Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
Scand J Gastroenterol. 2022 Dec;57(12):1478-1485. doi: 10.1080/00365521.2022.2094725. Epub 2022 Jul 6.
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.
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).
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.
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 StudyA 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.
脂肪肝疾病是一个全球性的健康问题，但由于缺乏具体的指南，目前的转诊模式因全科医生的偏好而有所不同。门诊胃肠病学诊所浪费了大量资源在肝脏健康的患者身上，而错过了代偿失调患者的诊断时机。我们旨在描述向区域门诊胃肠病学诊所的转诊模式。
我们回顾了 2016-2017 年两年间来自初级保健的 9684 例疑似肝病患者的转诊，从患者的医院记录中提取数据，以评估临床检查结果和患者的预后，直到转诊后平均 43 个月。转诊被分为不必要（无肝病迹象）、及时（显著纤维化/代偿性肝硬化）或延迟（失代偿性肝硬化）。
我们纳入了来自初级保健的 375 例患者转诊。转诊的主要原因是转氨酶升高。超过一半（54%）的患者没有肝病迹象，被不必要地转来评估，而 17%的患者患有失代偿性肝病，因此转诊太迟。
只有三分之一的疑似肝病患者被及时转诊，要么在出现失代偿性肝硬化之前，要么在出现显著的肝病迹象之前，如肝纤维化。初级保健中对临床转诊途径的需求巨大，但未得到满足。本研究的优点和局限性本研究的一个优点是在两年期间完整地绘制了所有可能转诊到门诊诊所的路径。我们不是依靠 ICD-10 诊断代码检索历史数据，反映那些全科医生明显怀疑有肝病的患者，而是依靠我们的方法。我们筛选了所有潜在的相关转诊，例如因体重减轻或疲劳而转诊的患者，这些可能反映了肝硬化的症状。因此，我们有信心没有遗漏任何最初因非特异性症状而转诊，但在评估后被诊断为肝病的患者。我们研究的另一个优点是随访时间长，这使我们能够充分评估个体患者的病程，以及患者后来可能的诊断。最后，该研究的一个优点是它不仅包括酒精性肝病病因，还包括非酒精性脂肪性肝病病因。本研究的一个局限性是使用历史数据，以及这是一项单中心研究，仅显示了一个门诊胃肠病学诊所的转诊模式。
