How you can overcome the barriers to treating ARLD in primary and secondary care Slides by Stephen Ryder

1. How you can overcome the barriers
to treating ARLD in primary and
secondary care
Stephen Ryder
NIHR Biomedical Research Unit in
Gastrointestinal and Liver Diseases at
Nottingham University Hospitals NHS Trust and
The University of Nottingham

2. Dataset Updated
0
100
200
300
400
500
600
700
800
900
01/01/2008
01/04/2008
01/07/2008
01/10/2008
01/01/2009
01/04/2009
01/07/2009
01/10/2009
01/01/2010
01/04/2010
01/07/2010
01/10/2010
01/01/2011
01/04/2011
01/07/2011
01/10/2011
01/01/2012
01/04/2012
01/07/2012
01/10/2012
01/01/2013
01/04/2013
01/07/2013
01/10/2013
01/01/2014
01/04/2014
01/07/2014
01/10/2014
01/01/2015
01/04/2015
01/07/2015
01/10/2015
01/01/2016
01/04/2016
01/07/2016
01/10/2016
CountofPatients
Alcohol or Cirrhosis Diagnoses
Patients per Month
Had Cirrhoses
Had Procedure

3. Who dies from alcoholic liver disease
and where are potential therapeutic
interventions missed? An analysis of 755
deaths in a Health Community 2007-
2010
S Ryder, T Coles, K Bash, T Allen.
Nottingham University Hospitals NHS Trust and
Public Health Intelligence and Information NHS
Nottinghamshire County

4. Aims
1. Who dies from Alcohol Liver Disease?
2. What are possible points for healthcare
intervention efforts prior to death?
3. Communities where these people lived –
which ones carry disproportionate burden of
ALD deaths?

5. Methods
• Identified deaths in 2 PCT areas via death
certification, HES and hospital coding
• Looked at attendances in the years prior to
death
• Information from area of residence and
demography
• Data available from 2006 but complete from
2007

6. Results
• 755 deaths identified
• Primary or underlying cause of death recorded
as alcoholic liver disease

7. Deaths from ALD in Nottinghamshire

8. DSRs by Area of Residence
0
10
20
30
40
50
60
Newark and
Sherwood
Rushcliffe Bassetlaw Gedling Broxtowe Ashfield Mansfield Nottingham
Deaths from Alcohol Liver Disease 2007 - 2009
Annualized DSRs per 100,000 resident population

9. 0
5
10
15
20
25
30
35
40
45
Rushcliffe Broxtowe Gedling N&S Ashfield Bassetlaw Mansfield Nottingham
Ave IMD2007 Scores by Region
People died from ALD versus Ave LA ID 2007 Score (Higher score
reflects higher level of deprivation)
Sources: Data warehouse IMD 2007 scores and
Communities.gov.uk - LA Summaries ID 2007
Ave for ALD deaths Ave IMD score for district resident population

10. Impact on secondary care services
• 755 patients died from ALD
• 95% of these patients were admitted to
hospital prior to dying
–6,954 total admissions
–Average of 7.06 per patient in 5 years
prior to death
• 80% patients had A&E visits prior to dying
–1,215 total A& E visits

11. 0
100
200
300
400
500
600
<1 1 to 6 6 to 12
Numberofadmissions
No of admissions
No ALD

12. Digestive
Abnormal
signs/tests
Circulatory
Neoplasms
Injury/poisoning
Mental/behavioural
Disorder of blood
Other
32%
Diagnoses in previous admission

13. Place of death
• 72% hospital
• 24% home
• 0.13% hospice

14. Conclusions
• Mortality from ALD is high and liked to
deprivation
• High risk groups can be identified in
populations
• People who die from ALD have multiple
contacts with secondary care
• Only a minority have ALD recognised/coded

15. Why are mortality rates continuing to
rise?
• Identification of at risk population
• Interventions
• Tools to diagnose early
• Perceptions of healthcare workers and reality
of effectiveness of interventions
• Stigmatisation
• NHS and Social care structures

16. Identification of those at risk
• Primary care
• Secondary care
Q. Why is identification of high risk drinkers a key priority?
A. Because we have a highly effective intervention

18. What can we do: early diagnosis
• No reliable test for alcohol excess
• If we don’t ask we don’t find
• Primary care awareness of liver disease low
• Standard LFTs unhelpful

19. How good is alcohol screening in
primary care?
• No systematic data
• Ballets study

20. BALLETS study
• 8 practices in Birmingham
• 2006-2008
• Abnormal test in liver panel
• No symptoms of liver disease
• No history of liver disease/alcohol/ivdu
Armstrong MJ et al. J Hepatol 2012;56:234

21. Cause of Abnormal LFTs
• 54.9% had a cause
identified
0
5
10
15
20
25
30
35
40
45
50
NAFLD ALD Screen + unexplained

22. Potential solutions
• RCGP have identified liver disease as priority
area for primary care education (Dr Jez
Thompson) linked with Lancet commission
• Local solutions needed (STP/CCG)
• There are good models
– Nottingham City AUDIT C in all new registrations
– Local targets for alcohol/tobacco histories

23. 16/02/2017
The Scarred Liver Project: a novel diagnostic
pathway to detect significant liver disease in
the community
Harman DJ et al. BMJ Open2015;5:e007516
doi:10.1136/bmjopen-2014-007516
Direct targeting of risk factors significantly increases the
detection of liver cirrhosis in primary care: a cross-sectional
diagnostic study utilising transient elastography

24. Practice based screening for risk
• Four representative GP practices; >20,000 adult patients
– Initial pilot phase in 2 suburban GP centres
– Validation phase in 2 Inner City GP centres
• GP systems searched for codes for Type 2 DM and alcohol excess
• 12 % have risk factors for significant liver disease
• All invited for fibroscan

25. Novel community pathway
• Diagnostics performed in the community
• Point of care diagnostics in primary care
• Diagnostics/brief intervention delivered by nurses
• Specialists placed in the community
• Integrated primary and secondary care
• Hepatology clinics in primary care
McCorry et al., QIM 2012;
Dolman et al., Liv Int 2013

26. General Practice Population Risk Factors
Group Population Type 2
Diabetes
Alcohol
Practice A 7,612 304 522
Practice B 2,867 86 136
Practice C 6,412 391 482
Practice D 3,977 226 298
TOTAL 20,868 1,007 1,438

27. Changing our Approach to Liver Disease
Current approach:
•Lacks accuracy
•Late detection
•Hospital based
•Costly and invasive
Alternative approach:
•Focus on risk factors
•Early detection
•Community testing
•Cost saving
NHS innovations award winners 2013
BMJ team of the year finalists 2015

28. ALT Liver Enzyme Performance
• 68.3% of patients with elevated liver stiffness
had normal liver function enzymes
• 73.1% of patients with proven cirrhosis had
normal liver function enzymes

30. Secondary care: ED screening
• Key part of “every contact counts”
• Evidence base strong for identification and
brief advice
• Many models of how to implement

33. ED screening
• Many challenges to doing it
• Perception in staff that “extra task with no
reward”
• Perceived as complex and “no time for brief
advice”
• Client group are “unattractive as recipients of
care”
• No national data on brief advice in ED

34. Nottingham ED and screening
0
10
20
30
40
50
60
70
80
90
100
20062007200820092010201120122013201420152016
% SCREENED
CQUIN

35. Nottingham ED screening
• Two questions mandated:
– Have you drunk 6u or more on any occasion in the
last month?
– Was this attendance related to alcohol?
• Answers go back to GP
• Primary care to provide brief
advice/intervention
• Audit set up to see if it happens

36. Hospital beyond ED
• 50% of liver disease still presents with
decompensation
• Admissions increasing
• Must have appropriate services for patients
who get beyond ED

37. Alcohol liaison

38. Models for alcohol teams
Good community services
95%
Hospital Liaison

39. Nottingham model
• 5 WTE in reach (Framework)
• 1 WTE employed by the Trust
• All patients identified in Trust seen by ALN
assessed and referred into community
treatment as required
• Trust employee works on hepatology ward
and runs clinics with consultants
• 1 High volume service user (band 7) in ED

40. High Volume service user
• Identified “top 50” high volume users of ED
• Average number of ED attendances 36 per
year
• Average cost >£30,000
• Alcohol is the cause or a significant cofactor in
67%

41. High Volume Service Users
• ED nurse coordinates care
• MDT with community services-housing,
finances, medical
• Alert on hospital system flags any attendance
• Care plan available on hospital and
community systems
• Data sharing agreements (consent)

42. HVSU: impact
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300
400
500
600
Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14
Series2
Series1

43. Community care
• Range of services required
• Includes detoxification in-patient beds
(Mental Health Trust)
• About to have nursing facility for alcohol
related brain injury patients

44. Challenges in provision
• Commissioning fragmentation
• Retendering of services
• Public Health support vital to achieve anything
• Support from local government essential

45. Improving Liver Health in the East Midlands – A Call to Action
This report has been prepared by:
Ben Anderson, Ann Goodwin, Sean Meehan and Natalie Cantillon
– Public Health England East Midlands
In collaboration with:
Dr Stephen Ryder – Consultant Hepatologist, Nottingham University Hospitals and
Chair of East Midlands Clinical Liver Network
Jonathan Gribbin – Consultant in Public Health, Nottinghamshire County Council
East Midlands Directors of Public Health including Elaine Michel,
Lead for Alcohol and DPH Derbyshire County Council and Mike Sandys,
Lead for Obesity and DPH Leicestershire County Council.

46. RAID model
• Birmingham Mental Health Initiative
• Included alcohol services
• Attractive concept for some clients:
– Severe physical disease
– Told to go home and drink and access community
services
– Access to detox beds 3 months
– Not very helpful if you have cirrhosis

47. Cirrhosis and end of life care
0
20
40
60
80
100
120
0 5 10 15 20 25 30
Drinking
Not

48. Blue Light Project: treatment resistant
drinkers

53. Gaps in our knowledge
• Final order of priority of Alcohol-related Liver Disease questions,
agreed at James Lind Alliance Priority Setting Partnership
workshop 16 September 2016
• What are the most effective ways to help people with alcohol-
related liver disease stop drinking?
• What are the most effective ways of delivering healthcare
education and information about excessive alcohol consumption,
the warning signs and the risks of alcohol-related liver disease to
different demographics (including young people)?
• What is the most effective model of community-based care for
patients with alcohol-related liver disease?
• What is the patient's experience of alcohol-related liver disease?

54. • Do attitudes to perceived 'self-induced illness' amongst healthcare
professionals affect treatment, care provision and compassion for
individuals with alcohol-related liver disease?
• What are the most effective strategies to reduce the risk of alcohol-
related liver disease in heavy drinkers?
• Does the stigma associated with alcohol misuse affect the willingness of
people with alcohol-related liver disease to ask for help?
• What interventions improve survival in individuals with complications of
advanced alcohol-related cirrhosis?
• How should depression be managed in the context of alcohol-related
liver disease?
• What models of involvement of palliative care services in advanced
alcohol-related liver disease are most beneficial?