Examination of the effectiveness and cost-effectiveness of the introduction of a novel patient-centered community metabolic liver clinic
- Supervisors: Dr Theresa Hyde Dr Dan Cuthbertson
Description
Background
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the UK due to the obesity and type 2 diabetes (T2D) epidemics. While there are no approved therapies for NAFLD, weight loss can reverse disease progression, and optimal control of diabetes and hypertension can slow disease progression.1,2 NAFLD predominantly affects populations with high levels of deprivation3 and Merseyside has some of the highest rates of NAFLD in the country.4 The growing burden of NAFLD has led to the publication of numerous practice guidelines.5,6 These guidelines represent a significant shift in practice however, and are resource heavy, therefore are generally poorly implemented.7 Additional challenges include low levels of health literacy surrounding NAFLD.8 There is also a lack of data for the cost-effectiveness of wide-spread screening for NAFLD in all individuals with obesity/diabetes.
Aim
The goal of this project is to test one of the first models of a community metabolic liver clinic (the Mersey Metabolic Community liver Clinic - MMCC) supported by a multi-disciplinary team to see if it can lead to improvements in clinical outcomes and demonstrate cost-effectiveness. The clinic will adopt a multimorbidity approach and aim to enable patients to interpret their test results and empower individuals to understand where to access help with lifestyle change locally.
Objectives
O-1: Examine whether the MMCC can lead to improvement in cardiometabolic risk and non-invasive markers associated with NAFLD severity
O-2: Examine the cost-effectiveness and change in quality of life associated with the MMCC
O-3: Examine whether the MMCC can improve health literacy for patients with or at risk of NAFLD
Methods
The primary care centre will search records for patients with overweight/T2D and invite them to attend the MMCC. A clinic proforma has been developed with the aim of providing guidelines that a nurse can follow with supervision from a multi-disciplinary team, and as a means of providing written personalised feedback to patients on their condition. It consists of the following sections: (1) Assessment – history (smoking, alcohol, diet, physical activity), anthropometrics, relevant blood tests, liver assessment (Fibrosis-4 test and fibroscan), cardiovascular assessment. For each section, written and verbal feedback is given on lifestyle recommendations and where to seek advice. Anthropometric and blood results are displayed with either a traffic system to describe risk, or using the normal ranges. (2) Management – education, lifestyle advice including a personalised weight loss target, optimisation of medication for all aspects of the metabolic syndrome, referral to lifestyle hub, or enhanced weight management services and referral to secondary care if significant liver fibrosis is detected. Patient and nurse led actions will be documented.
The proforma will be uploaded to the medical records and a copy will be given to each patient at the end of the clinic. Patients will be asked for consent for long-term follow-up to monitor cardiometabolic risk and non-invasive markers associated with NAFLD severity and to complete pre and post EQRD quality of life and health literacy questionnaire.
Data collection
O-1: Outcome data will be collected via electronic health records on cardiometabolic risk and non-invasive markers associated with NAFLD severity at 6, 12 and 24 months.
O-2: Data will be collected on resource use and the EQ5D system will be used to evaluate quality of life data at baseline and 6 months following the clinic.
O-3: A validated health literacy questionnaire (HLQ) will be recorded at baseline and 6 months following the clinic appointment.9
Qualitative work
There is also the opportunity to work on an allied project which will support this study, which will take in an in-depth look at patient preferences for the NAFLD care pathway. This will involve undertaking semi-structured interviews and focus groups with patients and performing thematic analysis.
MD/PhD position – candidate suitability and training environment
The successful applicant should have a clinical background (medical doctor, nurses, health care assistant, all allied health professionals welcome). Applicants should have a previous degree and a keen interest in prevention of metabolic liver disease and patient pathways. Some quantitative/qualitative research experience is preferable but not essential.
The research will be carried out in Department of Cardiovascular and Metabolic Medicine at the University of Liverpool, in collaboration with Kirkby Primary Care Network and Liverpool University Hospitals NHS Foundation Trust. The student will be supported by a team of experts in the field of metabolic liver disease to complete a MD or PhD. The student will gain substantial skills in project management, quantitative research methods and health economics. Depending on their background skills set the student could also run the clinic.
How to apply: Please email theresa.hydes@liverpool.ac.uk with a cover letter stating why you would like the position and how you are qualified, in addition to an up to date CV.
Availability
Open to students worldwide
Funding information
Self-funded project
The project is open to European/UK and International students. There is no financial support available from Liverpool for this study. We are looking for self-funded students or students who have secured funding from an independent body. The successful applicant will be expected to have funding in place for the tuition fees (View Website) and living expenses.
Supervisors
References
1. Vilar-Gomez E, Calzadilla-Bertot L, Friedman SL, Gra-Oramas B, Gonzalez-Fabian L, Villa-Jimenez O, Lazo-del Vallin S, Diago M, Adams LA, Romero-Gomez M, et al. Improvement in liver histology due to lifestyle modification is independently associated with improved kidney function in patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2017;45:332–344.
2. Brown E, Hydes T, Hamid A, Cuthbertson D. Emerging and Established Therapeutic Approaches for Nonalcoholic Fatty Liver Disease. Clin Ther. 2021;
3. Giammarino AM, Qiu H, Bulsara K, Khan S, Jiang Y, Da BL, Bernstein DE, Satapathy SK. Community Socioeconomic Deprivation Predicts Nonalcoholic Steatohepatitis. Hepatol Commun [Internet]. 2021 [cited 2022 Jan 13];0:2021. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/hep4.1831
4. National Institute Health and Care Research (NIHR) Qlik sense® enterprise hub (NIHR targeting liver disease tool) .
5. National Institute for Health and Care Excellence. Non-alcoholic fatty liver disease (NAFLD): assessment and management. 2016.
6. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO). EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388–1402.
7. Jarvis H, Worsfold J, Hebditch V, Ryder S. Engagement with community liver disease management across the UK: a cross-sectional survey. BJGP Open. 2021;5:1–8.
8. Tincopa MA, Wong J, Fetters M, Lok AS. Patient disease knowledge, attitudes and behaviours related to non-alcoholic fatty liver disease: a qualitative study. BMJ Open Gastroenterol. 2021;8.
9. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health [Internet]. 2013 [cited 2022 Dec 16];13:1–17. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-658
2. Brown E, Hydes T, Hamid A, Cuthbertson D. Emerging and Established Therapeutic Approaches for Nonalcoholic Fatty Liver Disease. Clin Ther. 2021;
3. Giammarino AM, Qiu H, Bulsara K, Khan S, Jiang Y, Da BL, Bernstein DE, Satapathy SK. Community Socioeconomic Deprivation Predicts Nonalcoholic Steatohepatitis. Hepatol Commun [Internet]. 2021 [cited 2022 Jan 13];0:2021. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/hep4.1831
4. National Institute Health and Care Research (NIHR) Qlik sense® enterprise hub (NIHR targeting liver disease tool) .
5. National Institute for Health and Care Excellence. Non-alcoholic fatty liver disease (NAFLD): assessment and management. 2016.
6. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO). EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388–1402.
7. Jarvis H, Worsfold J, Hebditch V, Ryder S. Engagement with community liver disease management across the UK: a cross-sectional survey. BJGP Open. 2021;5:1–8.
8. Tincopa MA, Wong J, Fetters M, Lok AS. Patient disease knowledge, attitudes and behaviours related to non-alcoholic fatty liver disease: a qualitative study. BMJ Open Gastroenterol. 2021;8.
9. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health [Internet]. 2013 [cited 2022 Dec 16];13:1–17. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-658