Liver transplantation for alcohol-related liver disease in the UK: revised UK Liver Advisory Group recommendations for referral.

Liver disease, of which liver cirrhosis is the most advanced stage, constitutes the fourth most common cause of life-years lost in men and women younger than 75 years in England, where mortality rates from liver disease have increased by 25% in the past decade. Alcohol consumption is the most common modifiable risk factor for disease progression in these individuals, but within the UK, there is substantial variation in the distribution, prevalence, and outcome of alcohol-related liver disease, and no equity of access to tertiary transplantation services. These revised recommendations were agreed by an expert panel convened by the UK Liver Advisory Group, with the purpose of providing consensus on referral for transplant assessment in patients with alcohol-related disease, and clarifying the terminology and definitions of alcohol use in liver injury. By standardising clinical management in these patients, it is hoped that there will be an improvement in the quality of care and better access to liver transplant assessment for patients with alcohol-related liver disease in the UK.

The prevalence of multimorbidity in primary care and its effect on health care utilization and cost.

INTRODUCTION: Multimorbidity is common among the heterogeneous primary care population, but little data exist on its association with health care utilization or cost. OBJECTIVE: The aim of this observational study was to examine the prevalence and associated health care utilization and cost of patients with multimorbidity. METHODS: All patients >50 years of age were eligible for the study which took place in three primary care practices in the West of Ireland. Chronic medical conditions and associated health care utilization in primary and secondary care were identified through patient record review. RESULTS: In a sample of 3309 patients in the community, the prevalence of multimorbidity was 66.2% (95% CI: 64.5-67.8) in those >50 years of age. Health care utilization and cost was significantly increased among patients with multimorbidity (P < 0.001). After multivariate adjustment for age, gender and free medical care eligibility, the addition of each chronic condition led to an associated increase in primary care consultations (P = 0.001) (11.9 versus 3.7 for >4 conditions versus 0 conditions); hospital out-patient visits (P = 0.001) (3.6 versus 0.6 for >4 conditions versus 0 conditions); hospital admissions (P = 0.01) [adjusted odds ratio (OR) of 4.51 for >4 conditions versus 0 conditions] and total health care costs (P < 0.001) (€4,096.86 versus €760.20 for >4 conditions versus 0 conditions) over the previous 12 months. CONCLUSIONS: Multimorbidity is very common in primary care and in a system with strong gatekeeping is associated with high health care utilization and cost across the health care system. Interventions to address quality and cost associated with multimorbidity must focus on primary as well as secondary care.