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GPs need more training to avoid missing liver disease

Late detection and high alcohol intake behind huge rise in liver morbidity and mortality

Louise Prime

Thursday, 27 November 2014

Knowledge and awareness of liver disease is poor in primary care in the UK and so people are not getting treatment early enough for it to have the best chance of being effective, say experts this morning. In their special report*, commissioned by The Lancet, they call for much better training and facilities in primary care and screening of high-risk patients.

They report that a lack of adequate diagnostic methods and training in the diagnosis and management of the early stages of liver disease means that presentation at hospital with end-stage liver disease is the first time that cirrhosis is detected for about three-quarters of patients – and unfortunately at this stage, there is ‘substantially reduced’ scope for interventions to reduce morbidity and mortality, they point out.

They argue that the often decades-long natural history of almost all liver diseases; the fact that they most commonly arise in highly recognisable at-risk groups; and the good success rates of treatment in disease detected early; should, in theory, make it easy to detect and manage them at an early stage. However, despite vast improvements in the UK over the past 30 years in health and life expectancy for other chronic disorders such as stroke, heart disease, and many cancers, mortality rates for liver disease have increased 400% since 1970, and by nearly five times in people younger than 65 years. They point out that liver disease is the third most common cause of premature death in the UK; and the rate of increase of liver disease is substantially higher in the UK than in other western European countries.

They write: “Increased engagement of primary care in the detection and management of the early stages of liver disease is imperative if this disease is to be detected at an early stage and those cases that are at risk of progressive disease are to be identified.

“The strong associations between risk factors for liver disease and mortality from other major diseases, such as hypertension and diabetes, that share common lifestyle risk factors and in which well-developed pathways of care are in place within general practitioner and community services, is not widely appreciated. We strongly recommend the inclusion of liver disease in this group.”

The report’s authors are also concerned about the role of increasing alcohol consumption – alcohol-related disorders result in more than a million admissions every year. They have found that both the number of admissions and the increase in mortality closely parallel the rise in alcohol consumption in the UK during the past three decades.

Dr Imran Rafi, chair of the Royal College of GPs' Clinical Innovation and Research Centre, welcomed the report’s recommendations. He told BBC News: "It is clear that more needs to be done to identify this condition as early as possible in adults – and to tackle the negative effects that alcohol consumption and obesity can have across society.

"With the resources available to us, it is difficult for GPs to identify liver disease in its early stages.

"So it is welcome that the report recognises the need for GPs and practice teams to have better access to diagnostic and screening tools.”

But he added: "Our influence is limited. It is politicians who need to act now and introduce measures to really make a difference."

The commission’s key recommendations include:

  • Strengthening the detection of early liver disease and its treatment by improving the level of expertise and facilities in primary care.
  • Improving support services in the community for screening high-risk patients.
  • Implementing a minimum price per unit, health warnings on alcohol packaging, and restriction of alcohol advertising and alcohol sales.
  • Promoting healthy lifestyles to reduce obesity.
  • Increasing the provision of medical and nursing training in hepatology and wider educational opportunities for health-care professionals to increase the number of doctors and nurses in hospitals and primary care.


* Roger Williams, at al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. The Lancet, Early Online Publication, 27 November 2014. doi:10.1016/S0140-6736(14)61838-9

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