The Problem
NAFLD is a prevalent disease with variable severity, ranging from simple fat to cirrhosis. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the US, affecting about 1 out of 3 adults(1). Current estimates suggest two-thirds of US adults are overweight or obese, translating to an estimate of 75 to 100 million US adults with NAFLD 2. Though the majority (~70-75%) of patients with NAFLD have simple steatosis, ~25-30% have the progressive subtype non-alcoholic steatohepatitis (NASH), which increases the risk of fibrosis progression to cirrhosis and the development of hepatocellular carcinoma(2). NASH furthermore independently increases the risk of cardiovascular events and cardiovascular-related mortality(3).
NAFLD is typically asymptomatic and under recognized, even if advanced to early cirrhosis.Unfortunately, patients with NAFLD typically do not have any symptoms nor knowledge of the disease. Patients are often diagnosed only if they develop significant disease decompensation such as ascites, encephalopathy, variceal bleeding, jaundice, or liver cancer(2, 4).
Current Duke referral practices to Hepatology do not take into account NAFLD severity. Currently at Duke, no guidelines or structured support tools exist to assist in primary care referral of NAFLD to Hepatology. This results in variable referral practices. Many high risk NAFLD patients (i.e., NASH and/or advanced fibrosis) unfortunately fail to receive a timely Hepatology referral, and conversely, many low risk NAFLD patients are referred to Hepatology clinic when they could have avoided a subspecialist visit.
Duke is uniquely positioned to offer interventions for high risk NAFLD patients.In addition to encouraging weight loss through exercise and a hypocaloric diet, Hepatologists may help guide consideration for bariatric surgery or offer off label therapies such as high dose Vitamin E for high risk patients(5, 6). Moreover, if high risk NAFLD has progressed to cirrhosis, then cirrhosis maintenance care is needed, which includes consideration of liver cancer screening and variceal screening. Though no FDA approved pharmacotherapeutics for NAFLD exist currently, many are in later stage clinical trials, and some medications are expected to be approved within the next year. Furthermore, Duke has one of the most robust clinical trials programs for high risk NAFLD in the US. In our GI division, it is routine practice for Hepatologists to discuss participation in clinical trials for patients with high risk NAFLD.
Our Solution
We propose developing a disease specific E-Consult initiative for existing referrals for patients with NAFLD, and using natural language processing to identify unrecognized NAFLD patients. Subsequently, these newly identified patients can be used to pilot a Proactive E-Consult initiative targeted at those with suspected advanced disease.
We believe that this will allow us to deliver high impact care through a Proactive E-Consult for high-risk poor outcome patients; thereby reducing unnecessary subspecialty visits for low risk patients.
