Improved Detection of Fibrotic Nonalcoholic Fatty Liver Disease in Community-Based Referrals

Background: Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease with increasing rates globally. Patients with type 2 diabetes mellitus have higher risk of developing NAFLD. Patients with a higher degree of liver fibrosis in NAFLD are at an increased risk for liver-related mortality, but get missed easily during the referral process. This project aims to improve early detection and linkage-to-care of fibrotic NAFLD patients. Methods: We utilized a combination of automated electronic health record (EHR)-based fibrosis (FIB)-4 score and directed provider education. A health-system wide FIB-4 score calculator that providers can easily add to their workflow for NAFLD patient triaging. Data were analyzed at 6 and 12 months after implementation. Results: Postimplementation, there was an increase in patients referred to hepatology with higher degree of liver fibrosis and decreased referral to hepatology with low risk of liver fibrosis, measured by FIB-4 score. At baseline, similar to 55% of referred patient to hepatology had FIB-4 score <1.3 compared to 38% at 12 months postimplementation. There was an increase in referral of patients with FIB-4 scores >1.3 when compared to preinterventions, 62% versus 45%. This is most pronounced in patients with severe fibrotic disease with FIB-4 score >2.67, 30% versus 12%. Conclusions: Automated FIB-4 score in EHR can improve appropriate linkage-to-care for at-risk fibrotic NAFLD, especially when coupled with targeted provider education. The durability of such improvement is essential to study along with the need to increase broad acceptance across health systems.