Discussion
Although previous survey-based studies have been undertaken to gauge physician perceptions and practices with regard to NAFLD, this is the first analysis of the process of NAFLD management in the primary care setting. Our results show that the majority of NAFLD patients in care are not being recognized or evaluated for this condition. This is in spite of the fact that all of our patients met the criteria for metabolic syndrome—a condition that places patients at a higher risk for progressive liver inflammation and fibrosis. Our findings did not change when we limited our analysis to the small subset of patients with a high NFS. Recognition of patients at a high risk for NASH-related complications is likely to be the first essential step toward the goal of reducing NAFLD-related morbidity and mortality. Our data show that we are far from meeting the standards recommended in the clinical guidelines.
We also found that only the magnitude (with at least one ALT >80 IU/ml) and proportion (where ≥50% of a patient's ALT values >40 IU/ml) of transaminase elevation predicted receipt of NAFLD care. Data show that liver biochemistries are imperfect surrogates of the degree of necroinflammation and fibrosis in NAFLD. In contrast, numerous studies have found that other strong, routinely available predictors of liver fibrosis in patients with NAFLD include age, body mass index, hypertension, hypertriglyceridemia, and diabetes. We did not find any association between these factors and the likelihood of meeting NAFLD processes of care. Collectively, these results suggest that providers may be using an incorrect heuristic in delivering NAFLD care by focusing on those with high ALT levels.
The gaps that we found in NAFLD care likely reflect the gaps in provider knowledge and awareness of relevant practice guidelines. Kallman et al. were the first to report on primary care attitudes in screening for liver diseases, including NAFLD. Over 40% of PCPs surveyed in this study were not familiar with clinical published guidelines for NAFLD management. This suboptimal knowledge translated into paradoxical screening practices. Specifically, these PCPs were more likely than hepatologists to screen low-risk patients while neglecting patients at a high risk for NASH. Said et al. and Wieland et al. again found low rates of screening for NAFLD in their surveys of PCPs. Physicians in both studies acknowledged the need for more didactic training. Offering continuing medical education to PCPs that focuses on NAFLD may be one way to make inroads into the problem of suboptimal NAFLD care. These efforts can include academic teaching regarding the burden of NAFLD, identification of patients who are at risk for NAFLD, and building awareness regarding online resources and tools (http://www.nafldscore.com) that can allow risk stratification of patients seen in routine clinical practice.
This study has several limitations. Our findings may have limited generalizability, as they are derived from a single VA center. It is likely that practices may vary between different VA and non-VA primary care settings. Nonetheless, previous survey-based studies lend validity to our findings by identifying similar problems in NAFLD care in other patient populations. Another limitation is the lack of a 'gold standard' definition for NAFLD in the charts. We attempted to minimize this by specifying a hierarchical algorithm that rendered our definition highly specific for the presence of clinically important NAFLD. Last, the value of identifying patients with NAFLD may be questioned given the lack of easily applicable treatments. However, we believe that recognition and counseling on NAFLD and the underlying metabolic syndrome are essential first steps to any successful management program, especially if new treatments arise in the future.
In summary, we found that many patients with likely NAFLD may not be evaluated for this condition. Our data also suggest that providers may be concentrating care on those with high ALT levels and not on patients who indeed are at a high risk for progressive hepatic damage. Our results indicate that one way to alleviate the problem of suboptimal care in NAFLD is to focus on primary care-level changes.