The communication of a secondary care diagnosis of autoimmune hepatitis to primary care practitioners: a population-based study

Autoimmune hepatitis (AIH) is a chronic liver disease with an immune mediated aetiology. The disease is rare with an annual incidence of 1.9/100000 [1] and has a bimodal age distribution with median age at diagnosis approximately 43 years [2]. It is an uncommon but important disease due to the potential for decompensated cirrhosis and the requirement of an orthotropic liver transplant in otherwise young, healthy people. Recent data from a non-transplant centre in the UK has estimated the 10 year survival to be 82% [3].

The clinical features of AIH are complicated and require a strong clinical suspicion with contributory evidence such as a suggestive liver biopsy, auto-antibodies (anti-nuclear antibodies, anti-smooth muscle cell and anti-liver kidney microsomal antibodies) or an elevated Immunoglobulin G (IgG) titre. Liver biopsy should classically show active interface hepatitis with lymphocytic and plasma-cell infiltrates. There have been several scoring criteria formulated for diagnosis which include the original, revised and simplified [4] criteria by the International Autoimmune Hepatitis group. However, the consensus is that clinical diagnosis is most important [1].

As AIH is a relatively uncommon but important disease, it is difficult to obtain large cohorts of patients to study. Previous studies have used multiple hospital data collection methods, and the largest study so far has obtained 473 patients with Autoimmune Hepatitis [2]. However, these methods are not without potential selection bias and considerable expense. The use of population-based databases may provide an alternative means of obtaining a large cohort of AIH patients. The strengths of databases include prospective, systematic collection of data including exposures, confounders and outcome information. However, their limitations include concerns about the validity of a diagnosis of Autoimmune Hepatitis within the database. The UK General Practice Research Database is one such population-based database. It has over 5 million currently registered patients [5] and it is therefore estimated would provide between 1000–2500 unique patients for studies of the epidemiology of Autoimmune Hepatitis. We have therefore aimed to validate the sensitivity of diagnosis of AIH in electronic primary care data in order to assess its usefulness for studying AIH.

More than 300 studies have been performed to assess the positive predictive value of the coding of diseases for the presence of the coded diagnosis. These have in general found high positive predictive values in the order of 90% [7, 8]. It is likely that the same will be true for Autoimmune Hepatitis, but that is not what this study has examined. We in contrast have examined the sensitivity of the coded diagnosis of a chronic disease for its presence, and this to our knowledge has very rarely been done before [9].

We assessed the validity of the coding of AIH using a cohort of 42 patients with AIH and 7 patients with other diagnoses or an overlap syndrome whose biopsies were reviewed at the liver biopsy meeting at the Queens Medical Centre, Nottingham, UK, between 2004 and 2009. The diagnosis of AIH is complicated, as essentially there is no single pathognomonic feature [1] and the clinical context is of the utmost importance. Despite there being validated scoring criteria, the consensus of recent British Society of Gastroenterology guidelines on AIH is that this diagnosis requires considerable “clinical expertise” [1] and scoring should be used as an adjunct. We chose to use a consultant diagnosis of autoimmune hepatitis as our gold standard as had Yeoman [10]. We had 42 patients available to us who had a clinical diagnosis of AIH as confirmed by the managing hepatologist, for whom we requested coding information from GPs. We received 39 responses, 37 of the patients had coded or free text information available for the diagnosis of autoimmune hepatitis. Two additional practices wrote back to us to state the patient had left the practice or that they patient was deceased and they no longer held their electronic or paper records (Table 4). Of the 37 GP practices which had information available on the electronic recording of patient data, 89% used a specific READ code for Autoimmune Hepatitis (J638.00 Autoimmune Hepatitis). Others had used non-specific codes which may be interpreted as other forms of liver disease or used free text (Table 4).

We believe therefore that the sensitivity of the coded diagnosis of Autoimmune Hepatitis for the detection of this condition in General Practice is 89% i.e. 89% of all people diagnosed with Autoimmune Hepatitis in hospital get a specific code in electronic primary care records for Autoimmune Hepatitis. This high sensitivity ensures that electronic records are unlikely greatly to underreport the incidence and prevalence of AIH and thus such records are suitable for studying the epidemiology of AIH in databases such as the General Practice Research Database, QResearch or the Health Improvement Network in the United Kingdom. Mediplus is a general practice database used in France, Austria and Germany; Holland uses PHARMO, IPCI and PALGO. In addition there are hospital based databases in England, Spain, Sweden Canada, Australia, Asia (China, Hong Kong, Japan, South Korea, Taiwan and Singapore), Latin America (Brazil, Argentina, Mexico, Venezuela, Peru, Chile). Evidence exists that data from the UKGPRD correlates with other databases in Europe e.g. fracture risk in coeliac disease was found to be increased to the same extent in both the UK GPRD [11] and in the Swedish National Inpatient Register [12] There are also Danish Registries which have been used to look at liver diseases [13].

Seven of the initial fifty patients were subsequently found to have other diagnoses, or overlap syndromes. We wrote to their general practitioners to assess the possibility of a miscoded diagnosis of AIH. If we were considering performing population-based studies, we would be able to exclude most of the overlap and misdiagnosed patients by excluding any person with a code for another form of liver disease as well as autoimmune hepatitis. 71% of these overlap syndromes or those with subsequent diagnoses were accurately coded.

Use of electronic primary care data for studying the epidemiology of Autoimmune Hepatitis will be an efficient means of studying this disease, enabling access to large population-based cohorts in order to answer some of the important questions of the contemporary natural history of this disease. Our results suggest, we will through such work be able to precisely quantify the incidence and prevalence of AIH without fear of grossly underestimating the disease as the sensitivity of the recording is so good. Equally, studies of aetiology and consequence should be able to provide much needed insights into this condition. Further work into the positive predictive value of this disease in electronic data is still required.