Long-term conditions in West Bengal, followed as one person, not five lists

West Bengal now has more raised blood sugar and blood pressure than India as a whole, and the gap opened in the last three years. A neighbourhood lab in Barasat already holds the results that show who has diabetes, failing kidneys, high cholesterol, an underactive thyroid or a scarring liver, and who has stopped coming back. This page sets the state against the country, then turns the lab's results into one follow-up call per person across all five conditions.

West Bengal and India figures: published surveys, cited · lab figures: synthetic cohort shaped like the AKTIV research mirror, 11,403 people, 76,995 results, 3.5 years to 23 Sep 2026, no real patient data.

34.1%

of people tested are on at least one follow-up pathway

3,887 of 11,403, simulated

42.6%

of them are on two or more

1,657 people, simulated

1,397

calls this week, one per person

instead of 1,801 across five lists

22.4%

fewer calls for the same checks

404 calls saved

West Bengal against India

Noncommunicable diseases cause 63% of deaths in India (WHO). Every figure in this section is published and linked to its source; none is computed from the lab.

NFHS-6 2023-24 vs NFHS-5 2019-21adults 15+ unless stated

Same survey, same method: West Bengal and India

% of adults, NFHS-6 2023-24; the dark tick marks NFHS-5 2019-21

Women: blood sugar over 140 mg/dL or on medicine

West Bengal22.7% +5.2 since NFHS-5

India17.8% +4.3 since NFHS-5

Men: blood sugar over 140 mg/dL or on medicine

West Bengal26.8% +5.5 since NFHS-5

India20.9% +5.3 since NFHS-5

Women: blood sugar over 160 mg/dL

West Bengal12.1% +4.4 since NFHS-5

India9.1% +2.8 since NFHS-5

Men: blood sugar over 160 mg/dL

West Bengal14.3% +4.8 since NFHS-5

India10.9% +3.8 since NFHS-5

Women: blood pressure 140/90+ or on medicine

West Bengal24.3% +3.8 since NFHS-5

India19.4% −1.9 since NFHS-5

Men: blood pressure 140/90+ or on medicine

West Bengal24.9% +4.8 since NFHS-5

India22.1% −1.9 since NFHS-5

Women 15-49: overweight or obese (BMI 25+)

West Bengal34.6% +11.9 since NFHS-5

India30.7% +6.7 since NFHS-5

Men 15-49: overweight or obese (BMI 25+)

West Bengal24.5% +8.3 since NFHS-5

India27.3% +4.4 since NFHS-5

Men: use any tobacco

West Bengal46.2% −1.9 since NFHS-5

India36.3% −1.7 since NFHS-5

West Bengal
India

West Bengal is above India on every blood sugar and blood pressure measure, for women and for men. Raised blood pressure rose in West Bengal (women 20.5% to 24.3%, men 20.1% to 24.9%) while it fell nationally. Blood sugar over 160 mg/dL, the level that usually means untreated or uncontrolled diabetes, rose by about half in five years. Source: NFHS-6 (2023-24) fact sheets, IIPS / MoHFW 2026.

Condition by condition

best published estimate for each; studies differ in method, age and year, so read across a row with care

Condition	West Bengal	India	This lab, simulated
Diabetes	22.7% / 26.8%women / men, random sugar over 140 or on medicine · NFHS-6 (2023-24) fact sheets, IIPS / MoHFW 2026	11.4%adults 20+, OGTT or HbA1c; NFHS-6 equivalent 17.8% / 20.9% · Anjana et al., ICMR-INDIAB-17, Lancet Diabetes Endocrinol 2023	17.7%of people tested at the lab
High blood pressure	24.3% / 24.9%women / men, 140/90+ or on medicine · NFHS-6 (2023-24) fact sheets, IIPS / MoHFW 2026	35.5%adults 20+; NFHS-6 equivalent 19.4% / 22.1% · Anjana et al., ICMR-INDIAB-17, Lancet Diabetes Endocrinol 2023	not a lab test
Kidney disease	4.1%adults over 30 with eGFR under 60, rural South 24 Parganas · Gallieni et al., Sci World J 2014	3.5–17.2%range across methods and settings · Singh et al., SEEK-India, BMC Nephrol 2013	5.8%of people tested at the lab
High cholesterol	no open estimatestate figures sit in the INDIAB-17 appendix; not reproduced here	24.0%total cholesterol 200 mg/dL or more · Anjana et al., ICMR-INDIAB-17, Lancet Diabetes Endocrinol 2023	13%of people tested at the lab
Hypothyroidism	21.7%Kolkata, highest of eight cities · Unnikrishnan et al., Indian J Endocrinol Metab 2013	10.95%eight-city average; 15.9% of women, 5.0% of men · Unnikrishnan et al. 2013	5.5%of people tested at the lab
Fatty liver	8.7%rural adults by ultrasound, 2010; 75% of them not overweight · Das et al., Hepatology 2010	38.6%pooled across 50 studies, mostly urban and later · Shalimar et al., J Clin Exp Hepatol 2022	12.1%of people tested at the lab

The lab column is simulated until result values are synced, and even then it is not a prevalence: people come to a lab because a doctor suspected something, so the share on a pathway will run above the survey figure. What the lab adds is the part surveys cannot see: whether the same person came back. Kolkata has twice the eight-city rate of hypothyroidism, which is why thyroid sits beside the metabolic conditions here.

The same people, on several lists

A person is on a condition's pathway once a result puts them there (definitions in each condition's tab below). Counts come from one linked timeline per person, so a person is counted once however many visits and PATIENT_KEYs they have.

11,403 people3,887 on a pathwayas of 23 Sep 2026

If someone is on this list, how often are they on that one

% of people on the row's pathway also on the column's

also on

DiabetesKidney diseaseCholesterolThyroidFatty liver

Diabetes

100%

14%

45%

28%

Kidney disease

42%

100%

45%

25%

Cholesterol

61%

20%

100%

24%

Thyroid

22%

18%

100%

16%

Fatty liver

42%

12%

26%

100%

rows: on this pathway

Diabetes sits in the middle of the web: people on the kidney, cholesterol and liver lists often have it too. Thyroid disease overlaps least; it is the condition of younger women, not of the metabolic cluster.

Conditions per person

n = 11,403 people tested

None7,516
One2,230
Two1,120
Three or more537

Multimorbidity climbs with age

% of people in each age band on 1, 2, or 3+ pathways

age

18–2930–3940–4950–5960–6970+

One

16%

17%

20%

22%

20%

21%

Two

10%

12%

14%

Three or more

22% of people tested in their sixties are on two or more pathways, against 3% under thirty. A programme that follows one disease at a time calls them more than once and still misses the checks nobody owns.

One call, one sample

Each condition list ranks who is due or overdue this week. Merged by person, the coordinator makes one call, books one home collection, and every overdue test runs from the same blood draw. Only the urine ACR for kidney follow-up needs a second container.

Calls this week

keep-in-care queues, all five conditions

One list per condition1,801
One call per person1,397

404 fewer calls (22.4%) for exactly the same set of overdue checks. The saving goes to the re-engagement queue, where 1,968 people have lapsed on at least one condition.

How many checks each call covers

n = 1,397 people due this week

One condition75% 1,045
Two conditions22% 302
Three or more4% 50

230 of these calls include a kidney check, so the collection agent brings a urine container.

Checks nobody ordered

people with a diabetic-range result, n = 2,018

No kidney test (creatinine or urine ACR) ever25.6%
No lipid profile ever38.4%
No computable FIB-4 ever59.2%

These people never reach the kidney, cholesterol or liver list because the test that would put them there was never done. The merged call adds the missing test to the same sample.

Each condition

The summary row for every condition, then one tab per condition with its cohort, who gets lost, its own call list and the guideline rules behind it.

Condition	On pathway	% of tested	Also another condition	Due this week	Lost now	Lost within 12 mo	Follow-up tests
Diabetes	2,018	17.7%	65.8%	663	48.9%	on /diabetes	HbA1c, fasting glucose
Kidney disease	661	5.8%	71.7%	230	40.5%	53.5%	creatinine, urine ACR
Cholesterol	1,477	13%	77.2%	423	48.7%	51.6%	lipid profile
Thyroid	630	5.5%	39.2%	165	50.2%	58.4%	TSH
Fatty liver	1,376	12.1%	54%	320	38.4%	41.8%	LFT, CBC

Diabetes rules are the ones on the diabetes page, run on this all-tests cohort, so its counts differ from that page's sugar-test-only cohort. Hypertension, the commonest NCD in West Bengal, is missing because blood pressure is not a lab result; it needs a reading at the camp or the collection visit.

Kidney disease follow-up, from creatinine the lab already runs

Creatinine is one of the most-ordered tests at Anubhav Life Care, Barasat, but the report shows a number in mg/dL, not kidney function. This tab turns every creatinine into an eGFR, confirms chronic kidney disease the way KDIGO asks (a raised marker lasting more than three months), sets the recall interval from the KDIGO heat map, and ranks who to call when the next check is missed.

661

people on the follow-up pathway

of 6,185 tested

40.5%

of them lost to follow-up now

268 people, 180+ days past due

147

overdue, still reachable

0 to 180 days past due

critical + high this week

the top of the call list

Where the cohort stands today

Everyone with at least one of the relevant tests (8,329bills), using each person's latest results. Linking turned the 12,343 PATIENT_KEYs across all their visits into 6,185 people.

Who was tested

sex as recorded; age at latest visit

6,185

people

52 : 48

female : male

569

18–29

1,062

30–39

1,648

40–49

1,482

50–59

844

60–69

580

70+

Latest eGFR

5,836 people

G1 ≥ 903,40958%
G2 60–891,82331%
G3a 45–592785%
G3b 30–442064%
G4 15–291002%
G5 < 15200%

On the pathway, by sex and age

% of people tested with egfr under 60 or urine acr 30+

age

18–2930–3940–4950–5960–6970+

Female

11%

18%

28%

Male

10%

12%

15%

24%

A referral lab, not a survey: people are tested because a doctor suspected something. The age gradient is the useful part.

Where people on the pathway sit now

n = 661; 42.1% also have a diabetic-range result

Raised once, not yet confirmed48.1% 318
CKD, very high risk21% 139
CKD, high risk17.4% 115
CKD, moderate risk12.9% 85
CKD, low risk0.6% 4

KDIGO grid for everyone on the pathway

latest eGFR stage × latest urine ACR, n = 641; colour is KDIGO risk, small number is checks per year

eGFR stage	A1 < 30	A2 30–300	A3 > 300	ACR never done
G1 ≥ 90	0 1×	9 1×	0 2×	0
G2 60–89	3 1×	18 1×	6 2×	1
G3a 45–59	52 1×	48 2×	5 3×	173
G3b 30–44	47 2×	49 3×	5 3×	105
G4 15–29	31 3×	26 3×	4 4×	39
G5 < 15	9 4×	4 4×	1 4×	6

324 of 641 people (51%) have never had a urine ACR, so their real KDIGO risk is unknown. Albuminuria is the earlier and cheaper warning; this column is the first thing to fix.

People with diabetes: the yearly kidney pair

n = 2,018 with a diabetic-range result

Ever had a creatinine (eGFR)69.7%
Ever had a urine ACR25.7%

ADA and KDIGO ask for both every year. The blood test is routine; the urine test that catches diabetic kidney disease earliest is the one that gets skipped.

Found only by urine

people on the pathway with a normal eGFR but ACR 30+

people

7.7%

of the pathway

Without urine ACR these people would not be on any list: their creatinine looks fine.

Following the same people over time

The clock starts at each person's first result that put them on the pathway. Someone is lost to follow-up once they are more than 180 days past their due date with no follow-up test here.

The follow-up cascade

people who joined the pathway at least 12 months ago, n = 441; each step counts people who also passed every step above

eGFR under 60 or urine ACR 30+100% 441
Came back for any follow-up test67.1% 296
Repeat within 4 months (confirms CKD)15% 66
Still testing in the last 12 months8.8% 39
Both eGFR and urine ACR in the last year4.8% 21

Show as table

Step	People	% of start
eGFR under 60 or urine ACR 30+	441	100%
Came back for any follow-up test	296	67.1%
Repeat within 4 months (confirms CKD)	66	15%
Still testing in the last 12 months	39	8.8%
Both eGFR and urine ACR in the last year	21	4.8%

Still in care, months after the first abnormal result

Kaplan-Meier, censored at 23 Sep 2026

Own mobile on file (n = 524)
Agent's number or none (n = 137)

At 12 months 54% of people with their own number are still in care, against 13% without one (only 10 still at risk in that group by then, so the line stops early).

Gap between consecutive eGFR tests

748 repeat tests in people on the pathway

25%

≤ 3 mo

39%

3–6 mo

17%

6–9 mo

9–12 mo

12–18 mo

> 18 mo

Within 6 months
Longer

36% of repeat tests arrive more than 6 months after the previous one, even among people who do come back.

Month-end status of everyone on the pathway so far

last 24 months

400

800

Oct 24Jan 25Apr 25Jul 25Oct 25Jan 26Apr 26Jul 26

On track or due soon
Overdue, still reachable (0 to 180 days)
Lost (over 180 days past due)

The lost pool grows from 61 to 268. The overdue-but-reachable band averages 141 over the last six months: that middle band is where a call list pays off.

Show as table

Month end	On track	Overdue	Lost
31 Oct 2024	116	82	61
30 Nov 2024	117	80	73
31 Dec 2024	124	90	76
31 Jan 2025	136	91	80
28 Feb 2025	137	96	95
31 Mar 2025	144	99	99
30 Apr 2025	145	107	107
31 May 2025	150	113	116
30 Jun 2025	151	116	127
31 Jul 2025	163	120	135
31 Aug 2025	169	110	151
30 Sep 2025	168	118	156
31 Oct 2025	184	125	159
30 Nov 2025	189	123	174
31 Dec 2025	198	117	187
31 Jan 2026	194	131	196
28 Feb 2026	202	130	201
31 Mar 2026	221	129	207
30 Apr 2026	229	128	215
31 May 2026	227	141	226
30 Jun 2026	232	148	230
31 Jul 2026	239	132	251
31 Aug 2026	213	152	265
23 Sep 2026	246	147	268

Who gets lost

Share of people lost within 12 months of joining the pathway, among those who joined at least a year ago. Overall: 53.5%. People without their own mobile on file are lost at 89% and 85%, against 46% for people with one.

Contact on file

% lost within 12 months

Own mobile46% n = 359
Agent's number only89% n = 55
No usable number85% n = 27

First came through

% lost within 12 months

Walk-in, Barasat51% n = 223
Home collection52% n = 103
Partner centre62% n = 58
Screening camp58% n = 57

Age

% lost within 12 months

Under 4063% n = 35
40 to 5954% n = 215
60 and over52% n = 191

Also has diabetes

% lost within 12 months

Diabetic-range result on file46% n = 197
No diabetic-range result59% n = 244

This week's eGFR call list

People who can still be kept are ranked by how sick and how late they are; people already lost go to a slower re-engagement queue. 230 to keep in care, 268 to re-engage; the top 120 and 40 are loaded here. Open a name to see the timeline.

Keep-in-care queue by who acts

178Care coordinator

24Collection agent

15Duty doctor

13Referring doctor / outreach

WhyWho actsFind

120 match · top 120 of 230 in this queue loaded · 0 actioned · 0 booked

Critical80
P-05827 · F · 65y99xxx xx254
33 mL/min↓9.0eGFR · 7 Jan 2026
Overdue 137 dayslast test 7 Jan 2026
Nephrology referral rangeeGFR falling fast+1
Doctor call first. Book creatinine + urine ACR, refer to nephrologyDuty doctor
Critical79
P-06984 · M · 42y85xxx xx616
19 mL/min↓12eGFR · 18 Dec 2025
Overdue 157 dayslast test 18 Dec 2025
Nephrology referral rangeeGFR falling fast+2
Doctor call first. Book creatinine + urine ACR, refer to nephrologyDuty doctor
Critical77
P-05492 · M · 58y82xxx xx949
25 mL/min↓16eGFR · 23 Jan 2026
Overdue 121 dayslast test 23 Jan 2026
Nephrology referral rangeeGFR falling fast+2
Doctor call first. Book creatinine + urine ACR, refer to nephrologyDuty doctor
Critical72
P-02278 · F · 79y90xxx xx126
33 mL/min↓5.0eGFR · 17 Sep 2025
Overdue 160 dayslast test 15 Dec 2025
eGFR falling fastKidney check overdue
Doctor call first. Book creatinine + urine ACRDuty doctor
Critical70
P-06796 · F · 40y98xxx xx669
11 mL/min↓12eGFR · 20 Mar 2026
Overdue 96 dayslast test 20 Mar 2026
Nephrology referral rangeeGFR falling fast+1
Doctor call first. Book creatinine + urine ACR, refer to nephrologyDuty doctor
High69
P-03454 · F · 55y97xxx xx825
24 mL/mineGFR · 9 Dec 2025
Overdue 166 dayslast test 9 Dec 2025
Nephrology referral rangeUrine ACR never done+1
Book creatinine + urine ACR, refer to nephrologyCare coordinator
High69
P-04732 · M · 45y83xxx xx089
25 mL/mineGFR · 9 Jan 2026
Overdue 135 dayslast test 9 Jan 2026
Nephrology referral rangeUrine ACR never done+1
Book creatinine + urine ACR, refer to nephrologyCare coordinator
High67
P-01014 · M · 49y78xxx xx665
44 mL/mineGFR · 1 Dec 2025
Overdue 174 dayslast test 1 Dec 2025
eGFR falling fastKidney check overdue
Book creatinine + urine ACRCare coordinator
High66
P-07749 · F · 61y99xxx xx046
25 mL/min↓10eGFR · 3 Feb 2026
Overdue 110 dayslast test 3 Feb 2026
Nephrology referral rangeUrine ACR never done+1
Book creatinine + urine ACR, refer to nephrologyCare coordinator
High66
P-04914 · M · 80y92xxx xx331
37 mL/min↓6.0eGFR · 27 Feb 2026
Overdue 86 dayslast test 27 Feb 2026
eGFR falling fastKidney check overdue
Book creatinine + urine ACRCare coordinator
High65
P-03070 · M · 56y81xxx xx601
28 mL/mineGFR · 2 Dec 2025
Overdue 173 dayslast test 2 Dec 2025
Nephrology referral rangeKidney check overdue
Book creatinine + urine ACR, refer to nephrologyCare coordinator
High65
P-07143 · M · 47y94xxx xx166
27 mL/mineGFR · 2 Jan 2026
Overdue 142 dayslast test 2 Jan 2026
Nephrology referral rangeKidney check overdue
Book creatinine + urine ACR, refer to nephrologyCare coordinator
High65
P-07117 · M · 89y78xxx xx158
20 mL/mineGFR · 15 Feb 2026
Overdue 98 dayslast test 15 Feb 2026
Nephrology referral rangeKidney check overdue
Book creatinine + urine ACR, refer to nephrologyCare coordinator
Critical65
P-01343 · M · 65y87xxx xx594
5.0 mL/min↓3.0eGFR · 5 Sep 2026
Due in 73 dayslast test 5 Sep 2026
Very low eGFR or sudden dropNephrology referral range+1
Doctor callback within 48 h, repeat creatinine + electrolytesDuty doctor
Critical64
P-02223 · F · 49y75xxx xx279
8.0 mL/min↓9.0eGFR · 7 Jul 2026
Due in 13 dayslast test 7 Jul 2026
Very low eGFR or sudden dropNephrology referral range+1
Doctor callback within 48 h, repeat creatinine + electrolytesDuty doctor

The rules behind the list

What is due, and when

Trigger	Next step	Basis
First eGFR under 60 or urine ACR 30+	repeat at 90 days	KDIGO: CKD needs more than 3 months of abnormality
Confirmed CKD, KDIGO low or moderate risk	every 365 days	KDIGO heat map: once a year
KDIGO high risk (e.g. G3a A2, G3b A1)	every 183 days	KDIGO heat map: twice a year
KDIGO very high risk (G3b A2+, G4)	every 122 days	KDIGO heat map: three times a year
G4 A3 or G5	every 91 days	KDIGO heat map: four or more times a year
eGFR under 30 or ACR over 300	nephrology referral	KDIGO referral criteria
eGFR falling 5+ mL/min a year	flagged on the list	KDIGO: rapid progression
No kidney test > 180 days past due	marked lost to follow-up	Same rule as the diabetes list

How the priority score is built

0 to 100

Factor	Points
KDIGO risk low / moderate / high / very high	8 / 14 / 24 / 32
Raised once, not yet confirmed	20
In nephrology referral range	+8
eGFR falling 5+ a year	+10
Urine ACR never done	+4
eGFR under 15, or down 30% within 90 days	+10, forces Critical
Days past due (peaks at 180, then decays)	up to 25
Due within the next 30 days	4
Age 65+	5

Critical 70+ (or a result that forces it), High 55 to 69, Medium 38 to 54, Routine below 38.

Definitions and blind spots

eGFR from serum creatinine with the race-free CKD-EPI 2021 equation, using sex and age on the bill; when no sex is recorded (56people) no eGFR is computed rather than guessed. A kidney marker is eGFR under 60 or urine ACR 30 mg/g or more. CKD is confirmed when markers are at least 90 days apart; a single raised marker is “not yet confirmed” and recalled at 3 months. Staging uses the latest eGFR (G1 to G5) and latest ACR (A1 to A3); when ACR was never done the person is staged as A1, which understates risk.

Blood pressure, ACE inhibitor or SGLT2 inhibitor use and dialysis status are not in lab data, and acute illness can lower eGFR for a while.

Cholesterol follow-up, so LDL reaches target and stays there

Heart attack and stroke are the largest cause of death in India, and LDL cholesterol is the risk factor a lab can measure and a cheap tablet can move. This tab links every lipid profile done at Anubhav Life Care, Barasatinto one timeline per person, judges LDL against the target for that person's risk, and ranks who to call when the recheck after a statin change never happens.

1,477

people on the follow-up pathway

of 5,278 tested

48.7%

of them lost to follow-up now

720 people, 180+ days past due

332

overdue, still reachable

0 to 180 days past due

critical + high this week

the top of the call list

Where the cohort stands today

Everyone with at least one relevant test (7,787bills), using each person's latest results. Linking turned the 10,832 PATIENT_KEYs across all their visits into 5,278 people.

Who was tested

sex as recorded; age at latest visit

5,278

people

51 : 49

female : male

387

18–29

730

30–39

1,478

40–49

1,384

50–59

770

60–69

529

70+

Latest LDL

5,278 people

< 7051810%
70–991,41827%
100–1291,82635%
130–1591,20223%
160–1892455%
≥ 190691%

On the pathway, by sex and age

% of people tested with ldl 160+, or 100+ with diabetes or ckd, or tg 500+

age

18–2930–3940–4950–5960–6970+

Female

15%

23%

27%

28%

35%

36%

Male

14%

21%

30%

29%

36%

31%

Share with a lipid result that needs action. People with diabetes or kidney disease have a stricter target, so the curve climbs with age as those conditions accumulate.

Where people on the pathway sit now

n = 1,477; 61.3% also have a diabetic-range result

Diabetes or CKD, above LDL 7068.1% 1,006
LDL 160 to 18921.2% 313
LDL 190+ (possible familial)9.7% 143
Triglycerides 500+1% 15

LDL at target, by risk group

people on the pathway, latest LDL

Diabetes or CKD (target < 70)8.5% 90 / 1,059
Everyone else (target < 100)12.9% 54 / 418

The people with the most to gain are the least often at target. The high-risk target is stricter, and a single statin dose rarely gets there without a recheck and a dose change.

Diabetes or CKD, never a lipid profile

n = 2,386 high-risk people

930

never had a lipid profile here

39%

of high-risk people

These people are not on the cholesterol list at all, because nobody ordered the test. The diabetes list carries the reminder.

LDL 190 and over: test the family

possible familial hypercholesterolaemia, relatives found through a shared household mobile

143

people with any LDL 190+

household members on the same number

of them never had a lipid profile

Familial hypercholesterolaemia passes to half of first-degree relatives and is treatable from childhood. The linking step that separates family members on one phone number is the same step that finds who to test next.

Following the same people over time

The clock starts at each person's first result that put them on the pathway. Someone is lost to follow-up once they are more than 180 days past their due date with no follow-up test here.

The follow-up cascade

people who joined the pathway at least 12 months ago, n = 964; each step counts people who also passed every step above

LDL 160+, or 100+ with diabetes or CKD, or TG 500+100% 964
Came back for any follow-up test64.8% 625
Repeat lipid profile within 4 months31.4% 303
Still testing in the last 12 months15.9% 153
Latest LDL at target3.3% 32

Show as table

Step	People	% of start
LDL 160+, or 100+ with diabetes or CKD, or TG 500+	964	100%
Came back for any follow-up test	625	64.8%
Repeat lipid profile within 4 months	303	31.4%
Still testing in the last 12 months	153	15.9%
Latest LDL at target	32	3.3%

Still in care, months after the first abnormal result

Kaplan-Meier, censored at 23 Sep 2026

Own mobile on file (n = 1,202)
Agent's number or none (n = 275)

At 12 months 53% of people with their own number are still in care, against 23% without one.

Gap between consecutive LDL tests

2,033 repeat tests in people on the pathway

46%

≤ 3 mo

35%

3–6 mo

6–9 mo

9–12 mo

12–18 mo

> 18 mo

Within 6 months
Longer

19% of repeat tests arrive more than 6 months after the previous one, even among people who do come back.

Month-end status of everyone on the pathway so far

last 24 months

1,000

2,000

Oct 24Jan 25Apr 25Jul 25Oct 25Jan 26Apr 26Jul 26

On track or due soon
Overdue, still reachable (0 to 180 days)
Lost (over 180 days past due)

The lost pool grows from 148 to 720. The overdue-but-reachable band averages 323 over the last six months: that middle band is where a call list pays off.

Show as table

Month end	On track	Overdue	Lost
31 Oct 2024	236	196	148
30 Nov 2024	246	201	169
31 Dec 2024	267	199	189
31 Jan 2025	267	215	207
28 Feb 2025	274	221	228
31 Mar 2025	284	228	250
30 Apr 2025	285	235	267
31 May 2025	289	250	286
30 Jun 2025	296	268	305
31 Jul 2025	307	263	333
31 Aug 2025	302	273	363
30 Sep 2025	315	275	383
31 Oct 2025	355	261	400
30 Nov 2025	356	267	432
31 Dec 2025	357	288	452
31 Jan 2026	356	300	479
28 Feb 2026	374	286	506
31 Mar 2026	367	313	536
30 Apr 2026	389	319	561
31 May 2026	394	320	599
30 Jun 2026	402	304	639
31 Jul 2026	387	333	669
31 Aug 2026	387	332	695
23 Sep 2026	425	332	720

Who gets lost

Share of people lost within 12 months of joining the pathway, among those who joined at least a year ago. Overall: 51.6%. People without their own mobile on file are lost at 76% and 79%, against 47% for people with one.

Contact on file

% lost within 12 months

Own mobile47% n = 803
Agent's number only76% n = 98
No usable number79% n = 63

First came through

% lost within 12 months

Walk-in, Barasat49% n = 516
Home collection52% n = 224
Partner centre56% n = 119
Screening camp55% n = 105

Age

% lost within 12 months

Under 4051% n = 144
40 to 5953% n = 528
60 and over50% n = 292

Also has diabetes

% lost within 12 months

Diabetic-range result on file51% n = 592
No diabetic-range result53% n = 372

This week's LDL call list

People who can still be kept are ranked by how sick and how late they are; people already lost go to a slower re-engagement queue. 423 to keep in care, 720 to re-engage; the top 120 and 40 are loaded here. Open a name to see the timeline.

Keep-in-care queue by who acts

353Care coordinator

45Collection agent

25Referring doctor / outreach

WhyWho actsFind

120 match · top 120 of 423 in this queue loaded · 0 actioned · 0 booked

High69
P-03517 · F · 54y84xxx xx250
210 mg/dL↑59LDL cholesterol · 27 Feb 2026
Overdue 118 dayslast test 27 Feb 2026
LDL above targetLDL 190+: test the family+2
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High65
P-09111 · M · 64y92xxx xx043
268 mg/dLLDL cholesterol · 11 Jan 2026
Overdue 165 dayslast test 11 Jan 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High65
P-04773 · F · 63yagent's number only
195 mg/dL↑61LDL cholesterol · 7 Feb 2026
Overdue 138 dayslast test 7 Feb 2026
LDL above targetLDL 190+: test the family+2
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testPartner centre 3
High64
P-09423 · F · 59y91xxx xx961
200 mg/dLLDL cholesterol · 16 Feb 2026
Overdue 129 dayslast test 16 Feb 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High60
P-09141 · M · 70y78xxx xx794
166 mg/dLLDL cholesterol · 14 Jan 2026
Overdue 162 dayslast test 14 Jan 2026
LDL above targetLipid profile overdue
Book lipid profile (6 to 12 weeks after any statin change)Care coordinator
High57
P-06310 · F · 68y77xxx xx930
182 mg/dLLDL cholesterol · 9 Mar 2026
Overdue 108 dayslast test 9 Mar 2026
LDL above targetLipid profile overdue
Book lipid profile (6 to 12 weeks after any statin change)Care coordinator
High57
P-09854 · F · 46yagent's number only
194 mg/dLLDL cholesterol · 12 Apr 2026
Overdue 74 dayslast test 12 Apr 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testHome-collection agent 07
High56
P-04903 · F · 81y91xxx xx042
126 mg/dL↑64LDL cholesterol · 23 Jan 2026
Overdue 153 dayslast test 23 Jan 2026
LDL above targetLDL up 30+ since last+1
Book lipid profile (6 to 12 weeks after any statin change)Care coordinator
High56
P-08403 · M · 58y78xxx xx741
237 mg/dL↓29LDL cholesterol · 19 Apr 2026
Overdue 67 dayslast test 19 Apr 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High55
P-00519 · M · 61y76xxx xx744
178 mg/dL↑20LDL cholesterol · 12 Jan 2026
Overdue 164 dayslast test 12 Jan 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High55
P-01793 · M · 21y91xxx xx250
177 mg/dL↑57LDL cholesterol · 3 Feb 2026
Overdue 142 dayslast test 3 Feb 2026
LDL above targetLDL up 30+ since last+1
Book lipid profile (6 to 12 weeks after any statin change)Care coordinator
High55
P-01060 · M · 44y71xxx xx108
192 mg/dLLDL cholesterol · 12 Mar 2026
Overdue 105 dayslast test 12 Mar 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
High55
P-02414 · M · 36y79xxx xx584
224 mg/dLLDL cholesterol · 12 Mar 2026
Overdue 105 dayslast test 12 Mar 2026
LDL above targetLDL 190+: test the family+1
Book lipid profile (6 to 12 weeks after any statin change), offer family a lipid testCare coordinator
Medium54
P-04770 · M · 78yno usable number
130 mg/dLLDL cholesterol · 7 Feb 2026
Overdue 138 dayslast test 7 Feb 2026
LDL above targetLipid profile overdue
Book lipid profile (6 to 12 weeks after any statin change)Dr. J. Das (Medicine)
Medium54
P-09428 · M · 43y94xxx xx853
168 mg/dLLDL cholesterol · 17 Feb 2026
Overdue 128 dayslast test 17 Feb 2026
LDL above targetLipid profile overdue
Book lipid profile (6 to 12 weeks after any statin change)Care coordinator

The rules behind the list

What is due, and when

Trigger	Next step	Basis
LDL at or above target	every 90 days	Recheck 6 to 12 weeks after a statin is started or changed
LDL below target	every 365 days	Yearly review once at target
Diabetes or eGFR under 60 on file	target LDL under 70	Lipid Association of India: high risk
No diabetes or CKD on file	target LDL under 100	LAI: low to moderate risk
Any LDL 190 or more	family testing offered	Possible familial hypercholesterolaemia
Triglycerides 1,000 or more	doctor callback within 48 h	Risk of acute pancreatitis
No lipid test > 180 days past due	marked lost to follow-up	Same rule as the diabetes list

How the priority score is built

0 to 100

Factor	Points
Latest LDL ≥ 190 / 160 to 189 / above target ≥ 130 / above target < 130 / at target	34 / 24 / 18 / 14 / 6
Diabetes or CKD on file	+6
Triglycerides 500+ on the same test	+8
LDL up 30+ since the previous test	+6
Triglycerides 1,000+ with no repeat	+10, forces Critical
Days past due (peaks at 180, then decays)	up to 25
Due within the next 30 days	4
Age 65+	5

Critical 70+ (or a result that forces it), High 55 to 69, Medium 38 to 54, Routine below 38.

Definitions and blind spots

High risk means a diabetic-range result (HbA1c 6.5%+ or fasting glucose 126+) or an eGFR under 60 anywhere on the timeline; target LDL under 70 mg/dL. Everyone else: under 100. A person joins the pathway with LDL 160+, LDL 100+ when high risk, or triglycerides 500+. LDL 190+ at any point is flagged as possible familial hypercholesterolaemia. Household members are people sharing the same own mobile number after linking.

Smoking, blood pressure, previous heart attack or stroke and statin prescriptions are not in lab data, so some people placed at moderate risk are really very high risk with a stricter target of 55.

Thyroid follow-up, from the first odd TSH to a stable dose

Hypothyroidism is common in India, mostly in women, and much of it goes undetected. Treatment is a daily tablet, but the dose is only right if TSH is rechecked after every change. This tab links every TSH done at Anubhav Life Care, Barasat into one timeline per person, confirms a single abnormal result before it becomes a lifelong diagnosis, and ranks who to call when the recheck is missed.

630

people on the follow-up pathway

of 4,047 tested

50.2%

of them lost to follow-up now

316 people, 180+ days past due

113

overdue, still reachable

0 to 180 days past due

critical + high this week

the top of the call list

Where the cohort stands today

Everyone with at least one relevant test (5,422bills), using each person's latest results. Linking turned the 8,478 PATIENT_KEYs across all their visits into 4,047 people.

Who was tested

sex as recorded; age at latest visit

4,047

people

70 : 30

female : male

420

18–29

717

30–39

1,070

40–49

950

50–59

545

60–69

345

70+

Latest TSH

4,047 people

< 0.1100%
0.1–0.44110%
0.45–4.53,57088%
4.6–102987%
> 101584%

On the pathway, by sex and age

% of people tested with tsh outside 0.45 to 4.5

age

18–2930–3940–4950–5960–6970+

Female

22%

17%

20%

19%

20%

19%

Male

Women dominate at every age. Among people tested here the gap is wide enough to plan outreach around.

Where people on the pathway sit now

n = 630; 22.4% also have a diabetic-range result

Hypothyroid (TSH over 10 at some point)46.7% 294
Abnormal once, repeat pending28.6% 180
Subclinical hypothyroid17% 107
Hyperthyroid (low TSH)7.8% 49

Abnormal TSH, women and men

% of people tested with any TSH outside range

Women19.4% 547 / 2,816
Men6.7% 80 / 1,188

Women are 2.4 times as likely to be tested and 2.9 times as likely to have an abnormal result.

Women 18 to 45 on the pathway

where a missed recheck matters most

236

women 18 to 45

67.4%

overdue or lost now

159 women

Untreated or under-treated hypothyroidism in early pregnancy affects the baby's development. These women are scored up on the list.

Confirm before treating

first TSH 4.6 to 10 with at least one repeat, n = 196

33.7%

came back normal on every repeat

66 people

41.3%

had free T4 with the first abnormal TSH

Mildly raised results often settle on their own. Treating on one result commits people to a lifelong tablet they may not need; the 12-week recall is there to stop that.

Following the same people over time

The clock starts at each person's first result that put them on the pathway. Someone is lost to follow-up once they are more than 180 days past their due date with no follow-up test here.

The follow-up cascade

people who joined the pathway at least 12 months ago, n = 442; each step counts people who also passed every step above

TSH outside 0.45 to 4.5100% 442
Came back for any follow-up test57.5% 254
Repeat TSH within 4 months42.5% 188
Still testing in the last 12 months21.5% 95
Latest TSH back in range12.7% 56

Show as table

Step	People	% of start
TSH outside 0.45 to 4.5	442	100%
Came back for any follow-up test	254	57.5%
Repeat TSH within 4 months	188	42.5%
Still testing in the last 12 months	95	21.5%
Latest TSH back in range	56	12.7%

Still in care, months after the first abnormal result

Kaplan-Meier, censored at 23 Sep 2026

Own mobile on file (n = 498)
Agent's number or none (n = 132)

At 12 months 48% of people with their own number are still in care, against 15% without one (only 13 still at risk in that group by then, so the line stops early).

Gap between consecutive TSH tests

838 repeat tests in people on the pathway

63%

≤ 3 mo

17%

3–6 mo

6–9 mo

9–12 mo

12–18 mo

> 18 mo

Within 6 months
Longer

20% of repeat tests arrive more than 6 months after the previous one, even among people who do come back.

Month-end status of everyone on the pathway so far

last 24 months

400

800

Oct 24Jan 25Apr 25Jul 25Oct 25Jan 26Apr 26Jul 26

On track or due soon
Overdue, still reachable (0 to 180 days)
Lost (over 180 days past due)

The lost pool grows from 83 to 316. The overdue-but-reachable band averages 107 over the last six months: that middle band is where a call list pays off.

Show as table

Month end	On track	Overdue	Lost
31 Oct 2024	123	65	83
30 Nov 2024	117	80	89
31 Dec 2024	131	75	98
31 Jan 2025	140	73	109
28 Feb 2025	142	73	118
31 Mar 2025	144	74	130
30 Apr 2025	143	88	135
31 May 2025	148	86	148
30 Jun 2025	143	89	159
31 Jul 2025	139	101	163
31 Aug 2025	150	102	172
30 Sep 2025	164	99	182
31 Oct 2025	170	103	195
30 Nov 2025	162	109	203
31 Dec 2025	163	113	211
31 Jan 2026	168	111	219
28 Feb 2026	177	110	228
31 Mar 2026	179	115	234
30 Apr 2026	181	110	255
31 May 2026	189	107	270
30 Jun 2026	197	95	285
31 Jul 2026	188	109	297
31 Aug 2026	191	108	309
23 Sep 2026	201	113	316

Who gets lost

Share of people lost within 12 months of joining the pathway, among those who joined at least a year ago. Overall: 58.4%. People without their own mobile on file are lost at 82% and 90%, against 52% for people with one.

Contact on file

% lost within 12 months

Own mobile52% n = 357
Agent's number only82% n = 56
No usable number90% n = 29

First came through

% lost within 12 months

Walk-in, Barasat54% n = 226
Home collection56% n = 123
Partner centre69% n = 49
Screening camp73% n = 44

Age

% lost within 12 months

Under 4064% n = 132
40 to 5957% n = 209
60 and over54% n = 101

Also has diabetes

% lost within 12 months

Diabetic-range result on file40% n = 90
No diabetic-range result63% n = 352

This week's TSH call list

People who can still be kept are ranked by how sick and how late they are; people already lost go to a slower re-engagement queue. 165 to keep in care, 316 to re-engage; the top 120 and 40 are loaded here. Open a name to see the timeline.

Keep-in-care queue by who acts

132Care coordinator

20Collection agent

13Referring doctor / outreach

WhyWho actsFind

120 match · top 120 of 165 in this queue loaded · 0 actioned · 0 booked

High63
P-09306 · F · 28y86xxx xx792
62.8 µIU/mLTSH · 3 Feb 2026
Overdue 176 dayslast test 3 Feb 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High62
P-04435 · F · 32yagent's number only
22.9 µIU/mL↓18TSH · 21 Mar 2026
Overdue 130 dayslast test 21 Mar 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCamp desk 2
High61
P-09546 · F · 21y71xxx xx478
11.6 µIU/mL↑1.46TSH · 2 Apr 2026
Overdue 118 dayslast test 2 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High60
P-03621 · F · 91yno usable number
13.7 µIU/mL↓3.62TSH · 5 Mar 2026
Overdue 146 dayslast test 5 Mar 2026
TSH still out of rangeTSH overdue
Book TSH (6 to 8 weeks after any dose change)Dr. M. Hossain (Medicine)
High59
P-09883 · F · 39y74xxx xx272
13.1 µIU/mLTSH · 14 Apr 2026
Overdue 106 dayslast test 14 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High59
P-00384 · F · 44y95xxx xx257
14.8 µIU/mL↑6.03TSH · 19 Apr 2026
Overdue 101 dayslast test 19 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High59
P-09915 · F · 20y73xxx xx216
10.4 µIU/mLTSH · 19 Apr 2026
Overdue 101 dayslast test 19 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High58
P-09942 · F · 31y93xxx xx715
23.7 µIU/mLTSH · 21 Apr 2026
Overdue 99 dayslast test 21 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High58
P-09993 · F · 42yno usable number
10 µIU/mLTSH · 27 Apr 2026
Overdue 93 dayslast test 27 Apr 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansDr. N. Sarkar (Gynaecology)
High56
P-10118 · F · 30y99xxx xx206
23.2 µIU/mLTSH · 14 May 2026
Overdue 76 dayslast test 14 May 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High56
P-10120 · F · 36y71xxx xx036
22 µIU/mLTSH · 14 May 2026
Overdue 76 dayslast test 14 May 2026
TSH still out of rangeWoman 18 to 45+1
Book TSH (6 to 8 weeks after any dose change), ask about pregnancy plansCare coordinator
High55
P-07749 · F · 61y99xxx xx046
18.6 µIU/mLTSH · 3 Feb 2026
Overdue 176 dayslast test 3 Feb 2026
TSH still out of rangeTSH overdue
Book TSH (6 to 8 weeks after any dose change)Care coordinator
High55
P-09371 · F · 60yno usable number
57.8 µIU/mLTSH · 10 Feb 2026
Overdue 169 dayslast test 10 Feb 2026
TSH still out of rangeTSH overdue
Book TSH (6 to 8 weeks after any dose change)Dr. M. Hossain (Medicine)
High55
P-00365 · F · 25y86xxx xx372
0.06 µIU/mL↓1.39TSH · 13 Feb 2026
Overdue 166 dayslast test 13 Feb 2026
TSH still out of rangeTSH overdue
Book TSH (6 to 8 weeks after any dose change)Care coordinator
High55
P-03618 · M · 61y72xxx xx266
27.8 µIU/mLTSH · 15 Feb 2026
Overdue 164 dayslast test 15 Feb 2026
TSH still out of rangeTSH overdue
Book TSH (6 to 8 weeks after any dose change)Care coordinator

The rules behind the list

What is due, and when

Trigger	Next step	Basis
First TSH outside 0.45 to 4.5, under 10 and over 0.1	repeat at 84 days	Subclinical results often settle; confirm first
TSH over 10, under 0.1, or abnormal twice	diagnosis established	ATA / ETA thresholds
Established, TSH out of range	every 56 days	Recheck 6 to 8 weeks after a dose change
Subclinical hypothyroid, still raised	every 180 days	ETA: 6-monthly while untreated
Established, TSH in range	every 365 days	At least yearly once stable
Woman 18 to 45 with TSH over 2.5	pregnancy plans asked	Untreated hypothyroidism harms pregnancy
No TSH > 180 days past due	marked lost to follow-up	Same rule as the diabetes list

How the priority score is built

0 to 100

Factor	Points
Unconfirmed abnormal TSH	18
Established, latest TSH over 10 or under 0.1 / mildly out / in range	30 / 16 / 6
Woman 18 to 45, TSH over 2.5	+8
TSH 50+, or under 0.01 with high free T4	+10, forces Critical
Days past due (peaks at 180, then decays)	up to 25
Due within the next 30 days	4
Age 65+	5

Critical 70+ (or a result that forces it), High 55 to 69, Medium 38 to 54, Routine below 38.

Definitions and blind spots

Reference range 0.45 to 4.5 µIU/mL. Established: any TSH over 10 or under 0.1, or two abnormal results at least 42 days apart. A single subclinical result is “abnormal once” and recalled at 12 weeks; if the repeat is normal the person leaves the pathway. The direction of the first abnormal result sets hypo- versus hyperthyroid. Women 18 to 45 with TSH over 2.5 are flagged because guidance for pregnancy uses that lower threshold.

Whether someone is pregnant or taking thyroxine is not in lab data, so the list cannot tell an untreated person from one on the wrong dose; the reminder asks.

Fatty liver follow-up, scored from tests already on the bill

Fatty liver is common in India and silent until scarring is advanced. The tests that flag who needs a closer look (AST, ALT and a platelet count) are among the most-ordered at Anubhav Life Care, Barasat, yet the report never combines them. This tab computes FIB-4 on every bill where it can be computed, applies the AASLD 2023 cut-offs, and ranks who to call for elastography, referral or a repeat test.

1,376

people on the follow-up pathway

of 4,339 tested

38.4%

of them lost to follow-up now

529 people, 180+ days past due

273

overdue, still reachable

0 to 180 days past due

critical + high this week

the top of the call list

Where the cohort stands today

Everyone with at least one relevant test (6,393bills), using each person's latest results. Linking turned the 9,406 PATIENT_KEYs across all their visits into 4,339 people.

Who was tested

sex as recorded; age at latest visit

4,339

people

52 : 48

female : male

382

18–29

713

30–39

1,147

40–49

1,084

50–59

603

60–69

410

70+

Latest FIB-4

4,339 people

Low (< 1.3)2,00846%
Indeterminate (1.3–2.66)3428%
High (≥ 2.67)1614%
Not computable1,82842%

On the pathway, by sex and age

% of people tested with alt over 40 or fib-4 at or above the low cut-off

age

18–2930–3940–4950–5960–6970+

Female

20%

29%

33%

34%

38%

34%

Male

24%

29%

30%

34%

40%

34%

Share with a raised ALT or a FIB-4 above the low cut-off. Raised ALT dominates in the young, FIB-4 in the old.

Where people on the pathway sit now

n = 1,376; 41.7% also have a diabetic-range result

ALT raised, FIB-4 not computable30.4% 418
ALT raised, FIB-4 low27.8% 383
FIB-4 indeterminate24.9% 342
FIB-4 high: likely advanced scarring11.7% 161
Diabetes, FIB-4 now low5.2% 72

FIB-4 the report never printed

bills where AST, ALT and platelets were all present, age 35+

3,368

FIB-4 scores computed here

418

people with raised ALT but no platelets that day

Every one of these scores was computable from tests already paid for. The second number is the cheapest fix: order the blood count with the liver test and the score comes free.

People with diabetes, 35 and over

n = 1,913; AASLD and ADA ask for FIB-4 in everyone with type 2 diabetes

56.2%

ever had a liver test

43.1%

ever had a computable FIB-4

Low58271%
Indeterminate16620%
High769%

29.4% of people with diabetes who were scored need elastography or a referral.

Following the same people over time

The clock starts at each person's first result that put them on the pathway. Someone is lost to follow-up once they are more than 180 days past their due date with no follow-up test here.

The follow-up cascade

people who joined the pathway at least 12 months ago, n = 902; each step counts people who also passed every step above

ALT over 40 or FIB-4 at or above the low cut-off100% 902
Came back for any follow-up test62.7% 566
Repeat LFT within 6 months30.2% 272
Still testing in the last 12 months17% 153
FIB-4 scored in the last 2 years14.1% 127

Show as table

Step	People	% of start
ALT over 40 or FIB-4 at or above the low cut-off	902	100%
Came back for any follow-up test	566	62.7%
Repeat LFT within 6 months	272	30.2%
Still testing in the last 12 months	153	17%
FIB-4 scored in the last 2 years	127	14.1%

Still in care, months after the first abnormal result

Kaplan-Meier, censored at 23 Sep 2026

Own mobile on file (n = 1,105)
Agent's number or none (n = 271)

At 12 months 64% of people with their own number are still in care, against 31% without one.

Gap between consecutive FIB-4 tests

655 repeat tests in people on the pathway

24%

≤ 3 mo

31%

3–6 mo

19%

6–9 mo

11%

9–12 mo

12–18 mo

> 18 mo

Within 6 months
Longer

45% of repeat tests arrive more than 6 months after the previous one, even among people who do come back.

Month-end status of everyone on the pathway so far

last 24 months

1,000

2,000

Oct 24Jan 25Apr 25Jul 25Oct 25Jan 26Apr 26Jul 26

On track or due soon
Overdue, still reachable (0 to 180 days)
Lost (over 180 days past due)

The lost pool grows from 112 to 529. The overdue-but-reachable band averages 265 over the last six months: that middle band is where a call list pays off.

Show as table

Month end	On track	Overdue	Lost
31 Oct 2024	320	135	112
30 Nov 2024	317	150	121
31 Dec 2024	326	156	136
31 Jan 2025	328	158	156
28 Feb 2025	355	157	163
31 Mar 2025	368	169	173
30 Apr 2025	373	179	189
31 May 2025	384	175	208
30 Jun 2025	387	189	221
31 Jul 2025	388	194	242
31 Aug 2025	422	203	249
30 Sep 2025	439	202	268
31 Oct 2025	451	208	290
30 Nov 2025	451	225	306
31 Dec 2025	487	210	330
31 Jan 2026	506	205	351
28 Feb 2026	506	222	364
31 Mar 2026	522	226	386
30 Apr 2026	536	229	415
31 May 2026	542	239	440
30 Jun 2026	527	277	451
31 Jul 2026	529	290	470
31 Aug 2026	528	279	513
23 Sep 2026	574	273	529

Who gets lost

Share of people lost within 12 months of joining the pathway, among those who joined at least a year ago. Overall: 41.8%. People without their own mobile on file are lost at 70% and 69%, against 36% for people with one.

Contact on file

% lost within 12 months

Own mobile36% n = 742
Agent's number only70% n = 112
No usable number69% n = 48

First came through

% lost within 12 months

Walk-in, Barasat39% n = 469
Home collection37% n = 197
Partner centre55% n = 112
Screening camp51% n = 124

Age

% lost within 12 months

Under 4062% n = 190
40 to 5939% n = 455
60 and over32% n = 257

Also has diabetes

% lost within 12 months

Diabetic-range result on file32% n = 395
No diabetic-range result50% n = 507

This week's FIB-4 call list

People who can still be kept are ranked by how sick and how late they are; people already lost go to a slower re-engagement queue. 320 to keep in care, 529 to re-engage; the top 120 and 40 are loaded here. Open a name to see the timeline.

Keep-in-care queue by who acts

259Care coordinator

40Collection agent

21Referring doctor / outreach

WhyWho actsFind

120 match · top 120 of 320 in this queue loaded · 0 actioned · 0 booked

High68
P-00463 · F · 73y88xxx xx516
4.29 ↑0.72FIB-4 · 20 Feb 2025
Overdue 176 dayslast test 2 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High68
P-06143 · M · 70yagent's number only
6.71 ↓2.56FIB-4 · 2 Oct 2025
Overdue 176 dayslast test 2 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCHome-collection agent 03
High68
P-07453 · F · 66y86xxx xx818
2.83 ↑0.36FIB-4 · 6 Oct 2025
Overdue 172 dayslast test 6 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High68
P-08416 · F · 71y78xxx xx870
6.94 FIB-4 · 21 Oct 2025
Overdue 157 dayslast test 21 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High67
P-02734 · F · 66y97xxx xx089
2.87 ↓0.95FIB-4 · 16 Nov 2025
Overdue 131 dayslast test 16 Nov 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High63
P-05748 · M · 49y95xxx xx359
3.1 FIB-4 · 15 Oct 2025
Overdue 163 dayslast test 15 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High63
P-06215 · F · 52y74xxx xx473
2.9 ↓1.04FIB-4 · 9 Nov 2025
Overdue 138 dayslast test 9 Nov 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High63
P-04122 · F · 81y89xxx xx505
2.74 ↑0.46FIB-4 · 23 Dec 2025
Overdue 94 dayslast test 23 Dec 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High62
P-04519 · M · 79y68xxx xx997
5.23 ↑1.85FIB-4 · 7 Oct 2025
Overdue 171 dayslast test 7 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High62
P-02378 · F · 75y66xxx xx990
6.14 FIB-4 · 4 Nov 2025
Overdue 143 dayslast test 4 Nov 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High62
P-06723 · M · 40y89xxx xx639
3.15 FIB-4 · 22 Nov 2025
Overdue 125 dayslast test 22 Nov 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High60
P-03563 · M · 50y76xxx xx594
2.95 FIB-4 · 6 Dec 2025
Overdue 111 dayslast test 6 Dec 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High59
P-08826 · F · 91yagent's number only
4.76 FIB-4 · 6 Dec 2025
Overdue 111 dayslast test 6 Dec 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCamp desk 3
High58
P-05990 · F · 74y80xxx xx513
3.23 FIB-4 · 15 Dec 2025
Overdue 102 dayslast test 15 Dec 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator
High57
P-08248 · M · 38y80xxx xx853
2.94 FIB-4 · 4 Oct 2025
Overdue 174 dayslast test 4 Oct 2025
Refer to liver specialistLiver check overdue
Refer to hepatology, book LFT + CBCCare coordinator

The rules behind the list

What is due, and when

Trigger	Next step	Basis
AST, ALT and platelets on the same bill, age 35+	FIB-4 computed	Lab report does not print it
FIB-4 2.67 or more	hepatology referral, LFT every 180 days	AASLD 2023: high risk of advanced fibrosis
FIB-4 1.3 to 2.66 (2.0 to 2.66 at 65+)	elastography, recheck yearly	AASLD 2023: indeterminate
ALT over 40, no platelets that day	LFT + CBC within 90 days	So FIB-4 can be scored
ALT over 40, FIB-4 low	every 180 days	Persistent raised ALT needs review
Diabetes, FIB-4 low	every 730 days	AASLD / ADA: rescreen every 1 to 2 years
No LFT > 180 days past due	marked lost to follow-up	Same rule as the diabetes list

How the priority score is built

0 to 100

Factor	Points
FIB-4 high / indeterminate / not computable / ALT raised, FIB-4 low / low	32 / 20 / 14 / 12 / 4
Diabetes on file	+6
ALT 200 or more with no repeat	+10, forces Critical
Days past due (peaks at 180, then decays)	up to 25
Due within the next 30 days	4
Age 65+	5

Critical 70+ (or a result that forces it), High 55 to 69, Medium 38 to 54, Routine below 38.

Definitions and blind spots

FIB-4 = age × AST ÷ (platelets × √ALT), computed when all three are on the same bill and the person is 35 or older. Low risk under 1.3 (under 2.0 from age 65), indeterminate up to 2.66, high 2.67 or more. ALT over 40 U/L counts as raised. A person joins the pathway with a raised ALT or a FIB-4 at or above the low cut-off; people with diabetes stay on a two-yearly recall even once low risk, everyone else leaves when both values are back to normal.

Alcohol use, viral hepatitis, ultrasound and elastography results are not in lab data, so FIB-4 here is a risk score for who to send on, not a diagnosis of fatty liver.

How the numbers were made, and which are real

Real:every West Bengal and India figure, each linked to its source; the clinical rules (KDIGO, ADA, Lipid Association of India, ATA / ETA, AASLD), applied exactly as written in each condition's rule table; and the code, which reads one row per reported lab parameter, the shape of the planned AKTIV to Neon lab_results view.

Simulated: every lab count, percentage and name. The cohort is generated to look like the AKTIV mirror once result values are synced: bills with a monthly PATIENT_KEY, names and phone numbers as a busy front desk types them, and hidden states for diabetes, kidney disease, cholesterol, thyroid and fatty liver that improve while people keep coming and slip while they are away. Its prevalences are set to look like a referral lab, not measured, so none of them should be quoted as findings from Anubhav Life Care.

Linking. The same resolver as the diabetes page: mobile number first, then a Bengali-aware fuzzy name match with sex and birth year. On this all-tests cohort it keeps 89.5% of joins correct and recovers 84.4% of true repeat visits, scored against the generator's hidden person id.

What a lab cannot see.Only tests done at the lab. Someone “lost” here may be testing elsewhere, have moved or have died, which is why the re-engagement queue asks first where they test now. Prescriptions, symptoms and clinic visits are not in the mirror. Scoring weights are a starting point for the clinical team, not a validated model.

When the mirror carries results, the same build produces each lab figure from real data: people on each pathway, loss to follow-up at 12 months, how many calls merging saves, and the checks nobody ordered. Those, set against the West Bengal column above, are the numbers to report.