Costs of Investigating Abnormal Liver Biochemistry in Asymptomatic Individuals
The advent of automated laboratory testing has led to multiple
investigations being used to investigate those with non-specific symptoms.
This will invariably produce asymptomatic individuals with abnormal tests.
Sherwood et al highlight the importance of correctly evaluating such
individuals with deranged liver function tests at a primary care level
(1).
Recent reports suggest that as many as 6% of asymptomatic patients will
have an abnormality of liver function tests picked up on “screening” (2).
Sherwood et al demonstrated that 11% of patients in their study had
undetected major liver disease which would have benefited from hospital
follow-up.
An audit carried in our unit supports this observation that a significant
percentage of asymptomatic individuals with abnormal liver biochemistry,
have underlying liver disease. During the period from July 1999 to March
2000, all patients referred to the liver unit of the Royal Victoria
Hospital, Belfast, with abnormal LFTs detected on “screening”, were
followed to diagnosis. Each patient underwent various biochemical,
immunological, virological and radiological tests deemed necessary to
establish a diagnosis. In 38% of these individuals a diagnosis was
established for which a specific treatment was indicated. Diagnosis made
included primary biliary cirrhosis, hepatitis C, drug-induced hepatitis,
hepatic steatosis and alcoholic liver disease. As in previous studies,
hepatic steatosis was the most prevalent diagnosis (3).
In the current economic climate, cost-effectiveness of any policy is
obviously of paramount importance. We calculated the total costs
encountered in the investigation of these patients including the cost of
new patient referral and review clinic appointments, together with
investigation costs. We have established that an approximate cost of 270
is incurred to provide a diagnosis.
To conclude, we agree with Sherwood et al – these patients with
persistently abnormal test results benefit from referral to a
Hepatologist. The costs of identifying diagnoses in these individuals are
small and should not discourage those in primary care from making the
initial referral.
References :
1 Sherwood P., Lyburn I., Brown S., Ryder S. How are abnormal
results for liver function tests dealt with in primary care? Audit of
yield and impact. British Medical Journal 2001; 322: 276-278.
2 Gopal DV., Rosen HR. Abnormal findings on liver function tests.
Postgraduate Medicine 2000; 107(2): 100-114.
3 Daniel S., Ben-Menachem T., Vasudevan G., Ma CK., Blumenkehl M.
Prospective evaluation of unexplained chronic liver transaminase
abnormalities in asymptomatic and symptomatic patients. American Journal
of Gastroenterology 1999; 94(10): 3010-3014.
Rapid Response:
Costs of Investigating Abnormal Liver Biochemistry in Asymptomatic Individuals
The advent of automated laboratory testing has led to multiple
investigations being used to investigate those with non-specific symptoms.
This will invariably produce asymptomatic individuals with abnormal tests.
Sherwood et al highlight the importance of correctly evaluating such
individuals with deranged liver function tests at a primary care level
(1).
Recent reports suggest that as many as 6% of asymptomatic patients will
have an abnormality of liver function tests picked up on “screening” (2).
Sherwood et al demonstrated that 11% of patients in their study had
undetected major liver disease which would have benefited from hospital
follow-up.
An audit carried in our unit supports this observation that a significant
percentage of asymptomatic individuals with abnormal liver biochemistry,
have underlying liver disease. During the period from July 1999 to March
2000, all patients referred to the liver unit of the Royal Victoria
Hospital, Belfast, with abnormal LFTs detected on “screening”, were
followed to diagnosis. Each patient underwent various biochemical,
immunological, virological and radiological tests deemed necessary to
establish a diagnosis. In 38% of these individuals a diagnosis was
established for which a specific treatment was indicated. Diagnosis made
included primary biliary cirrhosis, hepatitis C, drug-induced hepatitis,
hepatic steatosis and alcoholic liver disease. As in previous studies,
hepatic steatosis was the most prevalent diagnosis (3).
In the current economic climate, cost-effectiveness of any policy is
obviously of paramount importance. We calculated the total costs
encountered in the investigation of these patients including the cost of
new patient referral and review clinic appointments, together with
investigation costs. We have established that an approximate cost of 270
is incurred to provide a diagnosis.
To conclude, we agree with Sherwood et al – these patients with
persistently abnormal test results benefit from referral to a
Hepatologist. The costs of identifying diagnoses in these individuals are
small and should not discourage those in primary care from making the
initial referral.
References :
1 Sherwood P., Lyburn I., Brown S., Ryder S. How are abnormal
results for liver function tests dealt with in primary care? Audit of
yield and impact. British Medical Journal 2001; 322: 276-278.
2 Gopal DV., Rosen HR. Abnormal findings on liver function tests.
Postgraduate Medicine 2000; 107(2): 100-114.
3 Daniel S., Ben-Menachem T., Vasudevan G., Ma CK., Blumenkehl M.
Prospective evaluation of unexplained chronic liver transaminase
abnormalities in asymptomatic and symptomatic patients. American Journal
of Gastroenterology 1999; 94(10): 3010-3014.
Competing interests: No competing interests