Primary care

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

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

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

Correspondence to: S Ryder stephen.ryder{at}qmcuh-tr.mail.trent.nhs.uk

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 -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.