Shared learning database

Frimley Park Hospital NHS Foundation Trust
Published date:
May 2013

Transient elastography is a non-invasive technique that uses both ultrasound and low-frequency elastic waves to quantify liver fibrosis. This example shows how we introduced the technology to our trust. There is a sample business case attached - this is not from our trust.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Our objective was to improve the management of liver disease.

To achieve this we had 4 aims:
1. Early and improved identification of fibrosis/cirrhosis in patients attending gastroenterology/hepatology/infectious diseases outpatients.
2. Risk stratification for patients at risk of progressing to cirrhosis.
3. Enhance management of patients with liver disease.
4. Improve outcomes with early discharge from out-patient services.

Reasons for implementing your project

NICE recommends that adults with chronic hepatitis B are offered transient elastography as the initial test for liver disease when newly referred for assessment, and that the test be repeated annually for those who are not taking anti-viral treatment. Adults with a transient elastography score <6 kPa are unlikely to have significant fibrosis. Adults with a transient elastography score <11 kPa are very likely to have cirrhosis and confirmation by liver biopsy is not needed before starting anti-viral treatment. For those people with a transient elastography score between 6 to 10 kPa, the degree of fibrosis cannot be accurately predicted and therefore some people may choose to have a liver biopsy in these circumstances to confirm the extent of liver disease. Prior to the initiative fibrosis was detected using liver biopsy, a procedure which has significant morbidity (pain 33%, significant bleeding 0.5%) and mortality (3-4/1000). Patients also require repeated biopsy at 3-5 year intervals if treatment is unsuccessful. Patients diagnosed with cirrhosis at liver biopsy require 6-monthly ultrasound screening for hepatocellular carcinoma and 1-2 yearly upper GI endoscopy to screen for varices. There was a need for a transient elastography service for a number of important reasons:
- Many patients did not want to have liver biopsy because of the risk and discomfort involved.
- Waiting times for ultrasound guided percutaneous biopsy and reporting times significantly increased.
- Patients are invariably worried about their liver biopsy.
- Avoiding a liver biopsy will remove the need for day case admission and monitoring. - In the 'marginal cases' a clinician may opt for transient elastography, to help make an instant decision, for example, cirrhosis vs non cirrhosis.

Before implementing the change we reviewed the published literature from the evidence base and performed a baseline assessment of annual liver biopsy performed, complications from liver biopsies and bed occupancy.

How did you implement the project

We identified several opportunities for improving efficiency, saving costs or increasing productivity.
These were:
- Waiting times for initiating therapy improved, for example, antiviral therapy.
- Cost saving from reducing liver biopsies and bed occupancy.
- Saving time, money and monitoring associated with performing liver biopsies.
- Potential financial gains from offering a transient elastography service.
- Improved positioning when competitively bidding for business from Clinical Commissioning Groups and other sources.

In order to implement we needed to identify space for the equipment and staff in outpatients to carry out the scan. This required training staff to use the equipment and has enhanced training of Specialist Registrars rotating through the unit.

After the initial purchasing of the equipment, there are on-going costs of for annual maintenance, and aqueous gel used during the scan.

Key findings

The main results showed early diagnosis of hepatic fibrosis and cirrhosis. For some patients diagnosed early with hepatic fibrosis, cirrhosis was either prevented or delayed. Patients in whom cirrhosis is identified are entered into a screening programme for hepatocellular carcinoma and varices, which aims to decrease the morbidity and mortality of these conditions. Long-term financial gains from the early diagnosis of cirrhosis with implementation of screening protocols should lead to a decrease in hospital admissions for these patients in the future.

Key learning points

- Overall reduction in costs to NHS and NHS Technology Adoption Centre (NTAC).
- Reduction in net costs for the Trust.
- Increased number of patients treated.
- Improvement in patient experience and patient safety.
- Reducing the risks to patients and anxiety of patient.
- Simplifying and improving the efficiency of the patient journey.

Contact details

Professor Aftab Ala PhD FRCP
Consultant Gastroenterologist and Hepatologist; NIHR Lead Hepatology Surrey and Sussex
Frimley Park Hospital NHS Foundation Trust

Primary care
Is the example industry-sponsored in any way?