Cirrhosis in primary practice: many patients remain potentially undiagnosed and are not receiving liver cancer surveillance

Background and aim: Most patients with cirrhosis have compensated disease and are cared for in primary care; however, the exact epidemiology within Australia remains largely unknown. The aim of this study was to assess cirrhosis care in an Australian primary care setting by evaluating rates of cirrhosis diagnosis, appropriate hepatocellular carcinoma (HCC) surveillance and specialist communication.

Methods: Electronic medical records in consenting general practices were reviewed using the "Liver Toolkit" to identify patients with an existing cirrhosis diagnosis. Individual cases were reviewed to identify outcomes of interest.

Results: One hundred seventy-one patients with confirmed cirrhosis across nine general practices were identified (74% male, mean age: 61.2 years). There was significant variation in the rate of cirrhosis diagnosis between practices (range 31.7-637.9 per 100 000 patients, P < 0.0001). Patients with cirrhosis had predominately compensated disease (75% Child-Pugh A) and common etiologies of cirrhosis were alcohol (49%), hepatitis C (47%), and metabolic dysfunction-associated steatotic liver disease (29%). Forty-two patients (25%) had received appropriate HCC surveillance. Predictors of inadequate HCC surveillance were time from last specialist correspondence (odds ratio [OR] = 1.06 per month increase, 95% confidence interval [CI]: 1.02-1.10, P = 0.002) and hepatitis B (OR = 0.24, 95% CI: 0.06-0.98, P = 0.047). Specialist correspondence with primary care was older than 2 years or absent in 37% of cases.

Conclusions: There was a 20-fold difference in the rate of cirrhosis diagnosis between general practices within Sydney, suggesting a large proportion of patients remain undiagnosed. Three quarters of patients with diagnosed cirrhosis are not receiving appropriate HCC surveillance.