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Lewis H, Parker R, Ul-Haq Z, Lucas A, Cohen C, Vergis N, Thursz M. Healthcare interactions prior to first hospital admission with alcohol-related liver disease. Liver Int 2024. [PMID: 38771187 DOI: 10.1111/liv.15969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/12/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND AND AIMS To examine the healthcare contacts of patients in the year before an index admission to hospital with alcohol-related liver disease (ArLD) to identify where opportunities for earlier identification of alcohol use disorders (AUD) and ArLD and intervention may occur. METHODS A retrospective cohort study using the regional database encompassing NHS organisations across North West London (344 general practitioner [GP] practices, 4 acute hospital trusts and 2 mental health and community health trusts). Patients who had an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured. RESULTS The ArLD cohort had 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD, 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts; 80% (n = 1199/1494) attended ED, 68% attended an outpatient clinic, and 42% (n = 628/1494) had at least one inpatient admission. Only 9% of the ArLD (137/1494) had formal testing for AUD. Abnormal bilirubin and platelets were more common in the ArLD than the control cohort 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784). CONCLUSIONS Prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.
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Affiliation(s)
- Heather Lewis
- Liver Unit, Imperial College NHS Healthcare Trust, St Marys Hospital London, London, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Zia Ul-Haq
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Carole Cohen
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Nikhil Vergis
- Digestive Diseases Division, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Mark Thursz
- Digestive Diseases Division, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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2
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Dhanda A, Andrade J, Allende H, Allgar V, Bailey M, Callaghan L, Cocking L, Goodwin E, Hawton A, Hayward C, Hudson B, Ingram W, Jeffery A, King A, Lavers V, Lomax J, McCune CA, Musicha C, Parker R, Rollinson C, Wilks J, Creanor ES. Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results. BMJ Open Gastroenterol 2024; 11:e001267. [PMID: 38286518 PMCID: PMC10870787 DOI: 10.1136/bmjgast-2023-001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. DESIGN Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. RESULTS Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. CONCLUSION Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. TRIAL REGISTRATION NUMBER ISRCTN41353774.
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Affiliation(s)
- Ashwin Dhanda
- Faculty of Health, University of Plymouth, Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Hannah Allende
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | | | - Laura Cocking
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Annie Hawton
- Medical School, University of Exeter, Exeter, UK
| | | | - Ben Hudson
- Royal Devon University Hospital Foundation NHS Trust, Exeter, UK
| | - Wendy Ingram
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Angela King
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Joe Lomax
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher Rollinson
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonny Wilks
- Faculty of Health, University of Plymouth, Plymouth, UK
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3
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Bodger K, Mair T, Schofield P, Silberberg B, Hood S, Fleming KM. Outcomes of first emergency admissions for alcohol-related liver disease in England over a 10-year period: retrospective observational cohort study using linked electronic databases. BMJ Open 2023; 13:e076955. [PMID: 37993152 PMCID: PMC10668174 DOI: 10.1136/bmjopen-2023-076955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVES To examine time trends in patient characteristics, care processes and case fatality of first emergency admission for alcohol-related liver disease (ARLD) in England. DESIGN National population-based, retrospective observational cohort study. SETTING Clinical Practice Research Datalink population of England, 2008/2009 to 2017/2018. First emergency admissions were identified using the Liverpool ARLD algorithm. We applied survival analyses and binary logistic regression to study prognostic trends. OUTCOME MEASURES Patient characteristics; 'recent' General Practitioner (GP) consultations and hospital admissions (preceding year); higher level care; deaths in-hospital (including certified cause) and within 365 days. Covariates were age, sex, deprivation status, coding pattern, ARLD stage, non-liver comorbidity, coding for ascites and varices. RESULTS 17 575 first admissions (mean age: 53 years; 33% women; 32% from most deprived quintile). Almost half had codes suggesting advanced liver disease. In year before admission, only 47% of GP consulters had alcohol-related problems recorded; alcohol-specific diagnostic codes were absent in 24% of recent admission records. Overall, case fatality rate was 15% in-hospital and 34% at 1 year. Case-mix-adjusted odds of in-hospital death reduced by 6% per year (adjusted OR (aOR): 0.94; 95% CI: 0.93 to 0.96) and 4% per year at 365 days (aOR: 0.96; 95% CI: 0.95 to 0.97). Exploratory analyses suggested the possibility of regional inequalities in outcome. CONCLUSIONS Despite improving prognosis of first admissions, we found missed opportunities for earlier recognition and intervention in primary and secondary care. In 2017/2018, one in seven were still dying during index admission, rising to one-third within a year. Nationwide efforts are needed to promote earlier detection and intervention, and to minimise avoidable mortality after first emergency presentation. Regional variation requires further investigation.
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Affiliation(s)
- Keith Bodger
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
- Gastroenterology Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Thomas Mair
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Peità Schofield
- Department of Public Health & Policy, University of Liverpool, Liverpool, UK
| | - Benjamin Silberberg
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Steve Hood
- Gastroenterology Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Kate M Fleming
- Data & Analytics Transformation Directorate, NHS England, Redditch, UK
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4
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Niu X, Zhu L, Xu Y, Zhang M, Hao Y, Ma L, Li Y, Xing H. Global prevalence, incidence, and outcomes of alcohol related liver diseases: a systematic review and meta-analysis. BMC Public Health 2023; 23:859. [PMID: 37170239 PMCID: PMC10173666 DOI: 10.1186/s12889-023-15749-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Alcohol related liver disease (ARLD) is one of the major chronic liver diseases worldwide. This review aimed to describe the global prevalence, incidence, and outcomes of ARLD. METHODS Medline, Embase, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were searched from inception to May 31, 2022. The language was restricted to English or Chinese. According to the criteria, articles describing the basic characteristics of the population were selected. Two reviewers extracted the data independently. RESULTS A total of 372 studies were identified: 353 were used for prevalence analysis, 7 were used for incidence analysis, and 114 were used to for outcome analysis. The prevalence of ARLD worldwide was 4.8%. The prevalence in males was 2.9%, which was higher than female (0.5%). Among the ethnic groups, the percentage was highest in Caucasians (68.9%). Alcoholic liver cirrhosis comprised the highest proportion in the disease spectrum of ARLD at 32.9%. The prevalence of ascites in ARLD population was highest (25.1%). The ARLD population who drinking for > 20 years accounted for 54.8%, and the average daily alcohol intake was 146.6 g/d. About 59.5% of ARLD patients were current or former smokers, and 18.7% were complicated with hepatitis virus infection. The incidence was 0.208/1000 person-years. The overall mortality was 23.9%, and the liver-related mortality was 21.6%. CONCLUSION The global prevalence of ARLD was 4.8% and was affected by sex, region, drinking years, and other factors. Therefore, removing the factors causing a high disease prevalence is an urgent requisite. TRIAL REGISTRATION PROSPERO Nr: CRD42021286192.
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Affiliation(s)
- Xuanxuan Niu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lin Zhu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yifan Xu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Menghan Zhang
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yanxu Hao
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lei Ma
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yan Li
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Huichun Xing
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China.
- Peking University Ditan Teaching Hospital, Beijing, 100015, China.
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King J, Walker K, Van Der Meulen J, Bernal W. Editorial: the burden of alcohol-related liver disease emergency admissions in England may be twice as high as previously thought. Aliment Pharmacol Ther 2023; 57:435-436. [PMID: 36710537 DOI: 10.1111/apt.17335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Jessica King
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kate Walker
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jan Van Der Meulen
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
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Bodger K, Dhanda A. Editorial: the burden of alcohol-related liver disease emergency admissions in England may be twice as high as previously thought-authors' reply. Aliment Pharmacol Ther 2023; 57:437-438. [PMID: 36710535 DOI: 10.1111/apt.17366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Keith Bodger
- University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ashwin Dhanda
- Faculty of Health, University of Plymouth, Plymouth, UK.,South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
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7
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Dhanda A, Bodger K, Hood S, Henn C, Allison M, Amasiatu C, Burton R, Cramp M, Forrest E, Khetani M, MacGilchrist A, Masson S, Parker R, Sheron N, Simpson K, Vergis N, White M, Boyd A, Brind A, Joshi A, Rund A, Srivastava A, McCune A, Gartland A, Hudson B, Stableforth B, John C, Maxan E, Unitt E, Beetteridge F, Lewis H, Fellows H, Haq I, Patel J, Ryan J, Cobbold J, Pohl K, Raeburn K, Corless L, Johnston M, Subhani M, Shah N, Ali N, Rajoriya N, Bendall O, Saeed O, Berry P, Moodley P, Abdelbadiee S, Davies S, Kotha S, Ryder S, Verma S, Manship T, Kumar V, Haddadin Y. The Liverpool alcohol-related liver disease algorithm identifies twice as many emergency admissions compared to standard methods when applied to Hospital Episode Statistics for England. Aliment Pharmacol Ther 2023; 57:368-377. [PMID: 36397658 PMCID: PMC10099257 DOI: 10.1111/apt.17307] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/19/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency admissions in England for alcohol-related liver disease (ArLD) have increased steadily for decades. Statistics based on administrative data typically focus on the ArLD-specific code as the primary diagnosis and are therefore at risk of excluding ArLD admissions defined by other coding combinations. AIM To deploy the Liverpool ArLD Algorithm (LAA), which accounts for alternative coding patterns (e.g., ArLD secondary diagnosis with alcohol/liver-related primary diagnosis), to national and local datasets in the context of studying trends in ArLD admissions before and during the COVID-19 pandemic. METHODS We applied the standard approach and LAA to Hospital Episode Statistics for England (2013-21). The algorithm was also deployed at 28 hospitals to discharge coding for emergency admissions during a common 7-day period in 2019 and 2020, in which eligible patient records were reviewed manually to verify the diagnosis and extract data. RESULTS Nationally, LAA identified approximately 100% more monthly emergency admissions from 2013 to 2021 than the standard method. The annual number of ArLD-specific admissions increased by 30.4%. Of 39,667 admissions in 2020/21, only 19,949 were identified with standard approach, an estimated admission cost of £70 million in under-recorded cases. Within 28 local hospital datasets, 233 admissions were identified using the standard approach and a further 250 locally verified cases using the LAA (107% uplift). There was an 18% absolute increase in ArLD admissions in the seven-day evaluation period in 2020 versus 2019. There were no differences in disease severity or mortality, or in the proportion of admissions with decompensation of cirrhosis or alcoholic hepatitis. CONCLUSIONS The LAA can be applied successfully to local and national datasets. It consistently identifies approximately 100% more cases than the standard coding approach. The algorithm has revealed the true extent of ArLD admissions. The pandemic has compounded a long-term rise in ArLD admissions and mortality.
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Affiliation(s)
- Ashwin Dhanda
- University of Plymouth, Plymouth, UK.,South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Keith Bodger
- University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Steve Hood
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Clive Henn
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
| | - Michael Allison
- Cambridge Liver Unit, Cambridge NIHR Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Chioma Amasiatu
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
| | - Robyn Burton
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
| | - Matthew Cramp
- University of Plymouth, Plymouth, UK.,South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Meetal Khetani
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
| | | | - Steven Masson
- Liver Unit, Newcastle Hospitals NHS Trust, Newcastle, UK
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nick Sheron
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
| | - Ken Simpson
- Liver Unit, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Nikhil Vergis
- Imperial College London, London, UK.,Research and Development, GlaxoSmithKline (GSK), Hertfordshire, UK
| | - Martin White
- Addiction and Inclusion Directorate, Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK
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8
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Williams R, Alessi C, Alexander G, Allison M, Aspinall R, Batterham RL, Bhala N, Day N, Dhawan A, Drummond C, Ferguson J, Foster G, Gilmore I, Goldacre R, Gordon H, Henn C, Kelly D, MacGilchrist A, McCorry R, McDougall N, Mirza Z, Moriarty K, Newsome P, Pinder R, Roberts S, Rutter H, Ryder S, Samyn M, Severi K, Sheron N, Thorburn D, Verne J, Williams J, Yeoman A. New dimensions for hospital services and early detection of disease: a Review from the Lancet Commission into liver disease in the UK. Lancet 2021; 397:1770-1780. [PMID: 33714360 PMCID: PMC9188483 DOI: 10.1016/s0140-6736(20)32396-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/29/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022]
Abstract
This Review, in addressing the unacceptably high mortality of patients with liver disease admitted to acute hospitals, reinforces the need for integrated clinical services. The masterplan described is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospitals-a pattern of care similar to that successfully introduced for stroke services. The plan includes the establishment of a lead and deputy lead clinician in each acute hospital, preferably a hepatologist or gastroenterologist with a special interest in liver disease, who will have prime responsibility for organising the care of admitted patients with liver disease on a 24/7 basis. Essential for the plan is greater access to intensive care units and high-dependency units, in line with the reconfiguration of emergency care due to the COVID-19 pandemic. This Review strongly recommends full implementation of alcohol care teams in hospitals and improved working links with acute medical services. We also endorse recommendations from paediatric liver services to improve overall survival figures by diagnosing biliary atresia earlier based on stool colour charts and better caring for patients with impaired cognitive ability and developmental mental health problems. Pilot studies of earlier diagnosis have shown encouraging progress, with 5-6% of previously undiagnosed cases of severe fibrosis or cirrhosis identified through use of a portable FibroScan in primary care. Similar approaches to the detection of early asymptomatic disease are described in accounts from the devolved nations, and the potential of digital technology in improving the value of clinical consultation and screening programmes in primary care is highlighted. The striking contribution of comorbidities, particularly obesity and diabetes (with excess alcohol consumption known to be a major factor in obesity), to mortality in COVID-19 reinforces the need for fiscal and other long delayed regulatory measures to reduce the prevalence of obesity. These measures include the food sugar levy and the introduction of the minimum unit price policy to reduce alcohol consumption. Improving public health, this Review emphasises, will not only mitigate the severity of further waves of COVID-19, but is crucial to reducing the unacceptable burden from liver disease in the UK.
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Affiliation(s)
- Roger Williams
- Institute of Hepatology, Foundation for Liver Research, London, UK
| | | | - Graeme Alexander
- UCL Institute for Liver & Digestive Health, Royal Free Hospital, London, UK
| | - Michael Allison
- Liver Unit, Department of Medicine, Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard Aspinall
- Department of Gastroenterology & Hepatology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Rachel L Batterham
- National Institute of Health Research, UCLH Biomedical Research Centre, London, UK
| | - Neeraj Bhala
- NIHR Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Gastrointestinal and Liver Services, Queen Elizabeth Hospital Birmingham at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Natalie Day
- Institute of Hepatology, Foundation for Liver Research, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Colin Drummond
- Institute of Psychiatry, Psychology & Neuroscience, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - James Ferguson
- NIHR Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Graham Foster
- Bart's Liver Centre, Queen Mary University of London, London, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK; Alcohol Health Alliance, London, UK.
| | - Raphael Goldacre
- Unit of Health Care Epidemiology, Big Data Institute, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Harriet Gordon
- Gastroenterology Department, Hampshire Hospitals Foundation Trust, Winchester, UK
| | | | - Deirdre Kelly
- Liver Unit, Birmingham Women's and Children's Hospital and University of Birmingham, Birmingham, UK
| | | | | | | | - Zulfiquar Mirza
- Emergency Department, West Middlesex University Hospital, London, UK
| | | | - Philip Newsome
- NIHR Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Pinder
- School of Public Health, Imperial College of Science & Technology, London, UK
| | | | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Stephen Ryder
- NIHR Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Nick Sheron
- Institute of Hepatology, Foundation for Liver Research, London, UK
| | - Douglas Thorburn
- UCL Institute for Liver & Digestive Health, Royal Free Hospital, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
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