NAFLD Is Underrecognized in the Primary Care Setting
NAFLD Is Underrecognized in the Primary Care Setting
Objectives The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care.
Methods Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care.
Results Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65–7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03–3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists.
Conclusions Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.
Nonalcoholic fatty liver disease (NAFLD) is now the leading cause of chronic liver disease in the United States. NAFLD encompasses a spectrum of diseases ranging from simple hepatic steatosis to inflammatory steatohepatitis, cirrhosis, and hepatocellular carcinoma. Obesity, diabetes, dyslipidemia, and the metabolic syndrome are clear risk factors for developing NAFLD in all its forms.
Studies in NAFLD patients indicate that weight loss and physical exercise may reduce aminotransferase levels and improve hepatic steatosis, lobular inflammation, and NAFLD activity score. Expert bodies have published practice guidelines that endorse screening patients with metabolic syndrome and persistently abnormal liver biochemistries for NAFLD; recommending lifestyle modifications for patients with NAFLD; and referring those at a high risk for nonalcoholic steatohepatitis (NASH) on the basis of metabolic syndrome or NAFLD fibrosis score (NFS) for further prognostic evaluation.
Little is known, however, about the extent to which such guidelines are followed. The initial identification and management of NAFLD are largely under the purview of the primary care provider (PCP). Recognition of NAFLD, particularly in those at a high risk for NASH, is required for initiating recommended early care. Yet, the practice of NAFLD care in the primary setting has never been studied.
Therefore, we sought to examine the level of meeting early processes of care in a cohort of patients with NAFLD who made clinic visits to a single Veterans Administration (VA) Medical Center between 2004 and 2009. We also evaluated the relationship between patients' demographic, clinical, comorbidity, and health-care utilization factors with receipt of early NAFLD care.
Abstract and Introduction
Abstract
Objectives The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care.
Methods Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care.
Results Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65–7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03–3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists.
Conclusions Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.
Introduction
Nonalcoholic fatty liver disease (NAFLD) is now the leading cause of chronic liver disease in the United States. NAFLD encompasses a spectrum of diseases ranging from simple hepatic steatosis to inflammatory steatohepatitis, cirrhosis, and hepatocellular carcinoma. Obesity, diabetes, dyslipidemia, and the metabolic syndrome are clear risk factors for developing NAFLD in all its forms.
Studies in NAFLD patients indicate that weight loss and physical exercise may reduce aminotransferase levels and improve hepatic steatosis, lobular inflammation, and NAFLD activity score. Expert bodies have published practice guidelines that endorse screening patients with metabolic syndrome and persistently abnormal liver biochemistries for NAFLD; recommending lifestyle modifications for patients with NAFLD; and referring those at a high risk for nonalcoholic steatohepatitis (NASH) on the basis of metabolic syndrome or NAFLD fibrosis score (NFS) for further prognostic evaluation.
Little is known, however, about the extent to which such guidelines are followed. The initial identification and management of NAFLD are largely under the purview of the primary care provider (PCP). Recognition of NAFLD, particularly in those at a high risk for NASH, is required for initiating recommended early care. Yet, the practice of NAFLD care in the primary setting has never been studied.
Therefore, we sought to examine the level of meeting early processes of care in a cohort of patients with NAFLD who made clinic visits to a single Veterans Administration (VA) Medical Center between 2004 and 2009. We also evaluated the relationship between patients' demographic, clinical, comorbidity, and health-care utilization factors with receipt of early NAFLD care.
