Primary Care Providers and Nonalcoholic Fatty Liver Disease: A Needs Assessment Survey.

BACKGROUND: Primary care providers (PCPs) face increasing numbers of patients at risk for NAFLD and are responsible for the detection of NAFLD and the decision on referral to specialists. We conducted a PCP needs assessment to ascertain the barriers and desired supports for NAFLD in primary care. METHODS: We designed a cross-sectional study of PCPs at a large diverse health system and surveyed faculty, residents, and nurse practitioners. Questions assessed NAFLD knowledge, approach to diagnosis and fibrosis testing including use of FIB-4, and attitudes toward support tools. RESULTS: The survey was sent to 115 PCPs with an 80% (n = 92) response rate. Respondents were 52% faculty and 48% residents. Over 40% were unsure of which diagnostic tests to order and which data constituted a diagnosis. PCPs were aware of the importance of fibrosis, yet few knew the components of FIB-4, few used FIB-4 in practice, and yet the most common reason for referral was to obtain fibrosis staging. The majority showed high levels of interest toward possible tools to improve NAFLD management, and only 5% perceived lack of time to be a barrier. DISCUSSION: Our survey revealed PCPs need and want strategic approaches to NAFLD. We found PCPs lack confidence in diagnosing NAFLD and are inconsistent in management strategies. PCPs had high awareness of the importance of fibrosis, but not of the FIB-4. It was encouraging that PCPs reported that time was not a major barrier and had positive attitudes toward potential practice support tools, indicating that practice guidelines designed for primary care should be created.

Prospective study of a case-finding algorithm to detect NAFLD with advanced fibrosis in primary care patients.

BACKGROUND AND AIMS: Primary care providers need strategies to identify NAFLD patients and select for specialty referral, but proposed algorithms have only been studied in established NAFLD patients. METHODS: We implemented an algorithm for all adults with diabetes mellitus in a large primary care practice and excluded hepatitis B and C or alcohol use. Applying annual Fibrosis-4 Index and NAFLD Fibrosis Score for 5 years, we categorized patients as low-risk, indeterminate-risk, or high-risk for advanced fibrosis. We targeted all high-risk and messaged each primary care provider, recommending hepatology linkage. We collected final diagnosis and fibrosis (F0-4) outcomes. Using multivariable logistic regression, we assessed risk factors for advanced fibrosis stage (F3-4). RESULTS: Of 3028 patients, 1018 were low-risk, 577 indeterminate-risk, and 611 high-risk. There were 264 target patients; their 89 primary care providers received a message per patient suggesting hepatology referral. The majority (n=149) were referred; at triage, 118 were deemed likely NAFLD. Of these, 90 completed visits, 78/90 were diagnosed as NAFLD, and 69/78 underwent fibrosis staging, with F3 to 4 in 25/69. In multivariable analysis, hemoglobin A1c ≥8% (OR=7.02, 95% CI: 1.29-38.18) and Fibrosis-4 Index (OR=1.79, 95% CI: 1.07-2.99) were associated with increased risk of F3 to 4. CONCLUSIONS: This is the first prospective study testing a case-finding strategy in primary care and almost 1/3 of diabetes mellitus were high-risk for advanced fibrosis. When prompted, 73% of primary care providers placed referrals and 76% of patients completed visits, revealing 86% NAFLD and 36% F3 to 4. This study demonstrates the readiness for such a strategy in primary care; integrating hemoglobin A1c into this algorithm may further improve the performance of Fibrosis-4 Index in this setting.