Dataset Information

What is the best strategy for investigating abnormal liver function tests in primary care? Implications from a prospective study.

ABSTRACT:

Objective

Evaluation of predictive value of liver function tests (LFTs) for the detection of liver-related disease in primary care.

Design

A prospective observational study.

Setting

11 UK primary care practices.

Participants

Patients (n=1290) with an abnormal eight-panel LFT (but no previously diagnosed liver disease).

Main outcome measures

Patients were investigated by recording clinical features, and repeating LFTs, specific tests for individual liver diseases, and abdominal ultrasound scan. Patients were characterised as having: hepatocellular disease; biliary disease; tumours of the hepato-biliary system and none of the above. The relationship between LFT results and disease categories was evaluated by stepwise regression and logistic discrimination, with adjustment for demographic and clinical factors. True and False Positives generated by all possible LFT combinations were compared with a view towards optimising the choice of analytes in the routine LFT panel.

Results

Regression methods showed that alanine aminotransferase (ALT) was associated with hepatocellular disease (32 patients), while alkaline phosphatase (ALP) was associated with biliary disease (12 patients) and tumours of the hepatobiliary system (9 patients). A restricted panel of ALT and ALP was an efficient choice of analytes, comparing favourably with the complete panel of eight analytes, provided that 48 False Positives can be tolerated to obtain one additional True Positive. Repeating a complete panel in response to an abnormal reading is not the optimal strategy.

Conclusions

The LFT panel can be restricted to ALT and ALP when the purpose of testing is to exclude liver disease in primary care.

SUBMITTER: Lilford RJ

PROVIDER: S-EPMC3686167 | biostudies-literature | 2013 Jun

REPOSITORIES: biostudies-literature

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Publications

What is the best strategy for investigating abnormal liver function tests in primary care? Implications from a prospective study.

Lilford Richard J RJ Bentham Louise M LM Armstrong Matthew J MJ Neuberger James J Girling Alan J AJ

BMJ open 20130620 6

<h4>Objective</h4>Evaluation of predictive value of liver function tests (LFTs) for the detection of liver-related disease in primary care.<h4>Design</h4>A prospective observational study.<h4>Setting</h4>11 UK primary care practices.<h4>Participants</h4>Patients (n=1290) with an abnormal eight-panel LFT (but no previously diagnosed liver disease).<h4>Main outcome measures</h4>Patients were investigated by recording clinical features, and repeating LFTs, specific tests for individual liver diseas ...[more]

PMID: 23794594

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Project description:BackgroundLiver function tests (LFTs) are routinely performed in primary care, and are often the gateway to further invasive and/or expensive investigations. Little is known of the consequences in people with an initial abnormal liver function (ALF) test in primary care and with no obvious liver disease. Further investigations may be dangerous for the patient and expensive for Health Services. The aims of this study are to determine the natural history of abnormalities in LFTs before overt liver disease presents in the population and identify those who require minimal further investigations with the potential for reduction in NHS costs.Methods/designA population-based retrospective cohort study will follow up all those who have had an incident liver function test (LFT) in primary care to subsequent liver disease or mortality over a period of 15 years (approx. 2.3 million tests in 99,000 people). The study is set in Primary Care in the region of Tayside, Scotland (pop approx. 429,000) between 1989 and 2003. The target population consists of patients with no recorded clinical signs or symptoms of liver disease and registered with a GP. The health technologies being assessed are LFTs, viral and auto-antibody tests, ultrasound, CT, MRI and liver biopsy. The study will utilise the Epidemiology of Liver Disease In Tayside (ELDIT) database to determine the outcomes of liver disease. These are based on hospital admission data (Scottish Morbidity Record 1), dispensed medication records, death certificates, and examination of medical records from Tayside hospitals. A sample of patients (n = 150) with recent initial ALF tests or invitation to biopsy will complete questionnaires to obtain quality of life data and anxiety measures. Cost-effectiveness and cost utility Markov model analyses will be performed from health service and patient perspectives using standard NHS costs. The findings will also be used to develop a computerised clinical decision support tool.DiscussionThe results of this study will be widely disseminated to primary care, as well as G.I. hospital specialists through publications and presentations at local and national meetings and the project website. This will facilitate optimal decision-making both for the benefit of the patient and the National Health Service.

Project description:BackgroundEffective infectious disease control requires early diagnosis and treatment initiation. Point-of-care testing offers rapid turn-around-times, facilitating same day clinical management decisions. To maximize the benefits of such POC testing programs, we need to understand how rapid tests are used in everyday clinical practice.MethodsIn this cross-sectional survey study, 400 primary healthcare providers in two cities in South Africa were interviewed on their use of rapid tests in general, and tuberculosis diagnostic practices, between September 2012 and June 2013. Public healthcare facilities were selected using probability-sampling techniques and private healthcare providers were randomly selected from the Health Professional Council of South Africa list. To ascertain differences between the two healthcare sectors 2-sample z-tests were used to compare sample proportions.ResultsThe numbers of providers interviewed were equally distributed between the public (n = 200) and private sector (n = 200). The most frequently reported tests in the private sector include blood pressure (99.5%), glucose finger prick (89.5%) and urine dipstick (38.5%); and in the public sector were pregnancy (100%), urine dipstick (100%), blood pressure (100%), glucose finger prick (99%) and HIV rapid test (98%). The majority of TB testing occurs in the public sector, where significantly more providers prefer Xpert MTB/RIF assay, the designated clinical TB diagnostic tool by the national TB program, as compared to the private sector (87% versus 71%, p-value >0.0001). Challenges with regard to TB diagnosis included the long laboratory turn-around-time, difficulty in obtaining sputum samples and lost results. All providers indicated that a new POC test for TB should be rapid and cheap, have good sensitivity and specificity, ease of sample acquisition, detect drug-resistance and work in HIV-infected persons.Conclusion/significanceThe existing centralized laboratory services, poor quality assurance, and lack of staff capacity deter the use of more rapid tests at POC. Further research into the practices and choices of these providers is necessary to aid the development of new POC tests.

Dataset Information

What is the best strategy for investigating abnormal liver function tests in primary care? Implications from a prospective study.

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusions

Publications

What is the best strategy for investigating abnormal liver function tests in primary care? Implications from a prospective study.

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