PT3 (NMC) “To have that done, very quick(ly), it was like a relief for me because I was very, very stressed” PT6 (NMC) “(I was) just really in limbo as to what I was going to do and then it was good to get the phone call to say, hey you can jump the queue by not seeing specialist but a nurse. So that was good reassurance… definitely good to speed up the process because when you hear something like that you freak out because you don’t understand it… it would be annoying now if I was still waiting to see a specialist. At least now I know that I have had improvement and that it’s not something to be worried about. Just need to make some lifestyle changes.” | Earlier access to screening resulted in a reduction in stress and anxiety for patients |
GP1 “So, they can be waiting months and months, sometimes years to see a Hepatologist… if we have little bit of the Fibroscan available, I suppose we can even stop the moderate fibrosis patient going to hospital… for me, it's going to be very helpful to have the Fibroscan available in the community.” | LOCATE model was perceived to be effective at improving access for patients and reducing hospital burden |
PT3 (NMC) “She just explain(ed) everything to me…show(ed) me the nearest screen and I saw everything there.” PT2 (NMC) “The lady there was wonderful. Really went and explained what she was doing. In a way that I think lay people like myself would understand.” PT5 (UC) “(it) would be nice to know exactly what it was, straight away… even within a fortnight, you know… I think I called to find out the information. Yeah. And they said that it hadn't been reported on, and this is like four months since I’d had it. And it still hadn't been reported on. So that's pretty poor.” | Nurses undertaking the LOCATE model were effective at communicating the test process and subsequent results Communication delays were experienced in the usual care arm. |
Adoption domain | Summary |
GP3 “I reckon I would diagnose NAFLD – once a week. Super common. So, a typical scenario would be maybe someone I send for check-up blood tests and their liver function tests are abnormal… and by and large the most common diagnosis is NAFLD… I just think it's such an important topic... thankfully, most people with fatty liver don't go on to get cirrhosis, but the rates of cirrhosis are increasing, as is patients having to have a transplant because of fatty liver and cirrhosis they cascade. So I just think it's such an important area that we shouldn't be brushing over and saying just fatty liver.” | GPs regularly manage patients with potential liver conditions and understand the need for better access to liver screening assessments |
GP1 “I think for me, it's going to be very, very helpful. But to be honest, when I came to speak to most of my colleagues...I'm talking about the general practitioners, they're not very familiar and they don't want to invest their time reading up… They find it easier just to refer the patient… If you are talking about the whole of the general practitioners, my understanding is that if you just make it (Fibroscan) available, most of the doctors they're not going to use it because they don't even, they don't know how to utilize it, don't know how to interpret it… they (need to) get better educated... I suppose even one page of information is enough to them to understand, accept it. I think that could stop heaps of patient going onto the waiting list.” GP2 “Getting a score is good, but further interpretation would be useful. A bit more information on what each of the scores means… How long do they have to "sort out" their lifestyle before they get into the next (risk) zone, etc.” | Further education for GPs is needed to support their referral to, and interpretation and use of screening results for broad adoption of the LOCATE model |
GP1 “I have to send some patients to hospital just because we can’t check them without a Fibroscan.” GP3 “I think I would be incredibly valuable to be able to refer for Fibroscan directly because that's (got) the best evidence... the main reason I refer to hospitals… if it's purely NAFLD, then it's really to get that opinion - Is there cirrhosis or not? The other time that I refer people is if I'm not sure NAFLD is the only thing going on… If it’s purely NAFLD then the main thing I am after is the Fibroscan.” | GPs highlighted a willingness to adopt the LOCATE model due to lack of access to diagnostic tools for NAFLD outside the specialist setting |
GP3 “I'm pretty confident, actually, unless there was something that didn't add up… but really other than something weird going on, I would (be) quite confident managing myself, yeah.” GP1 “I think I am pretty alright with that. From my knowledge of fatty liver disease, there is no particular pharmacological intervention, so at the end, it all comes to down to risk factor modification... All of these things we can do in primary care… I'm pretty confident that up to moderate fibrosis can be treated in the community... these are all things we can do by ourselves.” | GPs are confident addressing low risk NAFLD in the community without specialist review |
Implementation domain | Summary |
GP3 “Making sure its accessible to patients. I’ve got a lot of patients, you know, they wouldn't drive to the north side of Brisbane, for example, for a test. It has to be, you know, on the right side of town, so to speak. And I think that's important. Even simple things like parking. Can they get there in park or is there a fee for parking or is it in a major centre? ...then I know the funding and the cost, if any, to the patient, I think is another barrier to customer.” GP2 “Easy access to the facilities where the Fibroscan is… like radiology centres where they probably go normally for scans.” | GPs highlighted the importance of suitable locations and the need for access to community screening at low cost for patients. |
PT2 (NMC) “I went and had that scan, the non-invasive scan. Look, I just remember [family member] having to go and having biopsies… but sometimes it's quite invasive… Whereas having that scan was just great… It was perfect. It was just the local hospital. And you, you know, you just sat and waited your turn, like a doctor's surgery… (but) it would be great if you could get in sooner...” PT4 (NMC) “Yeah, that was that was fine. It wasn't invasive or anything.” PT1 (UC) “I jumped on the train. I didn’t have to walk far, they saw me straight away, they were magical…. The only thing I did say is why did I have to wait to go to the hospital when I could have probably had it done elsewhere?” PT6 (NMC) “It hasn't been an issue for me. It's fine. And even if I didn't have a car, there is public transport and everything, so that's fine. It was easy to find, and everyone's been friendly and that’s good.” | Patients highlighted the non-invasive nature of the screening test and the relative ease of access but flagged timeliness and location as key access considerations. |
PT1 (UC) “Oh, they were lovely over at the [hospital]… They were really good. Treated me absolutely lovely” PT4 (NMC) “Oh, good, good. Actually, the nurse was amazing, to be honest…. No, just positive feedback… I'm happy with the whole overall process - from seeing, from my GP to you guys, and go back to my GP, and everything has been very smooth.” PT6 (NMC) “I did find that last nurse was quite quick. I did feel that in the last appointment that I had she was time sensitive. Like, you could tell she was just in a hurry with me. That wasn't a good feeling… I felt like I was just a number to her.” | Patients noted predominantly positive interpersonal experiences with the nursing staff performing the screening assessments, but this was not universal. |
PT4 “This is a kind of normal for you. I don't drink. I usually have a good diet. I exercise every day. So, we have been checking up every six months and having a blood test since then. And then the numbers haven't changed at all yet…. He's actually pretty happy with my normal life.” PT1 (UC) “I don’t take any medication… I’m not on anything… So, you know I’m pretty healthy… not like all the pills my friends are on.” PT6 (NMC) “I actually do lots of exercise, so I don’t really have an issue in the exercise area. Obviously, my diet is the issue, so I could really use some advice on dietary.” | There was a range of awareness and experiences related to NAFLD diagnoses and the understanding of the relative contribution of lifestyle factors to liver disease. |
Maintenance domain | Summary |
GP1 “Number 1. Fibroscan available for some patients on Medicare so they don’t have to pay out of pocket, 2. Able to be done without patients going on the waiting list, and 3. Just be able to refer to Fibroscan (performed) by a nurse, not have to go to hospital… (but) that’s going to be a big job to get that on Medicare through the Federal government. Maybe just through the state level… No need to see Hepatology... like fast-track fibro-scan.” GP3 “Previously we had people come and do some lunch time meetings… whoever championed for hepatitis B, you know, offering free Fibroscans for people with hepatitis B. Or, just knowing that it (Fibroscan) was even an option… the other way is through the general primary health networks. And certainly, a lot of us subscribe to the weekly newsletter from them. And that goes is not only to the GP who prescribe, subscribes, but also to practice nurses. And a lot of practice nurses are really good resources in terms of what's available in the community and they can share which can be beneficial to everyone the practice. I think it is a really good way of reaching a lot of people.” | A Medicare rebate and GP education were recommended for sustainability of any future scale-up of the LOCATE model |
GP3 “The usual barriers to lifestyle management, unfortunately, as it's hard. It’s not as simple as just taking a tablet. What we all want things that we can fix easily. And you know, the idea of taking a tablet, I can understand that - I have this tablet, I understand that my blood pressure or my Diabetes or whatever it is, it's fixed. And the fact that there is no option like that for NAFLD, I think it makes it really tricky because it is hard to exercise, and it is hard to lose weight. And so those things, I think, you know, that's almost universally difficult.” GP3 “I suppose I work in an area that is mixed SES (socioeconomic status), so for some people money is not a problem, whereas for other people might struggle to see a dietitian or see an exercise physiologist. And there's things we can do to try to help, such as their care plan, where they can access allied health professionals, but there might still be a gap, say on top of that. If you're really struggling to pay the bills an extra $30, you know, to see the dietitian, is a lot of money… the other thing that people have been feeding back to me particularly recently is just the cost of living and how expensive groceries are… I think financial limitations is certainly a big thing as well when it comes to making those lifestyle changes” | GPs highlighted multiple barriers to subsequent lifestyle modification once screening results had been received by patients, such as cost of living pressures. |
PT2 (NMC) “When I was younger… I was exercising five, six times a week... But I struggle with it now when I'm trying to work full time and manage a home, my husband often works away so it's like just me delivering boys in different directions, and it’s really hard.” PT6 (NMC) “I am allowed to get some (exercise) support and dietary (advice), however, because I can't get a whole Tuesday off… (I’m) on the wait list. So that's kind of been disappointing… I've got an appointment, which I just confirmed today in [3-months' time]… I gave up and found my own dietitian. My GP is not really, well, she's in a hurry all the time… I feel going back to her would be a waste of time.” PT5 (UC) “I've just dropped one day of work a week in the last couple of months... so that I can accommodate the appointments... Again, they haven't really given me any advice other than other than the Mediterranean diet... I kind of think this day off will help me with losing weight.” | Patients noted both individual and system level barriers to lifestyle modification such as competing work and family commitments, as well as challenges accessing publicly funded services |