Towards collaborative management of non‐alcoholic fatty liver disease: a ‘real‐world’ pathway for fibrosis risk assessment in primary care

Abstract

Background The optimal strategy to support primary care practitioners (PCP) to assess fibrosis severity in non‐alcoholic fatty liver disease (NAFLD) and thereby make appropriate management decisions remains unclear. Aims To examine the feasibility of using a two‐step pathway that combined simple scores (NAFLD Fibrosis Score and Fibrosis‐4 Index) with transient elastography (FibroScan) to streamline NAFLD referrals from a ‘routine’ primary care population to specialist hepatology management clinics (HMC). Methods The two‐step ‘Towards Collaborative Management of NAFLD’ (TCM‐NAFLD) fibrosis risk assessment pathway was implemented at two outer metropolitan primary healthcare practices in Brisbane. Patients aged ≥18 years with a new or established PCP‐diagnosis of NAFLD were eligible for assessment. The pathway triaged patients at ‘high risk’ of clinically significant fibrosis to HMC for specialist review, and ‘low risk’ patients to receive ongoing management and longitudinal follow up in primary care. Results A total of 162 patient assessments between June 2019 and December 2020 were included. Mean age was 58.7 ± 11.7 years, 30.9% were male, 54.3% had type 2 diabetes or impaired fasting glucose, and mean body mass index was 34.2 ± 6.9 kg/m2. A total 122 patients was considered ‘low risk’ for clinically significant fibrosis, two patients had incomplete assessments and 38 (23.5%) were triaged to HMC. Among 31 completed HMC assessments to date, 45.2% were considered to have clinically significant (or more advanced) fibrosis, representing 9.2% of 153 completed assessments. Conclusion Implementation of the two‐step TCM‐NAFLD pathway streamlined hepatology referrals for NAFLD and may facilitate a more cost‐effective and targeted use of specialist hepatology resources.

Making Sense of the Nonalcoholic Fatty Liver Disease Clinical Practice Guidelines: What Clinicians Need to Know

“…These system barriers may be overcome with appropriate institutional leadership, the development of a multidisciplinary care team, and recurrent professional education about clinical practice guidelines for all health care professionals involved in screening and managing patients ( 48 ). Such efforts are actively underway across the United States ( 21 ) and globally ( 70 , 71 ) and are radically changing models of care for NAFLD ( 47 ).…”

Community pathways for the early detection and risk stratification of chronic liver disease: a narrative systematic review

“…The pathway was unique amongst those identified as it performed both a NFS and FIB4 in all referred patients and only if both were low were patients discharged back to primary care, by a community-based liver fellow or liver nurse specialist. Intermediate results were referred for TE and high FIB4 or NFS was referred to direct to secondary care clinic (22).…”

“…Three pathways presented results which incorporated evaluation of patients with abnormal LFTs and those with known liver disease risk factors primarily included harmful alcohol consumption, obesity, type 2 diabetes (T2DM) and dyslipidaemia, with the latter three variables focusing on NAFLD (9,(22)(23)(24). Shaheen et al described a Canadian pathway dedicated to NAFLD detection and risk stratification utilising shear wave elastography in conjunction with abdominal ultrasound amongst patients with risk factors for NAFLD, facilitating the diagnosis of NAFLD in 94•1% of cases (23).…”

Predicting Liver-Related Outcomes in People With Nonalcoholic Fatty Liver Disease: The Prognostic Value of Noninvasive Fibrosis Tests

“…(3) Due to the high prevalence of NAFLD in primary care and in people with cardiometabolic risk factors, several local health districts and specialty networks are exploring the role of integrated referral pathways and management plans for NAFLD. (6)(7)(8)(9)(10)(11) Once a diagnosis of NAFLD is made, assessment of fibrosis severity is important in order to guide decisions about patient referral and follow-up. Although there are currently no guidelines for NAFLD assessment in the community in Australia, "expert opinion" recommends using simple fibrosis scores (NAFLD fibrosis score [NFS] or fibrosis-4 [FIB-4] test) as a first step to identify individuals at low risk of advanced fibrosis who can be managed in primary care.…”