1092 Referral Trends Show Low Linkage-to-Care of NAFLD Patients at a Tertiary Care Academic Center in Northern California

Abstract

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) has emerged as the most common cause of chronic liver disease. NAFLD affects ∼1/3rd of the US population, with ∼70% prevalence in diabetics of whom 4-5% have advanced fibrosis. Despite its prevalence, NAFLD is under-recognized by physicians. Defining at-risk NAFLD patients is a cost-effective strategy. There is limited data on the referral process of NAFLD patients to help incorporate changes within health systems. In this study we queried referral trends for NAFLD, with specific focus on diabetes patients and non-invasive fibrosis score. METHODS: This is a retrospective analysis of referrals to gastroenterology at a tertiary care referral center for a large part of Northern California, for fatty liver disease between Jan 1, 2017 – December 31, 2018. Demographics, laboratory data, imaging (Fibroscan, MR elastography), comorbidities and liver biopsy, if available, were recorded. Well-validated FIB-4 score was calculated. RESULTS: Of 435,739 active patients at the center, 31,934 (7%) were diabetics. In 2 years, 188 referrals were made for NAFLD of whom 23% had diabetes, 67% did not have diabetes, 8% were unknown. Primary care providers made 86% referrals; there were no referrals from endocrinology. Approximately half of referrals (46%) had elevated ALT. Among them, 40% were referred for chief complaint of abnormal labs. As noted in the Table 1, FIB-4 >2.67 was seen in 14% of diabetics and 12% non-diabetics, while FIB-4< 1.3 was 39% and 57% of diabetics and non-diabetics. Nearly half of the referred patients underwent fibroscan, MRE or liver biopsy with the tests primarily in those with higher FIB-4 (66% of those with FIB-4≥1.3). Based on biopsy and/or imaging, 45% had stage 0-1 fibrosis while 24% and 6% were stages 2-3 or 4, respectively. Of those with FIB-4< 1.3, 84% had fibrosis 0-1 on further imaging/biopsy, while in those with FIB-4 1.3- 2.67 or >2.67 had stage 2-4 fibrosis in 29% and 54%, respectively. CONCLUSION: In the span of two years, only a handful of diabetic patients with NAFLD have been linked to care, with a notable lack of referrals from endocrinology. Majority of the referrals were for those with low FIB-4 scores, potentially missing a large percentage of advanced fibrosis patients. Our data shows a significant need for systems change and provider education to link-to-care patients at high risk of advanced NAFLD, with FIB-4 as a starting point.