Pryke Rachel, Guha I Neil
Bewdley Medical Centre, Bewdley, UK.
NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.
J Hepatol. 2023 Mar;78(3):663-671. doi: 10.1016/j.jhep.2022.10.010. Epub 2022 Oct 23.
Addressing primary care's low confidence in detecting and managing chronic liver disease is becoming increasingly important owing to the escalating prevalence of its common lifestyle-related metabolic risk factors - obesity, physical inactivity, smoking and alcohol consumption. Whilst liver blood testing is frequently carried out in the management of long-term conditions, its interpretation is not typically focused on specific liver disease risk. Educational steps for primary care should outline how liver fibrosis is the flag of pathological concern, encourage use of pragmatic algorithms such as fibrosis-4 index to differentiate between those requiring referral for further fibrosis risk assessment and those who can be managed in the community, and emphasise that isolated minor liver function test abnormalities are unreliable for estimating the risk of fibrosis progression. Measures to increase primary care's interest and engagement should make use of existing frameworks for the management of long-term conditions, so that liver disease is considered alongside other metabolic disorders, including type 2 diabetes, cardiovascular disease, chronic kidney disease etc. Selling points when considering the required investment in developing local fibrosis assessment pathways include reduced repeat testing of minor abnormalities and improved secondary care referrals, plus improvements in the patient's journey through long-term multimorbidity care. A focus on improving chronic liver disease is likely to have wide-ranging benefits across co-existing metabolic disorders, particularly when pathways are aligned with community lifestyle support services. The important message for primary care is to increase the value of existing monitoring rather than to generate more work.
鉴于与生活方式相关的常见代谢危险因素——肥胖、缺乏身体活动、吸烟和饮酒的患病率不断上升，解决基层医疗在检测和管理慢性肝病方面信心不足的问题变得越来越重要。虽然在长期疾病管理中经常进行肝脏血液检测，但其解读通常并不侧重于特定的肝病风险。基层医疗的教育措施应概述肝纤维化是病理关注的标志，鼓励使用实用的算法，如纤维化-4指数，以区分那些需要转诊进行进一步纤维化风险评估的患者和那些可以在社区管理的患者，并强调孤立的轻微肝功能测试异常对于估计纤维化进展风险并不可靠。提高基层医疗兴趣和参与度的措施应利用现有的长期疾病管理框架，以便将肝病与其他代谢紊乱，包括2型糖尿病、心血管疾病、慢性肾病等一并考虑。在考虑为开发当地纤维化评估途径所需的投资时，卖点包括减少对轻微异常的重复检测和改善二级医疗转诊，以及改善患者在长期多重疾病护理中的就医过程。关注改善慢性肝病可能会给并存的代谢紊乱带来广泛益处，特别是当途径与社区生活方式支持服务保持一致时。给基层医疗的重要信息是提高现有监测的价值，而不是增加工作量。
