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Background & AimsThere is a need for accurate biomarkers of fibrosis for population screening of alcohol-related and non-alcoholic fatty liver disease (ALD, NAFLD). We compared the performance of the enhanced liver fibrosis (ELF) test to the fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS), using transient elastography as the reference standard.MethodsWe prospectively included participants from the general population, and people at risk of ALD or NAFLD. Screening positive participants (TE ≥8 kPa) were offered a liver biopsy. We measured concomitant ELF, FIB-4, and NFS using validated cut-offs: ≥9.8, ≥1.3, ≥-1.45, respectively.ResultsWe included 3,378 participants (1,973 general population, 953 at risk of ALD, 452 at risk of NAFLD), with a median age of 57 years (IQR: 51-63). Two hundred-and-forty-two were screening positive (3.4% in the general population, 12%/14% who were at-risk of ALD/NAFLD, respectively). Most participants with TE ConclusionThe ELF test alone or combined with FIB-4 for liver fibrosis screening in the general population and at-risk groups reduces the number of futile referrals compared to FIB-4 and NFS, without overlooking true cases.Impact and implicationsWe need referral pathways that are efficient at detecting advanced fibrosis from alcohol-related and non-alcoholic fatty liver disease in the population, but without causing futile referrals or excessive use of resources. This study indicates that a sequential test strategy of FIB-4 followed by the ELF test in indeterminate cases leads to few patients referred for confirmatory liver stiffness measurement, while retaining a high rate of detected cases, and at low direct costs. This two-step referral pathway could be used by primary care for mass, targeted, or opportunistic screening for liver fibrosis in the population.

Introduction Quality improvement is an inherent part of modern healthcare systems worldwide, used for the continuous advancement in effectiveness and safety. Amongst other approaches, the plan-do-study-act (PDSA) method, a four-step iterative method, is widely used for testing and implementation of quality-improving interventions in health care despite a poor evidence of its effectiveness. Accepting the premise that the underlying purpose of improvements in health care is to improve patients’ health as suggested by, amongst others, the American National Academy of Medicine, the data measurements used to assess the impact of quality improvement projects, consequently, ought to reflect how they eventually impact patients’ health.Objectives The purpose of the present paper is to review recently published PDSA projects to investigate how the effect of quality improvements are being measured, and if the authors provide scientific evidence that their choice of effect measure, i.e. the quality indicator, is associated with patients’ health. Methods The basis of the present study was a systematic review of studies on PDSA quality improvement projects published in 2015-2017. For all identified papers, the primary quality indicators were categorized in accordance with A. Donabedian’s three definitions of dimensions of quality, i.e., structure, process, and outcome indicators. Secondly, it was assessed if the authors of the studies reported the applied quality indicator as being evidence-based, i.e. whether they were associated with patient-relevant outcomes. In addition, adherence to the SQUIRE guidelines as reported in the studies was observed. The assessment was performed individually by NKS and ASV. Any disagreements were resolved through discussion.Results In all, 54 studies were included for assessment. One study was excluded, as reporting of any quality indicators was absent. The result of the systematic review showed that one out of 53 studies applied a structure indicator, in 83 percent (44/53) of the studies process indicators were applied, and outcome indicators were applied in 15 percent of the studies (8/53). In general, the quality indicators were very heterogeneous causing incomparability of results. The results from the assessment of whether authors identified the applied quality indicator as being an evidence-based indicator showed that only in four studies, the authors reported them as such. Conclusion Process indicators, rather than health-related outcome measures, appear to be used most often in quality improvement projects applying the PDSA method. Evidence-based indicators were only applied in four studies. Overall, this challenges the ability to show if, and how, interventions actually affect patients’ health. This is problematic for a number of reasons; if the applied quality indicator does, in fact, not signify final impact patients’ health, the value of the interventions might be questioned. If we cannot confirm an association between applied quality indicators and final impact on health, we may potentially harm patients indirectly by pursuing ineffective solutions. This would be a direct antithesis to the main purpose of the health care system. This study is based on assessments of self-reported information in the studies and, consequently, the results presented here is a reflection of the information reported in the studies. However, systematic reporting guidelines were only applied in two studies. Enhancement of the validity of the present results calls for an increase in the consistent and systematic reporting of quality improvement interventions.

Background: Echocardiographic imaging is paramount during left atrial appendage occlusion (LAAO). Observational studies have demonstrated similar efficacy and safety of intracardiac echocardiography (ICE) from the left atrium and transesophageal echocardiography (TEE).Purpose: To perform a cost-comparison of TEE and ICE guided LAAO by estimating the mean cost per patient.

Intracardiac echocardiography (ICE) from the left atrium is effective and safe, and enables left atrial appendage occlusion (LAAO) to be performed in local anesthesia. Thereby, personnel requirements and time spent in the catheter lab is reduced. However, high cost of the ICE catheter might be a