Liver disease management as routine in primary care? A qualitative interview study to guide implementation

Problem

Morbidity and mortality from liver disease is rising in the UK. Most cases of liver disease are caused by alcohol and/or NAFLD and are therefore preventable and treatable if caught early and lifestyle interventions enacted. Chronic liver disease has been omitted from long-term condition management in UK primary care and is not the subject of routine assessments or financial incentives.

Several research studies have shown pathways to find chronic liver disease in the community lead to an increase in detection of significant disease. Despite this, implementation of these pathways has been partial and there has been little study of how they may fit within routine primary care work.

This study explored primary care health care professional (HCP) experiences and understanding of chronic liver disease, and how this might fit into long-term condition management structures.

Approach

A qualitative cross-sectional study design used semi-structured interviews with HCP working in primary care in the North of England. Sampling was purposive to allow perspectives from HCPs working in demographically different practices with varying levels of experience. Interviews were conducted from October 2020-May 2021. To provide an overall focus, yet still allowing for flexibility, a semi-structured approach informed by a theory of implementation (normalisation process theory (NPT)) was used.

Data collection and analysis were concurrent. Interview data were analysed using thematic analysis.

Findings

Twenty interviews were conducted. Four themes encapsulated the interviewees’ views and perceptions: structural barriers to operationalising liver disease care, liver disease as part of multimorbidity, the value in managing liver disease and facilitators of change in liver disease care.

The results were analysed with reference to NPT to gain insight into the work that organisations and individuals may need to do to develop a framework for managing liver disease effectively in primary care. To make sense of, and be able to build and sustain a new way of working in the area of liver disease, participants identified key areas for action: integrated and incentivised frameworks and protocols to drive communal understanding as well as organise and sustain practice, incorporating common liver diseases into multimorbidity care to reduce complexity and allow individual sense making as well as manage workload, defining the GP role within a predominantly lifestyle focused treatment pathway for GPs to better understand the value in change, and education/local champions to help initiate and legitimise individual and organisational participation in change.

Consequences

The results of this study will be used directly to guide the development of a chronic liver disease framework being implemented into routine long-term condition management in the North East of England. It is anticipated that this embedded pathway will benefit from the consideration of successful implementation at the planning and development stage and that rapid wider national implementation will follow.