Congratulations to Professor Emmanuel Tsochatzis, Royal Free Hospital and UCL, and his team, for being runner up for the CSSC Service Development Prize 2021.

Read his full submission and watch his presentation recording below.

The Multidisciplinary Royal Free Hospital NAFLD Service

We have developed a comprehensive care model for patients with NAFLD that includes a dedicated referral pathway from primary to secondary care and a dedicated NAFLD multidisciplinary clinic in secondary care to look after these patients.

1) Referral pathway: This is based on the sequential use of non-invasive fibrosis tests in patients that are diagnosed with NAFLD, starting with a FIB-4 and then with an ELF test if required. The so called Camden and Islington pathway also consists of detailed advise for patients with NAFLD who are not deemed to be at increased risk of advanced fibrosis and who are managed in primary care. The pathway has resulted in a 4-fold improvement in the detection of advanced fibrosis and an 88% reduction in unnecessary referrals in an analysis of over 3,000 patients (Srivastava et al, Journal of Hepatology 2019;71:371-8). It also results in increased efficiency and cost savings (Srivastava et al BMC Gastroenterology 2019;19:122 and Crossan et al Liver International 2019;39:2052-2060). The pathway has received national and international attention and has informed the recently published EASL CPGs on non-invasive fibrosis testing. I had more than 10 invited lectures in the last 2 years world-wide to talk about this pathway and invited review articles in the Lancet Gastroenterology and Hepatology and Journal of Hepatology Reports.

2) The clinic consists of a hepatologist (Professor Tsochatzis), a chemical pathologist (Dr Goyale, who assesses the cardiovascular risk of patients), a dietitian (Mrs Roshni Patel), a clinical nurse specialist (Mrs Jennifer Clancy) and a Fibroscan technician for same day non-invasive fibrosis testing and provides a one-stop shop for patients with NAFLD who are referred to the service. There is also bio-banking for research purposes and a link with the clinical trial unit. In an audit of 273 patients managed in this clinic (Mantovani, oral presentation EASL ILC 2020), the MDT management results in significant improvements in liver blood tests, blood pressure, HBA1c, cholesterol and weight. Importantly, the proportion of patients with a QRISK3 score of >10% decreased from 63% to 48%. A patient survey of over 100 patients revealed that >95% of the patients were satisfied or extremely satisfied with the format of the clinic. Thanks to the MDT format, we successfully recruited to time and target for 7 phase II and III clinical trials with the lowest screening failure rate in the UK. Thanks to the one-stop shop format, 50% of patients are discharged with appropriate intervention and advice after a single appointment. The need for comprehensive models of NAFLD care was recently highlighted (Lazarus Nature Reviews Gastroenterology and Hepatology 2021) with a direct reference to the referral pathway and clinic outcomes at the Royal Free Hospital.

Team Members

Primary Care Pathway: Professor William Rosenberg, Dr Ankur Srivastava
Multidisciplinary clinic: Dr Davide Roccarina, Mrs Roshni Patel, Mrs Jeniffer Clancy, Dr Atul Goyale