Figure 1 shows the starting points condensed from analysis of the sub-studies with a view to more effective liver diagnostics by GPs. In the following, each of the dimensions presented will be discussed with reference to the respective central findings and correlated with existing research. The surveys with the much larger samples serve as the primary reference [32, 34].

Fig. 1
figure 1

Derived starting points for effective liver diagnostics by GPs (own figure)

Liver values and liver value constellations

The GP survey [32] has shown that, in everyday practice, there is a strong focus on a comparatively small number of selected liver parameters in the evaluation of (abnormally) elevated liver values. For example, γ-GT is the main laboratory value considered (95%). About two-thirds (65%) include aspartate aminotransferase (ASAT, AST, GOT) in their analysis, followed by alanine aminotransferase (ALAT, ALT, GPT) (63%), alkaline phosphatase (AP) (62%) and platelet count (57%). In a questionnaire, the respondents were asked to name which three indicators they considered to be most important and meaningful for the early detection of liver cirrhosis. Analogously, γ-GT (92%), aspartate aminotransferase (83%) and alanine aminotransferase (79%) are mentioned here, while other values lag a considerable distance behind.

At the same time, a factor analysis revealed a strongly heterogeneous and divergent approach on the part of GPs in the diagnosis of potential chronic hepatic parenchymal disease (see Table 2). Thus, GPs not only pay attention to very different symptoms, but also use different liver-associated laboratory parameters or value constellations as indicators for the identification of (incipient) liver disease within the framework of laboratory diagnostics ordered by GPs. While one cluster focuses on functional parameters such as bilirubin, PT according to Quick (INR), cholinesterase and albumin, another primarily looks at indicators of toxic cell damage or liver disease that has already occurred. Among other parameters, alanine aminotransferase receives particular attention. In addition, a third cluster that focuses on γ-GT as a parameter for possible liver disease stands out.

“We general practitioners are all-rounders in our day-to-day practice. The classification of liver values and the consideration of limit values is a very specific profession. Especially with moderate increases, it is not always easy to draw the right conclusions. I admit it’s hard for me.” (Interviewed GP 3m)

The survey of registered gastroenterologists [34] was able to confirm that, from the specialist’s perspective, GPs rely on highly divergent liver values to guide their everyday practice. For example, 57% of specialists experience it as a considerable inconvenience to have to constantly readjust to the diagnostic requirements due to the difference and lack of standardisation in the collection of liver values on the part of GPs. The spectrum for conclusions and further care decisions is correspondingly diverse.

“If you ask me: The behavior of general practitioners when considering and interpreting liver values is too uncontrolled and not supported enough by evidence-based guidelines. As a result, we often have to adapt our work to the preparatory work done by GPs from scratch.” (Interviewed gastroenterologist 1m)

Table 2 Laboratory values observed. Question: Which laboratory findings potentially linked to liver disease do you usually examine in routine lab work for general screening check-ups? (N = 2.701, GPs)

Diagnostic requirements

The GP survey [32] showed that 29% of the GPs included in the study offer a special liver check-up in their own practice in addition to the SHI screening. On the other hand, 66% do not offer such a service to supplement the SHI health check-up. In terms of the prerequisites for diagnostic equipment, standard upper abdominal sonography for the identification and further evaluation of liver disease is usually available in most GP practices (89%), and more rarely extended laboratory diagnostics (64%).Footnote 1 5% respectively offer an elastography or fibroscan investigation.

As was found in a detailed interrogation via item set, the surveyed GPs focus on certain indicators of incipient liver disease that prompt more in-depth diagnostics, while paying less attention to other indicators. From their previous experience, GPs pay particular attention to excessive alcohol consumption (94%) and also to signs such as upper abdominal complaints (76%), symptoms of fatigue (75%), ascites (71%), itching (71%) and skin changes (65%). In the experience of those surveyed, symptoms such as loss of appetite, weight loss, Dupuytren’s contracture, or gynaecomastia are less often a sign of potential liver disease.

Associated with this, there is evidence that GPs experience a lack of diagnostic certainty and a lack of guidance options when clarifying (abnormally) elevated liver values. For example, 38% consider themselves to be very or quite competent in the evaluation of elevated liver values, while around 50% consider themselves to be less or not at all competent in this area. Only one third of the surveyed GPs have consulted practice or action recommendations, expert opinions of medical societies or diagnostic pathways offered by healthcare providers (e.g. German Liver Foundation). The interest articulated by a majority of respondents in an expansion of adequate further training offerings is also an indication of the need for the training of GPs in this area.

“In my opinion, there should be more evidence-based tools tailored to general practitioners – on this topic in particular.” (Interviewed GP 5w)

From the point of view of the specialists interviewed [34], it would also be useful if there were more training formats that gave GPs more confidence in evaluating liver values, as this would have a direct impact on the quality and effectiveness of interdisciplinary collaboration.

“Fromt my point of view, primary care could do better at initial testing and diagnosis of (incipient) liver disease.” (Interviewed gastroenterologist 4m)

Referral behaviour

In the light of the study results, the referral behaviour of GPs reveals identifiable inconsistencies. On the one hand, almost two-thirds of the GPs surveyed [32] consider it sensible to initially practice a wait-and-see approach of several weeks (median: 5.0) after detecting moderately elevated liver values, and therefore only to consider referral to a higher specialist level after a repeat investigation at a later point in time. However, the respondents give divergent information about their actual referral behaviour, which they justify, in an open question, primarily on the basis of diagnostic uncertainties. Thus, around 40% state that they usually refer patients directly to a specialist or even to a specialist outpatient clinic after noticing abnormally elevated liver values. Only 32%, on the other hand, have consistently waited.

“Of course, the manual says ‘controlled waiting’. But the reality is sometimes different. Elevated liver enzymes are complex and to be honest I sometimes feel overwhelmed on the subject. That’s why I tend to transfer as quickly as possible.” (Interviewed GP 2w)

79% of the GPs reported that they had referred their patients to a gastroenterology practice; 44% had referred them directly to a liver outpatient clinic and 27% to a gastroenterology department or clinic.

The results attest to the central pilot role of the GP within the healthcare system. 98% of the internal medicine specialists surveyed stated that patients with (abnormally) elevated liver values are usually referred by their GP. 23% mention referral by another specialist and 20% that patients visit their practice on the advice of the clinic (40% self-referrals by the patient).

From the perspective of gastroenterological specialists [34], it can be seen that they, for their part, criticise the referral behaviour of GPs, which, in their opinion, is often either significantly premature (64%) or too tardy (57%). In addition, patients with slightly or moderately elevated liver values often turned out to be not affected by (incipient) liver disease (69%).

“In my experience, many general practitioners are even too quick to refer patients with elevated liver values of unknown aetiology. […] For example, many simply look at γ-GT and refer patients to specialists for small increases. […] It would be good if they could do part of the diagnostic work themselves and thus better pre-select our patients.” (Interviewed gastroenterologist 4m)

Interdisciplinary collaboration

Coordinated collaboration between GPs and specialists is essential for an effective, early diagnosis to explain elevated liver values and initiate appropriate treatment. Although both GPs and specialists experience collaboration with the other side as positive in the majority of cases, considerable interface problems and hurdles in interdisciplinary interaction are articulated.

Apart from a lack of specialised internal medicine practices in the vicinity (73%), frequent difficulties for GPs [32] are a lack of accessibility to discuss the usually complex patient problems (69%) (see Table 3). 90% state that there are often longer waiting times for an appointment for differential diagnostic assessment for suspected liver disease. In rural areas, these challenges are exacerbated due to the significantly lower density of specialists. Another considerable problem experienced by GPs is that patients are not sufficiently informed about their condition by their specialist colleagues and so return to the GP due to uncertainty (72%). Likewise, the referral behaviour of specialists following the diagnosis of liver disease seems to be characterised by frequent referrals back to the GP (63%). In the absence of prompt presentation to a specialist outpatient clinic, there is at least a risk of the patient entering an unnecessary loop as a result of being referred back.

“Working together with specialist colleagues is full of difficulties and stumbling blocks. Maybe it has something to do with the fact that in Germany the sectors are too separated from each other, but I can’t say that I’m usually well informed about what diagnostic steps the gastroenterological colleague takes. Or what I have to do when the patient comes back to me.” (Interviewed GP 4m)

Table 3 Challenges experienced in the interdisciplinary relationship, GPs. Question: A variety of challenges may arise when general practitioners and district specialists for outpatients collaborate on diagnosing cirrhosis. How often have you experienced the following challenges? (N = 2.701, GPs)

The views expressed by gastroenterological specialists [34] show that they are also critical of the interaction with primary care (see Table 4). Apart from the timing of patient presentation, the GP’s decision not to make a genuine basic assessment and to refer based on suspicion or doubt is experienced as a significant problem in the interaction with GPs (71%). From the point of view of registered gastroenterologists, further impediments to the interaction with GPs arise from the fact that the latter do not always follow up on elevated liver values (65%). Some of the respondents see the fact that GPs often follow a very different procedure for evaluating elevated liver values (e.g. collection of different liver values, 57%) as an additional hurdle and this corresponds with the impression articulated by specialists that the investigations, results and diagnoses are not always transparent (63%). As a result of such interdisciplinary problems, 84% of the specialists report that they frequently (25%) or occasionally (59%) encounter patients with liver disease that has not been detected by the GP.

“I don’t think the general practitioners or the specialists are at fault. Communication and patient treatment simply need to be better interlinked between the different levels of care. It would need a mechanism that creates a certain uniformity. I could well imagine an established and well-tested algorithm here.” (Interviewed gastroenterologist 1m)

Table 4 Challenges experienced in the interdisciplinary relationship, gastroenterological specialists. Question: A variety of challenges may arise when gastroenterologists and general practitioners work together to diagnose and treat cirrhosis. How often have you experienced the following challenges? (N = 313, gastroenterological specialists)

Approaches for optimising primary care

Respondents were given a list of various potential measures to increase the proportion of patients diagnosed early. There is a high level of agreement between the GPs and specialists included in the study. In view of the perceived inconsistency in the approach to evaluating elevated liver values in the outpatient sector, as well as existing interface problems, 80% of GPs and 85% of specialists support the introduction of a structured, evidence-based and broadly applicable diagnosis and treatment algorithm as a (highly) effective measure. 65% of GPs and 55% of specialists see an expansion of the laboratory workup included in the health check-up from the age of 35 as an effective measure. 61% of GPs and 60% of specialists consider the development of an explicit, evidence-based S3 guideline for the systematic evaluation of elevated liver values to be particularly effective. 50% of GPs and 52% of specialists are in favour of introducing a genuine liver check as part of the SHI regime.

In addition, 70% of GPs and 76% of specialists believe that a significant expansion of various kinds of training events for GPs on how to evaluate liver enzyme levels and practice a structured interaction within the healthcare chain would be (very) effective.

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