Composition of the patient population
The results confirm the central role of general practitioners in guiding patients through the healthcare system. In response to a question that allowed multiple replies, almost all internal specialists (98%) stated that patients with elevated liver values of unknown aetiology were usually referred by their general practitioners. Of the respondents, 23% responded that another specialist referred patients to their office compared to 20% reporting that their patients presented on the advice of the clinic (40% were direct appointments made by the patient).
Indicators for in-depth diagnostics
One item battery in the questionnaire asked for frequent indicators of liver disease onset usually leading to more in-depth diagnostics. From previous experience, specialists especially look for excessive alcohol consumption as well as signs such as upper abdominal discomfort, fatigue, ascites, itching and skin alterations (Table 1).
The Varimax factor analysis was chosen to search for underlying common dimensions. As described in the methods section, the statistical requirements for performing the factor analysis were met. The analysis turned out in favour of a three-factor solution, since in the present case three factors have a disproportionately high explanatory power and in each case an eigenvalue > 1 (Kaiser criterion). In addition to this, the explained overall variance is comparatively high (55%) in a three-factor solution. Even according to the scree test, the pattern of eigenvalues most readily points to a three-factor solution. Consequently, such a structure appears to be plausible and stable.
In keeping with the outlined procedure, it is possible to distinguish between three clusters of respondents. The analysis showed different focal points within the sample concerning potential indicators of incipient liver disease. The first and third clusters focused on more common and typical symptoms, whereas physicians in the second cluster also included less common signs of liver damage.
Table 2 shows laboratory values usually examined by specialist respondents. The data show that gastroenterological specialists collect extensive and specific values for more general and special laboratory parameters compared to other settings such as primary care.
Respondents were asked for their opinion on the most important and meaningful indicators for early detection of liver cirrhosis (multiple answers allowed). Like the previous results, responses included γ‑GT (87%), aspartate aminotransferase (82%), alanine aminotransferase (78%), PT according to Quick (61%) and cholinesterase (55%). Other values followed behind by a substantial margin.
Specialists usually had more laboratory budget available to them than general practitioners [19, 27]. This corresponds to the 88% of specialists responding that they frequently collected additional liver-associated laboratory values not determined in advance by the general practitioners, especially AMA, AMA/M2 (88%), ferritin (82%), hepatitis B/D (80%), hepatitis C (79%), and anti-LKM and anti-SLA (78%).
Apart from that, 54% of specialists responded that they often (occasionally in 34%) collected liver-associated laboratory values as controls that had previously been tested in primary care. Note that specialists work with a preselected patient group in interpreting these results.
Unlike the many general practitioners that usually prefer the wait-and-see approach towards elevated liver values with unclear aetiology [5, 33], the clear majority of gastroenterological specialists favour referral to a specialist clinic as soon as possible. Only 32% of the doctors surveyed believed in wait-and-see as an effective approach. Note that most patients with elevated liver values presenting to specialists did so on referral from their general practitioners, possibly after a waiting period in primary care. Of the specialists, 76% saw a waiting period of no more than four weeks as appropriate (median: 6.0).
Steps following diagnosis
Specialists were also asked about the subsequent course taken for patients diagnosed with liver disease onset over the past few years (multiple answers allowed). Of the respondents, 63% stated that these patients remained in their own care for observation or further treatment, 56% reported that they had referred their patients back to their general practitioners for further advice and analysis, and 38% opted to refer them to a specialist liver clinic.
Working relationship between primary and specialist care
As seen in Table 3, gastroenterologists saw the main obstacles in their relationship with general practitioners as being failure to follow up on elevated liver values and referring patients found to have elevated liver values referred to a specialised clinic too soon or too late. Some of the respondents also stated that the vastly different approach taken by general practitioners in analysing elevated liver values such as by collecting deviating liver values represents an additional obstacle, which may play a role in the impression that examinations, results and diagnoses are not always transparent.
Despite these issues in the relationship, 72% of responding specialists were highly or moderately satisfied with their relationships towards general practitioners. Only 25% were moderately or highly dissatisfied (difficult to say or no answer: 3%).
Approaches to optimisation
In view of the perceived inconsistency in approaches taken towards analysing elevated liver values in outpatient care and the existing issues in the relationship, the responding specialists saw a structured diagnosis and treatment algorithm for general practitioners as especially beneficial in increasing the relative numbers of patients diagnosed at an early stage. Of the respondents, 85% were of the opinion that establishing this treatment pathway would be moderately or highly effective, while 55% consider an extension of the health check-up on patients from the age of 35 to be a moderately or highly effective measure. Furthermore, 52% were in favour of explicit liver checks as part of statutory health insurance, and 76% anticipated that greater numbers of advanced training programmes would support general practitioners and specialists in detecting liver diseases sooner and more effectively.