How are abnormal results for liver function tests dealt with in primary care? Audit of yield and impact

Sherwood, Paul specialist registrar
Lyburn, Iain senior house officer
Brown, Sandy consultant biochemist
Ryder, Stephen consultant hepatologist

¹Division of Gastroenterology, Queen's Medical Centre, Nottingham NG7 2UH, ²Department of Clinical Chemistry, Queen's Medical Centre

Accepted for publication 9 November 2000

Contributors Contributors: PS helped plan the study, collected and analysed the hospital and general practice data, and wrote the paper. IL helped plan the study, collected the hospital data, and helped with the discussion section. SB produced the original patient sample and contributed to writing the paper. SR had the original idea for the study, helped plan it, collected and analysed the hospital and general practice data, and edited the paper; he will act as guarantor.

Correspondence to: S Ryder [email protected]

Funding: None.

Competing interests: None declared.

BMJ 322(7281):p 276-278, February 3, 2001.

Objective

To determine whether abnormal results for liver function tests are investigated in primary care and findings on full investigation.

Design

Retrospective audit and prospective clinical investigation.

Setting

University hospital and surrounding general practices serving around 330 000 people.

Subjects

Adults with abnormal results for liver function based on tests requested by their doctor between 1 January and 30 June 1995.

Interventions

All patients with γ-glutamyltransferase, alanine aminotransferase, or alkaline phosphatase concentrations at least twice the upper limit of the reference range were studied. A median of 15 months later (range 12-21) records of hospital attendances and further investigations were examined. Where investigations were incomplete the records from the general practice were examined, and suitable patients were invited to attend the liver clinic.

Main outcome measures

Investigations requested by the doctor and final diagnoses reached.

Results

933 patients with abnormal liver function tests were identified; follow up data were obtained in 873 (94%). 531 patients were already under hospital review. Of the remaining 342 patients, 157 were suitable for investigation; the others had died, moved away, were elderly, or had repeat liver function tests with normal results. No further tests were requested for 91 (58%) of these patients. 66 had been partially investigated by their doctor, and in seven patients results suggesting a treatable chronic liver disease had not been followed up. On investigation, 97 (62%) had an identifiable diagnosis requiring hospital intervention or follow up, or both.

Conclusions

Abnormal results for liver function are often not adequately investigated, missing an important chance of identifying treatable chronic liver disease.