1Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, California, USA.
2Division of Hospital Medicine, Department of Medicine, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California, USA.
3School of Medicine, University of California, San Francisco, California, USA.
4Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, New York, USA.
Background and aims: Primary care providers need strategies to identify NAFLD patients and select for specialty referral, but proposed algorithms have only been studied in established NAFLD patients.
Methods: We implemented an algorithm for all adults with diabetes mellitus in a large primary care practice and excluded hepatitis B and C or alcohol use. Applying annual Fibrosis-4 Index and NAFLD Fibrosis Score for 5 years, we categorized patients as low-risk, indeterminate-risk, or high-risk for advanced fibrosis. We targeted all high-risk and messaged each primary care provider, recommending hepatology linkage. We collected final diagnosis and fibrosis (F0-4) outcomes. Using multivariable logistic regression, we assessed risk factors for advanced fibrosis stage (F3-4).
Results: Of 3028 patients, 1018 were low-risk, 577 indeterminate-risk, and 611 high-risk. There were 264 target patients; their 89 primary care providers received a message per patient suggesting hepatology referral. The majority (n=149) were referred; at triage, 118 were deemed likely NAFLD. Of these, 90 completed visits, 78/90 were diagnosed as NAFLD, and 69/78 underwent fibrosis staging, with F3 to 4 in 25/69. In multivariable analysis, hemoglobin A1c ≥8% (OR=7.02, 95% CI: 1.29-38.18) and Fibrosis-4 Index (OR=1.79, 95% CI: 1.07-2.99) were associated with increased risk of F3 to 4.
Conclusions: This is the first prospective study testing a case-finding strategy in primary care and almost 1/3 of diabetes mellitus were high-risk for advanced fibrosis. When prompted, 73% of primary care providers placed referrals and 76% of patients completed visits, revealing 86% NAFLD and 36% F3 to 4. This study demonstrates the readiness for such a strategy in primary care; integrating hemoglobin A1c into this algorithm may further improve the performance of Fibrosis-4 Index in this setting.