Differences in NAFLD/NASH Management by Provider Specialty: Opportunities for Optimizing Multidisciplinary Care

Abstract

Purpose Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are a part of a complex metabolic disease process requiring a multi-faceted and multidisciplinary management approach. This study was conducted to identify areas where medical education across a multidisciplinary team could be optimized in providing optimal care of patients with NAFLD/NASH. Methods A survey instrument including a patient case vignette was developed to understand approaches of US clinicians to diagnosis and management of patients with NAFLD/NASH. The survey was fielded via email in December 2020–January 2021. Analysis was conducted using embedded Qualtrics analytic software. Results There were 629 survey respondents: 318 PCPs, including physicians, NPs, and PAs, 57 hepatologists, 156 gastroenterologists, and 98 endocrinologists. Survey results demonstrated variation in likelihood to screen patients for NAFLD/NASH among specialists and PCPs as well as in the types of clinicians that respondents would involve in the initial management of a patient diagnosed with NASH. Notably, between 15% and 33% across respondent clinician types would not include any other clinicians or medical specialists in initial management. For a patient with newly diagnosed NASH, the most likely initial management recommendations included drug therapy to improve control of diabetes and therapy to lower lipids and were less likely to recommend drug therapy for weight loss, drug therapy for NASH, or bariatric surgery. Respondents rated “poor patient adherence to lifestyle modifications” and “lack of approved therapies for NASH” as the most significant barriers to optimal management of patients with NASH. Conclusion Variation in the evaluation and management of patients with NAFLD/NASH across PCPs and medical subspecialists was identified in this study. Education aimed at multidisciplinary roles in optimally managing patients with NAFLD/NASH, can be beneficial, particularly if focused on increasing screening, implementing guideline updates as they emerge, and incorporating new therapies as they gain approval for clinical practice.

Nonalcoholic fatty liver disease from a primary care perspective

“…referral. 13,63 Hesitancy to diagnose NASH or to refer patients to subspecialty care may exist due to the lack of US Food and Drug Administration (FDA)-approved medications available to treat NASH. 64 In addition to diagnostic delays due to gaps in knowledge, the timely diagnosis of NAFLD may be hampered by its non-specific clinical presentation.…”

“…In a survey of 250 PCPs, self‐reported lack of knowledge regarding NAFLD was identified as a major obstacle to patient management 15 . Additional barriers to optimal care potentially leading to poor outcomes may include inconsistency around referral of patients to subspecialty care due to lack of clarity around which patients may benefit from referral 13,63 . Hesitancy to diagnose NASH or to refer patients to subspecialty care may exist due to the lack of US Food and Drug Administration (FDA)‐approved medications available to treat NASH 64 …”

Penthorum chinense Pursh extract ameliorates hepatic steatosis by suppressing pyroptosis via the NLRP3/Caspase‐1/GSDMD pathway

“…Lifestyle modifications, including dietary adjustments and increased physical activity, are the preferred therapeutic interventions for NAFLD (Romero‐Gómez et al., 2017 ). However, the efficacy of these interventions is hindered by low patient adherence, rendering the treatment of NAFLD challenging (Porayko et al., 2022 ). Currently, there is no effective medication for the treatment of NAFLD.…”

Nonalcoholic steatohepatitis diagnosis and treatment from the perspective of patients and primary care physicians: a cross-sectional survey

“…Despite the perception of NASH as a mostly asymptomatic condition, patients with NASH and advanced fibrosis were found to have worse physical health-related scores than matched patients with chronic hepatitis C [ 14 ]. A recent study investigated differences in NASH management from the perspective of clinicians, but did not capture patient experiences [ 16 ].…”