Primary Care Management of Non-Alcoholic Fatty Liver Disease at the Atlanta VA Medical Center: A Quality Improvement Project

Abstract

Purpose: Non-alcoholic fatty liver disease (NAFLD) and its severe clinical form, non-alcoholic steatohepatitis (NASH), are becoming increasingly prevalent in the U.S., along with the epidemic of obesity. It has been recommended that weight loss, exercise, reduction of sedentary lifestyle, and dietary changes should be implemented as first-line therapy, ideally on a long-term basis, in all patients. Primary care physicians (PCPs) who are at the first-line of management of patients with hepatosteatosis have a crucial role in diagnosing and managing this condition. The aim of this study was to determine the quality of care provided by PCPs for patients with NAFLD, who visited the Atlanta VA hospital. Methods: We retrospectively reviewed the charts of 100 veterans who visited with their PCP between October, 2011 and October, 2012 with a diagnosis of elevated liver enzymes on routine blood testing. PCP notes were carefully reviewed to look at the work-up and management for NAFLD, including if liver imaging was ordered, monitoring weight loss, counseling for exercise, dietary intervention, referral to GI specialist, and primary care follow-up intervals. Patients with history of alcohol abuse and chronic viral hepatitis were excluded. Results: Of the 100 patients we reviewed, 70 had the diagnosis of NAFLD based on some imaging modality. In 70% of the notes, exercise counseling was documented; 75% documented dietary counseling, and 66 % documented weight loss counseling. However, the objective amount of weight loss from the time of diagnosis to the most recent weight was only 1%. Thirty-five percent documented referral for dietary counseling to a nutritionist, and only 5% were referred to hepatology. Two percent of the PCPs arranged a visit specifically to discuss lifestyle modification as the primary objective. Conclusion: NAFLD is the most common cause of elevated liver enzymes in the U.S. According to AASLD, loss of at least 3-5% of body weight appears necessary to improve steatosis, but up to 10% may be needed to improve inflammation. In our patient cohort, although over half of the PCPs documented weight loss, dietary, and exercise counseling, the majority of patients were not meeting even the minimum weight loss goal. The PCP's ability to sustain the change in lifestyle and maintain patient compliance with weight loss, diet, and exercise is sub-optimal. PCPs should consider setting more objective weight loss goals, arranging patient visits specifically to discuss life style modification, and use a multidisciplinary approach to patients with NAFLD, including referral to nutrition and hepatology. Quality improvement measures need to be taken that will facilitate optimization of treatment delivery to this group of patients, soas to prevent the complications of cirrhosis and HCC.