Only one-third of referrals for fatty liver disease are on time: real-world study reveals opportunities to avoid unnecessary and delayed referrals

Abstract

Background and aims

Fatty liver disease is a global health concern, but in the absence of specific guidelines, current referral patterns differ according to the preferences of the general practitioners. Outpatient Gastroenterology clinics spend futile resources on liver-healthy patients while diagnosing decompensated patients delayed. We aimed to describe referral patterns to a regional outpatient Gastroenterology clinic.

Methods

We reviewed 9684 referrals from primary care for suspected liver disease in the years 2016–2017, during two years. Data were extracted from the patients’ hospital records to assess the clinical workup and patient outcomes until a mean of 43 months after the time of referral. Referrals were categorized as unnecessary (no signs of liver disease), timely (significant fibrosis/compensated cirrhosis), or delayed (decompensated cirrhosis).

Results

We included 375 patient referrals from primary care. The main reason for referral was elevated transaminases. More than half (54%) of patients had no signs of liver disease, being unnecessarily referred for evaluation, while 17% had decompensated liver disease and were thus referred too late.

Conclusions

Only one-third of patients referred on suspicion of liver disease were referred on time, either before presenting with decompensated liver cirrhosis or with some evidence of significant liver disease, e.g., liver fibrosis. There is a huge unmet need for clinical referral pathways in primary care.

Strengths and Limitations of this Study

• A strength of this study is the complete mapping of all potential referrals to the outpatient clinic in the two-year period. Instead of retrieving the historic data by ICD-10 diagnosis codes, and reflecting only those patients where the GP clearly suspects liver disease, we have a strong reliance on our methods. We screened all potentially relevant referrals, e.g., referrals due to weight loss or fatigue, which may reflect symptoms of cirrhosis. Thereby we are confident that we have not missed any patients that originally were referred with unspecific symptoms, but after evaluation are diagnosed with liver disease.

• Another strength of our study is the long follow-up period, which allows us to fully evaluate the course for the individual patient, and the potential later coming diagnoses.

• Finally, it is a strength of the study that we were not exclusive to one liver disease etiology, both ALD and NAFLD etiology were included in the study.

• A limitation of this study is the use of historic data, and the fact that it is a single-center study, showing only the referral patterns in one outpatient Gastroenterology clinic.

Keywords:

• Liver fibrosis
• liver cirrhosis
• primary care
• referral patterns

Acknowledgments

The authors acknowledge Mette Mauritzen, medical secretary at the Department of Gastroenterology and Hepatology, Odense University Hospital, for her kind support in undertaking the initial data retrieval from the electronic health records. The authors also acknowledge Louise Skovborg Just, Peter Andersen and Vibeke Nielsen, administrative employees in the Department of Gastroenterology and Hepatology, Odense University Hospital.

Author contributions

AK, KL and MT designed the study. KL, CW and AA conducted the study in Denmark. KL, CW, MK, KT and MT drafted the article. All authors edited the article and approved the final manuscript. AK is the guarantor.

Ethics approval

The study was approved by the National Danish Board of Health (No. 3-3013-2432/1). The study adheres to the ethical guidelines of the 1975 Declaration of Helsinki.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Additional information

Funding

The study was funded by Innovation Fund Denmark (InnovationFund Denmark) Grant number: InnoExplorer grant 9122-00119 A), Ph.D. stipends from the University of Southern Denmark (Syddansk Universitet), and Ph.D. and postdoc stipends from the Region of Southern Denmark. The funders had no role in study design, data collection, analysis, decision to publish or preparation of the manuscript.