Quality statement 3 (developmental): Non-invasive testing for cirrhosis

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

Young people and adults with risk factors for cirrhosis are offered non‑invasive testing for cirrhosis.

Rationale

Cirrhosis may cause few or no symptoms and may not be identified until serious complications arise. Young people and adults with risk factors for cirrhosis should therefore be tested to find out if they have cirrhosis. Diagnosing cirrhosis will ensure that they get the treatment and support they need to manage their condition. Non‑invasive testing is more acceptable to people than a liver biopsy and can be done in an outpatient setting with the results available immediately.

Quality measures

Structure

a) Evidence of local availability of non-invasive testing for cirrhosis.

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

b) Evidence of local arrangements to ensure that young people and adults with risk factors for cirrhosis are offered non‑invasive testing for cirrhosis.

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

Process

a) Proportion of young people and adults who have been drinking alcohol in a harmful way for several months (for measurement purposes this could be at least 3 months) who receive non‑invasive testing for cirrhosis.

Numerator – the number in the denominator who receive non‑invasive testing for cirrhosis.

Denominator – the number of young people and adults who have been drinking alcohol in a harmful way for several months (for measurement purposes this could be at least 3 months).

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

b) Proportion of young people and adults diagnosed with hepatitis C virus infection who receive non‑invasive testing for cirrhosis.

Numerator – the number in the denominator who receive non‑invasive testing for cirrhosis.

Denominator – the number of young people and adults diagnosed with hepatitis C virus infection.

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

c) Proportion of adults newly referred for assessment for hepatitis B virus infection who receive non‑invasive testing for cirrhosis.

Numerator – the number in the denominator who receive non‑invasive testing for cirrhosis.

Denominator – the number of adults newly referred for assessment for hepatitis B virus infection.

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

d) Proportion of young people and adults diagnosed with alcohol‑related liver disease who receive non‑invasive testing for cirrhosis.

Numerator – the number in the denominator who receive non‑invasive testing for cirrhosis.

Denominator – the number of young people and adults diagnosed with alcohol‑related liver disease.

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

e) Proportion of young people and adults diagnosed with non‑alcoholic fatty liver disease with advanced liver fibrosis who receive non‑invasive testing for cirrhosis.

Numerator – the number in the denominator who receive non‑invasive testing for cirrhosis.

Denominator – the number of young people and adults diagnosed with non‑alcoholic fatty liver disease with advanced liver fibrosis.

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

Outcome

Incidence of cirrhosis.

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 hospitals) ensure that they offer non‑invasive testing for cirrhosis to young people and adults with risk factors for cirrhosis and give them information about the accuracy, limitations and risks of the different tests for diagnosing cirrhosis.

Healthcare professionals (such as GPs, gastroenterologists and hepatologists) offer non‑invasive testing for cirrhosis to young people and adults with risk factors for cirrhosis, and discuss the accuracy, limitations and risks of the different tests for diagnosing cirrhosis with them.

Commissioners (such as clinical commissioning groups and NHS England) commission non‑invasive testing for cirrhosis and ensure that providers offer it to young people and adults with risk factors for cirrhosis. They also ensure that providers give young people and adults with risk factors for cirrhosis information about the accuracy, limitations and risks of the different tests for diagnosing cirrhosis.

Young people and adults who have a risk of cirrhosis either because they drink alcohol in a harmful way, or they have hepatitis B or C, alcohol‑related liver disease or non‑alcoholic fatty liver disease with advanced fibrosis, are offered a scan to check for cirrhosis. If cirrhosis is found, they are offered advice and treatment.

Source guidance

Definitions of terms used in this quality statement

Young people and adults

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

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

Risk factors

Young people and adults have risk factors for cirrhosis if they:

  • drink alcohol in a harmful way, defined as more than 50 units of alcohol per week for men and more than 35 units per week for women, and have done so for several months or

  • have hepatitis C virus infection or

  • have been newly referred for assessment for hepatitis B virus infection (adults only) or

  • have been diagnosed with alcohol‑related liver disease or

  • have been diagnosed with non‑alcoholic fatty liver disease with advanced liver fibrosis.

[NICE's guideline on cirrhosis in over 16s, recommendations 1.1.3 and 1.1.4, and NICE's guideline on hepatitis B (chronic), recommendation 1.3.3]

Non-invasive testing for cirrhosis

Non-invasive testing for cirrhosis includes:

  • transient elastography (for all people with risk factors for cirrhosis) or

  • acoustic radiation force impulse imaging (for young people and adults with non‑alcoholic fatty liver disease and advanced liver fibrosis).

[NICE's guideline on cirrhosis in over 16s, recommendations 1.1.3 and 1.1.4, and NICE's guideline on hepatitis B (chronic), recommendation 1.3.3]

Equality and diversity considerations

Community outreach services should support young people and adults with risk factors for cirrhosis who are homeless or who inject drugs to enable them to have non‑invasive testing for cirrhosis.

Prisons should ensure that prisoners who have risk factors for cirrhosis are offered non‑invasive testing for cirrhosis.