An exploration of barriers and facilitators to implementing a nonalcoholic fatty liver disease pathway for people with type 2 diabetes in primary care

Abstract

Aims We explored barriers and facilitators to the implementation of nonalcoholic fatty liver disease (NAFLD) pathway for people with diabetes to identify determinants of behaviour surrounding the diagnosis, assessment and management of NAFLD. Methods Health practitioners (n = 24) recruited from multidisciplinary diabetes clinics in primary care (n = 3) and hospital (n = 1) settings participated in four focus group discussions, and common themes were identified using thematic analysis. Results Lack of knowledge and access to resources were key factors that underpinned an inconsistent approach by clinicians to NAFLD diagnosis and risk stratification and impacted their confidence to discuss the diagnosis with patients. Participants often prioritised other medical issues above NAFLD due to lack of concern about liver‐related consequences, reluctance to overburden patients with information, lack of time and perceived absence of accessible fibrosis tests. All participants agreed that implementation of a NAFLD pathway would improve patient care and the general practitioners proposed that screening for NAFLD could be incorporated into routine review cycles for type 2 diabetes. A consistent message from participants was that educating patients about their liver disease needs to be implemented in an integrated care pathway. Conclusions From the perspectives of health practitioners, there is a gap in clinical practice for the implementation of clear, evidence‐based guidelines for NAFLD in people with T2D. By focusing on comorbidity prevention and integrating NAFLD as a diabetes complication to be addressed during established cycles of care, many barriers to implementing a NAFLD pathway in primary care could be overcome.

Screening for NAFLD—Current Knowledge and Challenges

“…On a similar note, a UK-based qualitative study demonstrated that the diagnosis and management of NAFLD is perceived as a great challenge by GPs [73,74]. Overall, less than 3% of patients with elevated FIB-4 are currently referred to the specialist setting for further investigations [75], with GPs not perceiving NAFLD as a priority in their clinical activities [76].…”

Implementation of a nurse-delivered, community-based liver screening and assessment program for people with non-alcoholic fatty liver disease (LOCATE-NAFLD trial)

“…In addition, a lack of effective strategies for behavioural regulation related to diet and exercise interventions can in uence prioritisation of management plans (24). In a recent Australian study that assessed the barriers and facilitators of implementing a NAFLD pathway within a specialist GP diabetes clinic, GPs were con dent in managing NAFLD in primary care, and despite agreeing that community brosis screening may improve patient care, this was often not prioritised as it was deemed unlikely to change treatment course (25). Across other settings, GPs have expressed con dence in managing NAFLD without an assessment of disease severity (26) (27).…”

Information needs for general practitioners on type 2 diabetes in Western countries. A systematic review

“…Bilello found inconsistent knowledge about managing Charcot neuroarthropathy among internal medicine physicians and GPs (58), and Alabdali found that most GPs who were asked were unaware that LJM is a diabetes complication (59). Lastly, Gracen found a gap in clinical practice related to the implementation of clear, evidence-based guidelines for NAFLD (60).…”

“…Six reports provided findings about GPs' limited knowledge of guidelines when treating type 2 diabetes and co-existing complications (30,32,44,52,60,61). Three studies on CKD, one on retinopathy, one on NAFLD and one on obesity and bariatric surgery all found a lack of knowledge about the most appropriate guidelines for screening and managing comorbidities.…”