Quality statement 2 (developmental): Testing for advanced liver fibrosis

Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People with non‑alcoholic fatty liver disease are offered regular testing for advanced liver fibrosis.

Rationale

There is a risk that non‑alcoholic fatty liver disease (NAFLD) will progress to fibrosis and then to cirrhosis. Regular testing for advanced liver fibrosis for people with NAFLD will enable those at high risk of disease progression to be identified so that they can receive advice, treatment and regular monitoring. Regular testing will also reduce unnecessary referrals or further testing for people who are at low risk of disease progression.

Young people and adults with NAFLD should be offered testing in primary care, and referred to a specialist in hepatology if advanced liver fibrosis is diagnosed. Children with NAFLD who are diagnosed with advanced liver fibrosis should already be supported by a paediatric specialist in hepatology in tertiary care.

Quality measures

Structure

a) Evidence of local referral pathways to ensure that people with NAFLD are offered regular testing for advanced liver fibrosis.

Data source: Local data collection, for example, service protocol.

b) Evidence that GP practices and paediatric hepatology services have arrangements to offer regular testing for advanced liver fibrosis to people with NAFLD.

Data source: Local data collection, for example, service protocol.

Process

a) Proportion of people newly diagnosed with NAFLD who are tested for advanced liver fibrosis.

Numerator – the number in the denominator who are tested for advanced liver fibrosis.

Denominator – the number of people newly diagnosed with NAFLD.

Data source: Local data collection, for example, audit of patient health records.

b) Proportion of adults with NAFLD identified as having a low risk of advanced liver fibrosis (such as an enhanced liver fibrosis [ELF] score below 10.51) who were tested for advanced liver fibrosis within the past 3 years.

Numerator – the number in the denominator who were tested for advanced liver fibrosis within the past 3 years.

Denominator – the number of adults with NAFLD identified as having a low risk of advanced liver fibrosis (such as an ELF score below 10.51).

Data source: Local data collection, for example, audit of patient health records.

c) Proportion of children and young people with NAFLD identified as having a low risk of advanced liver fibrosis (such as an ELF score below 10.51) who were tested for advanced liver fibrosis within the past 2 years.

Numerator – the number in the denominator who were tested for advanced liver fibrosis within the past 2 years.

Denominator – the number of children and young people with NAFLD identified as having a low risk of advanced liver fibrosis (such as an ELF score below 10.51).

Data source: Local data collection, for example, audit of patient health records.

Outcome

a) Inappropriate referrals to a specialist for young people and adults with NAFLD.

Data source: Local data collection, for example, audit of patient health records.

b) Incidence of advanced liver fibrosis in people with NAFLD.

Data source: Local data collection, for example, audit of patient health records.

What the quality statement means for different audiences

Service providers (such as general practices and tertiary paediatric hepatology services) ensure that processes are in place to offer regular testing for advanced liver fibrosis to people with NAFLD. They should ensure that young people and adults diagnosed with advanced liver fibrosis are referred to a specialist in hepatology, and that children diagnosed with advanced liver fibrosis are cared for by a tertiary paediatric hepatology service.

Healthcare professionals (such as GPs and paediatric hepatologists) offer regular testing for advanced liver fibrosis to people with NAFLD. GPs refer young people and adults diagnosed with advanced liver fibrosis to a specialist in hepatology. Paediatric hepatologists continue to care for children diagnosed with advanced liver fibrosis.

Commissioners (such as clinical commissioning groups and NHS England) commission testing for advanced liver fibrosis for people with NAFLD. Commissioners ensure that providers offer testing and re-testing for advanced liver fibrosis to young people and adults with NAFLD and that there is sufficient capacity in hepatology services to meet expected demand for referrals for people diagnosed with advanced liver fibrosis. Commissioners ensure that tertiary paediatric hepatology services have capacity to support children diagnosed with advanced liver fibrosis.

People with non-alcoholic fatty liver disease have a test to check if their liver is scarred every 3 years, or every 2 years if they are aged under 18. If the test shows that their liver is scarred, they are referred to a specialist in hepatology for further advice, treatment and check-ups, or cared for by a paediatric specialist in hepatology if they are under 16.

Source guidance

Non-alcoholic fatty liver disease (NAFLD): assessment and management (2016) NICE guideline NG49, recommendations 1.2.1 and 1.2.7

Definitions of terms used in this quality statement

Regular testing for advanced liver fibrosis

Testing for advanced liver fibrosis, for example with the enhanced liver fibrosis (ELF) test, should be offered to adults every 3 years and to children and young people every 2 years.

[NICE's guideline on non-alcoholic fatty liver disease, recommendations 1.2.2, 1.2.7 and 1.2.8]

Advanced liver fibrosis

A grade of F3 or above using the Kleiner (NASH-CRN) or the steatosis, activity and fibrosis (SAF) score. This is referred to as bridging fibrosis (the presence of fibrosis linking hepatic veins to portal tracts).

[NICE's guideline on non-alcoholic fatty liver disease]

Children, young people and adults

Children are aged under 16. Young people are aged 16 and 17. Adults are aged over 18.

[NICE's guideline on non-alcoholic fatty liver disease]