Enhanced liver fibrosis test facilitates stratification of people with alcohol use disorder in primary care.

Objective: Alcohol-related liver disease (ArLD) is a leading cause of liver-related mortality, but affects a minority of people with alcohol use disorder (AUD). Of people with AUD, only those with ArLD require hepatologist input, necessitating case stratification. However, many are referred with established cirrhosis, when opportunities for intervention are limited. We report the evaluation of a novel primary care pathway using the enhanced liver fibrosis (ELF) test for early detection and stratification of ArLD patients.

Methods: The ELF alcohol pathway (EAP) was established in January 2020 and evaluated in May 2023. General practitioner referrals to a single liver centre using the EAP were compared with standard care (SC) referrals. The presence of steatosis constituted an 'appropriate' referral. The prevalence of structural ArLD and each stage of fibrosis was assessed, with liver status ascertained through electronic patient records.

Results: The EAP was followed by 121 patients. Unnecessary referral (ELF<9.8) was avoided for 24.8% (n=30), with the 91 remaining EAP referrals compared with 197 contemporaneous SC referrals. Most referrals were deemed appropriate (97.5% vs 92.3% for SC and EAP, respectively), but significantly more SC referrals had advanced fibrosis (OR 2.68 (1.50 to 4.93); p<0.001), cirrhosis (OR 6.58 (2.84 to 17.79); p<0.0001) or decompensated cirrhosis (10.7% vs 0%; p<0.001).

Conclusion: Using the EAP facilitated earlier detection of ArLD, with 8% of EAP referrals having established cirrhosis versus 35.5% of SC referrals. Unnecessary specialist referral was avoided for one-quarter of those assessed on the EAP. Pathway uptake was impacted by poor dissemination during the COVID-19 pandemic. Better implementation is warranted.