An international survey on patterns of practice in NAFLD and expectations for therapies—The POP‐NEXT project

Abstract

Background and Aims Differences between countries in NAFLD patient care pathways and management need to be understood prior to defining supranational guidelines. Approach and Results We conducted an anonymous survey in France, Germany, Hong Kong, Italy, Romania, Spain, the United Kingdom, and the United States among physicians providing specialist care for patients with NAFLD. Modalities of patient referral, patterns of practice (diagnosis, staging, monitoring, and indications for liver biopsy), therapeutic management, and expectations for future NASH pharmacotherapies were assessed, with 664 physicians completing the survey. Referral to surveyed physicians (SPs) mostly came from primary care. Prior to referral, NAFLD was rarely diagnosed, and noninvasive tests were not performed. Screening for comorbidities by SPs was incomplete and cardiovascular risk not calculated. Elastometry in combination with a serum biomarker was the most common first‐line method for fibrosis staging. Liver biopsy, when performed, was often delayed by at least 1 year after diagnosis. It was, however, recommended even if noninvasive methods indicated advanced fibrosis. Frequent, biannual monitoring was conducted, including HCC surveillance in Stage 3 fibrosis. SPs rarely implemented and followed dietary and lifestyle changes themselves, and local availability of such programs was highly heterogenous. SPs favored pharmacotherapy based on mechanism of action adapted to the stage of the disease, including for early stages such as steatohepatitis with mild fibrosis. Conclusions This international survey revealed major deficiencies and delays in referral pathways, suboptimal screening for comorbidities or managing of lifestyle modifications by SPs, and limited local availability for nonpharmacological interventions. Monitoring practices are not aligned with current guidelines.

A global survey of health care workers' awareness of non‐alcoholic fatty liver disease: The AwareNASH survey

“…This is in accordance with a survey by Ratziu et al., which focused on modalities of patient referral and patterns of practice. In this study, 56% of surveyed hepatologists and gastroenterologists reported that less than half of the referred NAFLD patients had tried lifestyle changes before being referred to a hepatologist 27 . In order to support physicians who are not specialised in NAFLD, it is important to update guidelines with specific lifestyle interventions and include these in educational programs.…”

“…In contrast to several earlier NAFLD surveys, 17,19,21,27 the current study focused largely on healthcare workers from specialities other than hepatologists and gastroenterologists, in particular cardiologists, internists and GPs. Moreover, the current survey also Despite the growing disease burden of NAFLD, a significant gap in awareness, knowledge and management of NAFLD remains between physicians in different fields.…”

“…International guidelines increasingly advocate multidisciplinary approaches for patients with NAFLD 8,20,26 . However, there are still large differences in the management of NAFLD both internationally and between different specialities 19,27 . Guidelines advocate lifestyle intervention as the cornerstone of NAFLD treatment, increasing physical activity and adherence to the Mediterranean diet to achieve 5%–10% weight reduction 11,28,29 .…”

“… 8 , 20 , 26 However, there are still large differences in the management of NAFLD both internationally and between different specialities. 19 , 27 Guidelines advocate lifestyle intervention as the cornerstone of NAFLD treatment, increasing physical activity and adherence to the Mediterranean diet to achieve 5%–10% weight reduction. 11 , 28 , 29 In line with the guidelines, weight loss and exercise (i.e.…”

Letter to the Editor: More questions than answers—Response to the POP-NEXT project

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To the editor, Ratziu et al's [1] fascinating survey of clinical variability in the diagnosis and management of NAFLD emphasizes the uncertain place that it occupies in the field of hepatology. Is it a liver condition or one manifestation of a metabolic disorder?

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