Physicians’ Practices for Diagnosing Liver Fibrosis in Chronic Liver Diseases: A Nationwide, Canadian Survey

Abstract

OBJECTIVE: To determine practices among physicians in Canada for the assessment of liver fibrosis in patients with chronic liver diseases.METHODS: Hepatologists, gastroenterologists, infectious diseases specialists, members of the Canadian Gastroenterology Association and/or the Canadian HIV Trials Network who manage patients with liver diseases were invited to participate in a web-based, national survey.RESULTS: Of the 237 physicians invited, 104 (43.9%) completed the survey. Routine assessment of liver fibrosis was requested by the surveyed physicians mostly for chronic hepatitis C (76.5%), followed by autoimmune/cholestatic liver disease (59.6%) and chronic hepatitis B (52.9%). Liver biopsy was the main diagnostic tool for 46.2% of the respondents, Fibroscan (Echosens, France) for 39.4% and Fibrotest (LabCorp, USA) for 7.7%. Etiology-specific differences were observed: noninvasive methods were mostly used for hepatitis C (63% versus 37% liver biopsy) and hepatitis B (62.9% versus 37.1% liver biopsy). For 42.7% of respondents, the use of noninvasive methods reduced the need for liver biopsy by >50%. Physicians’ characteristics associated with higher use of noninvasive methods were older age and being based at a university hospital or in private practice versus community hospital. Physicians’ main concerns regarding noninvasive fibrosis assessment methods were access/availability (42.3%), lack of guidelines for clinical use (26.9%) and cost/lack of reimbursement (14.4%).CONCLUSIONS: Physicians who manage patients with chronic liver diseases in Canada require routine assessment of liver fibrosis stage. Although biopsy remains the primary diagnostic tool for almost one-half of respondents, noninvasive methods, particularly Fibroscan, have significantly reduced the need for liver biopsy in Canada. Limitations in access to and availability of the noninvasive methods represent a significant barrier. Finally, there is a need for clinical guidelines and a better reimbursement policy to implement noninvasive tools to assess liver fibrosis.

Serum fibrosis biomarkers predict death and graft loss in liver transplantation recipients

“…[16][17][18][19] However, difficult access to transient elastography can result in limiting screening for liver fibrosis. 35 Moreover, this method was just recently approved in the United States by the Food and Drug Administration, and it is still not widely available. 36 In conclusion, serum fibrosis biomarkers predict all-cause mortality, liver-related mortality, and graft loss after LT.…”

Letters to the Editor

“…The article by Kan et al (1) in the March 2015 issue of the Journal, describing patient preference and willingness to pay for transient elastography (TE) versus liver biopsy, confirms other recent publications that FibroScan (EchoSens, France) is now the preferred modality for the assessment of liver fibrosis by clinicians caring for patients with liver diseases in Canada (1)(2)(3). Notably, it is the first article to address the key value in confirming that FibroScan is also the preferred modality for the most important stakeholders: patients.…”

“…Review of Canadian clinicians' practice patterns and attitudes toward PLBs and noninvasive modalities of fibrosis assessment reveals that the majority of survey participants -nearly two-thirds of whom were gastroenterologists -required assessment of disease stage, and the greatest demand for fibrosis assessment was for patients with hepatitis C (76.9%) (2). In this same survey, noninvasive fibrosis assessment was ordered more frequently in patients with viral hepatitis than autoimmune hepatitis and, surprisingly, approximately 50% of surveyed physicians continue to use PLB as the primary modality of fibrosis assessment as opposed to FibroScan primarily for the reasons outlined above (2).…”

“…In this same survey, noninvasive fibrosis assessment was ordered more frequently in patients with viral hepatitis than autoimmune hepatitis and, surprisingly, approximately 50% of surveyed physicians continue to use PLB as the primary modality of fibrosis assessment as opposed to FibroScan primarily for the reasons outlined above (2).…”

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“…Although TE is generally accepted as a noninvasive alternative for the staging of liver fibrosis, which helps to avoid a liver biopsy [252], it does not represent the most effective approach with respect to resources in common clinical scenarios [253]. TE is considered cost-effective for annual cirrhosis screening in patients infected with HCV [254], with the most cost-effective treatment scenario for patients infected with HCV not depending on the fibrosis category ("treating all") [253].…”