NAFLD Is Underrecognized in the Primary Care Setting
NAFLD Is Underrecognized in the Primary Care Setting
We identified 251 patients who met our definition of NAFLD. The mean age of these patients at the time of initial ALT elevation (index date) was 53.6±11.3 years. Almost all were males (n=243, 97%), 74.9% were non-Hispanic whites, and 15.9% were African Americans. There were 95 patients (37.8%) who had a body mass index of ≥35 at the index date, among whom 33 (13.1%) had a body mass index ≥40. Approximately 55.0% of patients had hypertension, 75.3% had hypertriglyceridemia, 79.3% had hyperlipidemia, and 41.8% had diabetes mellitus ( Table 1).
The patient cohort on average had a high propensity to use health care, with a median of 6 (interquartile range, IQR=6–14) visits in the year before the index date. Patients were followed up for a median of 6.5 (IQR=6.5–8.8) years in the VA after their first elevated ALT. Only a few patients (n=37, 14.7%) had an NFS >0.675, denoting likely significant fibrosis; the NFS were either low (n=90, 35.9%) or indeterminate (n=124, 49.4%) for the remaining patients.
Among patients with NAFLD, 99 (39.4%). had documentation of abnormal transaminases in the PCP notes, 54 (21.5%) were ascribed NAFLD as a possible diagnosis, 37 (14.7%) were counseled regarding diet modification and exercise, and 26 (10.4%) were referred to a specialist for further evaluation. Only 99 patients (39.4%) had at least one of these processes fulfilled. For patients with predicted significant liver fibrosis (NFS >0.675), only 29.7% (n=11) garnered mention of transaminase elevation, and specialty evaluation and treatment was recommended for only 2.7% (n=1) ( Table 2).
The only factors associated with receiving NAFLD-related care, defined as meeting one or more of the aforementioned care processes, were the magnitude and proportion of ALT elevation ( Table 3). Compared with patients with lower ALT, the odds of receiving NAFLD care were higher for those patients with at least one measured ALT >80 IU/ml (adjusted odds ratio=4.4, 95% confidence interval=2.7–7.3). Patients with a majority of their ALT values >40 IU/ml were also more likely to receive NAFLD care compared with patients without persistent elevation of ALT (adjusted odds ratio=1.8, 95% confidence interval=1.03–3.14). There was no association between the NFS and receipt of care (NFS >0.675 vs. NFS <−0.1455, adjusted odds ratio=0.86, 95% confidence interval=0.29–2.53). Similarly, there was no association of age, race, or components of the metabolic syndrome with NAFLD care.
Results
Patient Characteristics
We identified 251 patients who met our definition of NAFLD. The mean age of these patients at the time of initial ALT elevation (index date) was 53.6±11.3 years. Almost all were males (n=243, 97%), 74.9% were non-Hispanic whites, and 15.9% were African Americans. There were 95 patients (37.8%) who had a body mass index of ≥35 at the index date, among whom 33 (13.1%) had a body mass index ≥40. Approximately 55.0% of patients had hypertension, 75.3% had hypertriglyceridemia, 79.3% had hyperlipidemia, and 41.8% had diabetes mellitus ( Table 1).
The patient cohort on average had a high propensity to use health care, with a median of 6 (interquartile range, IQR=6–14) visits in the year before the index date. Patients were followed up for a median of 6.5 (IQR=6.5–8.8) years in the VA after their first elevated ALT. Only a few patients (n=37, 14.7%) had an NFS >0.675, denoting likely significant fibrosis; the NFS were either low (n=90, 35.9%) or indeterminate (n=124, 49.4%) for the remaining patients.
Process of Care in NAFLD
Among patients with NAFLD, 99 (39.4%). had documentation of abnormal transaminases in the PCP notes, 54 (21.5%) were ascribed NAFLD as a possible diagnosis, 37 (14.7%) were counseled regarding diet modification and exercise, and 26 (10.4%) were referred to a specialist for further evaluation. Only 99 patients (39.4%) had at least one of these processes fulfilled. For patients with predicted significant liver fibrosis (NFS >0.675), only 29.7% (n=11) garnered mention of transaminase elevation, and specialty evaluation and treatment was recommended for only 2.7% (n=1) ( Table 2).
Determinants of NAFLD Consideration Among Primary Care Physicians
The only factors associated with receiving NAFLD-related care, defined as meeting one or more of the aforementioned care processes, were the magnitude and proportion of ALT elevation ( Table 3). Compared with patients with lower ALT, the odds of receiving NAFLD care were higher for those patients with at least one measured ALT >80 IU/ml (adjusted odds ratio=4.4, 95% confidence interval=2.7–7.3). Patients with a majority of their ALT values >40 IU/ml were also more likely to receive NAFLD care compared with patients without persistent elevation of ALT (adjusted odds ratio=1.8, 95% confidence interval=1.03–3.14). There was no association between the NFS and receipt of care (NFS >0.675 vs. NFS <−0.1455, adjusted odds ratio=0.86, 95% confidence interval=0.29–2.53). Similarly, there was no association of age, race, or components of the metabolic syndrome with NAFLD care.
