Primary care and referring physician perspectives on non-alcoholic fatty liver disease management: a nationwide survey

Abstract

Introduction: The optimal approach to screening and risk stratification for non-alcoholic fatty liver disease is challenging given disease burden and variable progression. The aim of this study was to assess primary care physician and referring physician practice patterns regarding non-alcoholic fatty liver disease. Methods: An anonymous nationwide survey was administered to primary care physicians, endocrinologists, and cardiologists in a: (1) tertiary academic hospital, (2) community hospital, and (3) the American College of Physicians Insider Panel. Survey domains assessed non-alcoholic fatty liver disease knowledge, recommendations for screening, risk stratification, treatment, and referral patterns. Results: A total of 440 providers completed the survey (35.2% completion rate; N = 82 academic hospital, N = 21 community hospital, N = 337 American College of Physicians). Half were male (51.7%), 78% from internal medicine, with 5% subspecialists. Providers were knowledgeable regarding prevalence and risk factors for non-alcoholic fatty liver disease. 58% would support screening for non-alcoholic fatty liver disease and used liver enzymes to do so. Only 22.5% used serum biomarkers and 23% used transient elastography for risk stratification. Primary reason for referral was advanced fibrosis/cirrhosis. 80% reported barriers to treating non-alcoholic fatty liver disease. There was no consistent diet recommended. Conclusion: In this nationwide survey, we demonstrated that while overall disease knowledge was good, there was an important disconnect between current guidelines and real-world clinical practice. There is also significant heterogeneity in practice patterns for first-line therapy of non-alcoholic fatty liver disease and the majority of provider’s report barriers to treating non-alcoholic fatty liver disease. These findings highlight the potential role for reevaluating screening and risk stratification recommendations in primary care to better align with needs in that setting.

The steatosis‐associated fibrosis estimator (SAFE) score: A tool to detect low‐risk NAFLD in primary care

“…One third of the respondents referred all or most of their patients with NAFLD to a specialist, whereas up to 10% referred none. This was in part due to lack of clinical tools for risk stratification, as less than 5% of community physicians reported using noninvasive diagnostic markers 9…”

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

“…Reasons cited for this lack of referral included cost concerns and lack of patient interest, primarily. 12 Altogether, these data suggest a substantial need to improve coordination of care among referring clinicians.…”

“…Reasons cited for this lack of referral included cost concerns and lack of patient interest, primarily. 12 Altogether, these data suggest a substantial need to improve coordination of care among referring clinicians. While hepatologists and gastroenterologists appear relatively likely to use the AASLD guidelines to help inform their patient management, 24% of PCPs and 33% of endocrinologists reported not using any guidelines for NAFLD/NASH management.…”

The paradigm shift from NAFLD to MAFLD: A global primary care viewpoint

“…These phenomena result in a substantial disconnect between current guidelines and real-world clinical practice. 30,31 Alarmingly, a recent study demonstrated that 71% of primary care patients had a non-invasive fibrosis score (Fibrosis-4 Index and NAFLD Fibrosis Score) in the indeterminate-risk or high-risk category for advanced fibrosis, reinforcing the clinical significance of knowledge deficits regarding diagnosis, although being the major determinant of complications. 29 Primary care uptake might be hampered by the limited involvement of primary care physicians in the development of clinical practice guidelines.…”

“…Reasons for these diagnostic errors are complex, with survey studies showing that NAFLD is not perceived as a priority in primary care, and there is a large knowledge deficit regarding NAFLD diagnosis and management. These phenomena result in a substantial disconnect between current guidelines and real‐world clinical practice 30,31 . Alarmingly, a recent study demonstrated that 71% of primary care patients had a non‐invasive fibrosis score (Fibrosis‐4 Index [FIB‐4] and NAFLD Fibrosis Score) in the indeterminate‐risk or high‐risk category for advanced fibrosis, reinforcing the clinical significance of knowledge deficits regarding diagnosis, although being the major determinant of complications 29 .…”