Improving care for patients with liver disease in East Kootenay

From streamlining the referral process to creating care pathways and education opportunities, the East Kootenay Division of Family Practice is working to better the quality of care for patients with liver disease in the region. With only one gastroenterologist servicing the entire East Kootenay, the project team hopes this work will increase efficiency and provide resources for patients with liver disease.

The East Kootenay Improving Access to Liver Care Project was inspired by numerous patient stories in which the lack of clarity, education, or resources resulted in negative experiences by patients. One case involved a woman who had been overweight for decades, despite not having experienced any complaints of illness or symptoms. After a year in Cranbrook, her family doctor told her that her liver enzymes were persistently elevated and that she had fatty liver disease. Her treatment for diabetes, hypertension, and hypercholesterolemia continued, and the physician advised her to lose weight. She was referred to a gastroenterologist and expected to wait 6-9 months for an appointment.

Prior to her appointment, she underwent an abdominal ultrasound as part of the work-up for her elevated liver enzymes. Unfortunately, this showed a small tumor that almost certainly represented primary liver cancer. The news came as a shock to the patient as she had never heard of obesity-related cirrhosis, known as Non-Alcohol Fatty Liver Disease (NAFLD), or NAFLD-related liver cancer before. She was frustrated to learn this might have been preventable.

“Over the past two years, our team has developed an algorithm to try and differentiate those patients most at risk of developing cirrhosis from non-alcohol fatty liver disease or NAFLD,” says Dr Tara Chalmers-Nixon, a Fernie-based gastroenterologist and physician lead of the EK Liver Care Project.

The project, which received funding from Shared Care in February 2021, engaged with several communities and over 30 physicians in the past year to gather data, identify existing gaps, and get input on the best referral methods.

Using published studies and validated calculators for assessing liver damage—namely, a FIB-4 score—the team engaged with primary care physicians to create a pathway to identify those most at risk of advanced liver disease and arrange initial workups and appropriate referrals. The local Medical Imaging Team at East Kootenay Regional Hospital supported the adoption of specialized “shear wave elastography” software that can assess the stiffness or fibrosis of a liver during a routine abdominal ultrasound.

As a result of the streamlined referral process, and primary care access to the liver damage assessment, primary care providers can appropriately assess patients to decide on referral to a specialist or continue care in their primary care home.

“For Sarah, this would mean that when her family doctor noted elevated liver enzymes and an abnormal FIB-4 score, the family physician could arrange an ultrasound with shear wave elastography to help determine if Sarah has advanced fibrosis and thus at risk of liver cancer,” explains Dr Chalmer-Nixon. “Early identification of liver fibrosis could change the trajectory of liver disease for some patients.”

The Liver Care team continues to work on improving access to liver care in East Kootenay and aims to finalize their NAFLD care pathway and referral in East Kootenay. They continue community education with Tobacco Plains First Nation and connecting with family physicians in the region. They hope the educational resources and process improvements they've made in their region will help other parts of BC facing similar challenges.