Title: Development of a 'Case-Finding' Database to identify individuals at risk of liver and metabolic disease within the Somerset Liver Improvement Programme
Funder: Department of Health and Social Care

Abstract: Background: 10% of the population have abnormalities on liver blood tests. Accurate diagnosis of clinically significant abnormalities is difficult due to the lack of symptoms, difficulty in interpreting liver tests, unclear referral pathways and absence of effective screening programmes. 50% are diagnosed as emergencies with complications; and chronic liver disease accounts for >100,000 lost years of life per annum in England and Wales. Preliminary work in Somerset has shown that patients with potential liver disease can be diagnosed earlier by analysis of pre-existing laboratory datasets - case-finding approach. However, the existing tools used to analyse these data are too complex for use in clinical practice at scale. Objectives: The aim of this innovation project will be to develop a computer system that will enable rapid, clinician-based analysis of laboratory data to identify patients with a high likelihood of undiagnosed liver disease. Patients can then be recalled for testing and treatment as required. The system will be scalable, will interface with all standard laboratory systems, and use pseudonymised data with re-identification only within patients own healthcare system. The intention is to deliver a solution usable across the NHS. Project plan: The system will use CareXML to extract and hold data in a Common Data Model. Adaptors will be created to import data from key NHS systems. An Analysis Tool will be developed using an Agile development approach. Clinical input will enable iterative development and testing of analytical algorithms. Through continuous patient and public involvement, and engagement with the wider NHS, the team will ensure delivery of a powerful case-finding tool for liver disease. Impact: A usable system should be available within 18-24 months, followed by testing and marketing to the NHS. Estimates of cost-effectiveness suggest a potential 10-fold return on total investment for every 1% improvement in effectiveness of liver services.

Lay abstract: Liver disease is becoming increasingly common and is a major cause of early death. This includes excess alcohol and infection with liver viruses. However even more important is non-alcoholic fatty liver disease. This occurs when the liver stores too much fat (e.g. due to lack of exercise or eating the wrong types of food) and critically it can predict the development of diabetes, high blood pressure and heart and kidney disease. It is estimated that more than 1 in 10 of the population are at risk from non-alcoholic fatty liver disease. Liver diseases do not present with symptoms (e.g. pain) or signs that a doctor would recognise, and patients are often underdiagnosed. However, many people are now having routine blood tests, which could be useful for early diagnosis. Our initial research has shown that many patients who present with advanced liver disease could have been diagnosed at a much earlier stage. The diagnosis often could have been made not on the basis of a single blood test, but by combining the results of multiple blood tests spread out over time. Therefore, a doctor might have looked at each blood test individually and concluded correctly that there was no immediate problem, but by combining the results of many blood tests we can see patterns emerging that indicate an existing or developing health problem. Therefore, the aim of this project is to develop a computer programme that will allow doctors to identify such patients. The programme will analyse information held about people who have previously had blood tests. At the time the tests were taken, the results may not have indicated a problem. However, we have found that by analysing this information in different ways and putting together results from blood tests spaced out over time we can identify which people are at high risk of disease. This has become possible in part because of the expansion of stored laboratory data (we have access to many millions of blood tests, going back 10-15 years), and also because of the increasing number of people having routine blood tests when they visit their doctor (for example over 200,000 routine liver blood tests taken by GPs each year in our local population of &frac12; million people). Initial research has shown that this method works but analysing the huge amount of data stored in laboratory systems is extremely complex and time consuming. The information is not stored in a way that makes analysis easy, and the tools available are not designed for this work. We therefore plan to develop a computer system specifically designed to combine information in new ways, as directed by the user and seek out and flag patients who are developing liver disease.

Research activity codes: 2.4 SURVEILLANCE AND DISTRIBUTION
Health categories: METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL