person who drinks too much alcohol is looked at down the microscope, the cells show excess fat storage. A very similar pattern is seen for patients who are overweight, sedentary, often with Type II Diabetes. In the past this caused confusion, with these individuals assumed to be covert drinkers of excess alcohol. This condition is much better understood now and well recognised. It comes under the umbrella of the ‘Metabolic Syndrome’, with associations as above, and also high blood cholesterol and lipid levels, and high blood pressure. This condition is now very common and increasingly is a reason for abnormal liver blood tests. Many of these patients will not need to see a liver specialist, but the liver abnormalities could be used to guide referral and treatment, and monitor both individual and population metabolic health.
My colleagues and I put all of this together in a proposal to our local hospital and named it the Somerset Liver Improvement Programme (SLIP). There were 3 main elements:
- Further promotion and implementation of our agreed liver pathway, engaging with GPs and others, and using IT to better enable use of the pathway
- Use the ‘case-finding’ approach for other chronic liver diseases (similar to the previous success with Hepatitis C)
- Use the data from liver tests to better signpost and engage patients with metabolic health problems, and use the data to better understand population metabolic health
Together these elements made up a very ambitious programme of work. It made a difference but given the constraints that the NHS was working under, didn’t realise its full potential. This is where Predictive Health Intelligence comes in: PHI is part of the solution for the second element of the project – ‘case finding for chronic liver disease’. I’ll talk about that more in the next blog.