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Missed and Delayed Diagnoses of Chronic Liver Disease in Primary Care Patients with Cirrhosis
Kush M Patel1, Jingwen Zhang2, Justin Marsden2
1Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA. patelkus@musc.edu.
Insights
Many patients with cirrhosis or liver cancer have delayed or missed diagnoses of chronic liver disease (CLD). Over-reliance on aminotransferase tests may contribute, highlighting a need for better primary care screening, especially for alcohol-related liver disease.
Area of Science:
- Hepatology
- Primary Care Medicine
- Diagnostic Accuracy
Background:
- Chronic liver diseases (CLD), including cirrhosis and hepatocellular carcinoma (HCC), are significant causes of illness and death.
- Patients with CLD are often diagnosed late, after the disease has progressed to cirrhosis or HCC.
- This study investigates missed or delayed diagnoses in primary care patients who later developed severe liver disease outcomes.
Purpose of the Study:
- To determine the proportion of primary care patients with severe liver disease outcomes who experienced missed or delayed diagnoses of CLD.
- To explore factors associated with missed or delayed CLD diagnoses, particularly aminotransferase levels.
Main Methods:
- Retrospective cohort study of primary care patients diagnosed with cirrhosis, HCC, or other severe liver disease outcomes between 2012 and 2021.
- Defined missed diagnosis as absence of CLD diagnosis before severe outcome, and delayed diagnosis as CLD diagnosis on the same day as the severe outcome.
- Used univariate analyses and multivariable logistic regression to assess associations, including aminotransferase elevations (ALT/AST).
Main Results:
- Of 667 patients, 20% had a missed CLD diagnosis and 36% had a delayed diagnosis.
- Alcohol-related liver disease was the most frequent cause among patients with missed/delayed diagnoses.
- Patients with missed/delayed diagnoses were less likely to have elevated ALT/AST (61% vs. 77%, p<0.001), and elevated aminotransferases were linked to lower odds of missed/delayed diagnosis (OR 0.47).
Conclusions:
- A majority of patients with cirrhosis or HCC experienced missed or delayed CLD diagnoses.
- Over-reliance on aminotransferase elevations for CLD detection appears to be a contributing factor.
- Enhanced primary care screening for prevalent CLD, particularly alcohol-related liver disease, is recommended.
Background:
Chronic liver diseases (CLD), cirrhosis, and hepatocellular carcinoma (HCC) cause significant morbidity and mortality. Unfortunately, patients with CLD often go undiagnosed until progression to cirrhosis and HCC. We aimed to determine the proportion of primary care patients with severe liver disease outcomes that had missed or delayed CLD diagnoses.
Methods:
This retrospective cohort study evaluated primary care patients with a diagnosis of cirrhosis, HCC, or other severe liver disease outcome between 2012 and 2021. The outcomes of interest were missed and delayed diagnoses of CLD, defined as the absence of a CLD diagnosis (missed) or first appearance of CLD on the same day as the cirrhosis diagnosis (delayed). Univariate analyses were performed to describe the cohort. Multivariable logistic regression models analyzed the association of aminotransferase elevations with the outcomes of interest.
Results:
Of 667 patients with cirrhosis or HCC, 133 (20%) had a missed CLD diagnosis, and 243 (36%) had a delayed CLD diagnosis. Alcohol-related liver disease was the most common etiology among patients with missed/delayed diagnoses. A lower proportion of patients with missed/delayed diagnoses had an elevation in ALT or AST compared to patients with timely diagnoses (61% vs. 77%, p < 0.001). Elevated aminotransferase values were associated with lower odds of a missed/delayed diagnosis (OR 0.47; 95%CI 0.34-0.66).
Conclusions:
Most patients with cirrhosis or HCC had missed or delayed diagnoses of CLD in the context of probable overreliance on aminotransferase elevation for CLD detection. Enhanced screening for high prevalence CLD, especially alcohol, in primary care is needed.
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