Addressing health inequality in chronic liver disease by evolving community pathways in nottingham

Background

Ninety percent of chronic liver disease is caused by lifestyle related risk factors which are readily coded in electronic health records. Higher prevalence of these risk factors is associated with a lower socioeconomic status which is itself strongly associated with liver disease mortality. Nottingham City is the 11th most socioeconomically deprived of 317 districts nationally. The Nottingham and Nottinghamshire Integrated Care System (ICS) including Nottingham University Hospitals collaborated to address health inequality using a Population Health Management approach. We aimed to target specific Primary Care Networks (PCN) with high socioeconomic deprivation and risk factor prevalence to implement a novel community-based model to identify patients at risk of undiagnosed chronic liver disease.

Methods

Identification of adult patients (≥18 years) at high risk (hazardous alcohol use and/or Diabetes + BMI ≥30kg/m2) was completed using General Practice Repository for Clinical Care (GPRCC) via eHealthScope; a unique and secure online integrated database of primary, secondary and social care data of patients in Nottingham. Patients were excluded if known to have chronic liver disease, housebound, severely frail or receiving end of life care. At risk patients were invited to attend for a liver health check at a community location using transient elastography (TE). All patients received a brief lifestyle intervention.

Results

Across the ICS, 21055 patients were identified to be at high risk of liver disease. Nottingham City East PCN (population 66,800) was nominated as the first implementation site. 1057 patients were identified to be at risk (hazardous alcohol use = 152, Type 2 Diabetes and BMI ≥30kg/m2 = 905). Sixty two percent of the population within this PCN live in areas defined as the most deprived in England. Black and Minority Ethnic groups form 35% of the resident population. Three-hundred and forty patients (32.2%) attended and were risk stratified using TE. Forty-seven percent of this cohort were female, the average age was 59 years and 35.3% were of non-white ethnicity (Asian 20.0%, Black/African/Caribbean 10.6%, Mixed ethnicity 3.5%, other ethnic group 1.2%, White 62.7%, not recorded 2.0%). TE identified 79.4% (n=270) to be low risk (TE<8kPa), 15.9% (n=54) to be intermediate risk (TE 8–14.9kPa) and 4.7% (n=16) to be high risk (TE≥15kPa) (figure 1).

Conclusion

A collaborative partnership within a newly evolving health infrastructure (ICS) has enabled the development and implementation of a community pathway that directly addresses health inequality in the early diagnosis of chronic liver disease.