Nonalcoholic Fatty Liver Disease is Underrecognized in the... : Official journal of the American College of Gastroenterology | ACG (original) (raw)

THE RED SECTION

Nonalcoholic Fatty Liver Disease is Underrecognized in the Primary Care Setting

Blais, Pierre MD1; Husain, Nisreen MD1,2; Kramer, Jennifer R MPH, PhD3,4; Kowalkowski, Marc3,4; El-Serag, Hashem MD, MPH1,2,3; Kanwal, Fasiha MD, MSHS1,2,3

1Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

2Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

3Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

4Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

Correspondence: Fasiha Kanwal, MD, MSHS, Department of Medicine, Baylor College of Medicine, 2002 Holcombe Boulevard (152), Houston, Texas 77030, USA. E-mail: [email protected]

Guarantor of the article: Fasiha Kanwal, MD, MSHS.

Specific author contributions: P. Blais: study design, data collection, results interpretation, and manuscript drafting and editing; N. Husain: study design, data collection, and review; J.R. Kramer: results interpretation, statistical analysis, and manuscript editing; M. Kowalkowski: statistical analysis; H. El-Serag: study design, results interpretation, and manuscript editing; F. Kanwal: research idea, study design, statistical analysis, results interpretation, and manuscript drafting and editing.

Financial support: This work is funded in part by the Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413). El-Serag is also supported by National Institute of Diabetes and Digestive and Kidney Diseases K24-04-107.

Potential competing interests: None.

Abstract

OBJECTIVES:

The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care.

METHODS:

Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers’ notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care.

RESULTS:

Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65–7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03–3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists.

CONCLUSIONS:

Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.