Differences in NAFLD/NASH Management by Provider Specialty: Opportunities for Optimizing Multidisciplinary Care

Figures & data

Table 1 Clinician Respondent Demographics

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Role, %
MD	56%	100%	100%	100%
NP	26%	–	–	–
PA	18%	–	–	–
Years in practice, mean	21	15	21	19
Practice location, %
Urban	34%	75%	49%	54%
Suburban	47%	21%	42%	41%
Rural	19%	4%	9%	5%
Certified by American Board of Obesity Medicine, %	16%	28%	14%	17%
Overweight and obese patients, %
Overweight (BMI of 25–29.9 kg/m^2)	44%	42%	45%	42%
Obese (BMI ≥30 kg/m^2)	36%	48%	36%	48%
Patients seen per week, mean	84	71	87	85
Patients seen with NAFLD per month, mean	18	78	32	39
NAFLD patients with NASH, %	33%	45%	34%	40%
Affiliated with academic institution, %	14%	67%	23%	42%

Table 2 Patient Screening and Evaluation

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Considering an otherwise healthy 50-year-old man presenting to your outpatient clinic, how likely are you to routinely screen for NAFLD if he has the following*:
Type 2 diabetes mellitus	3.4	4.0	3.4	3.6
Metabolic syndrome	3.7	4.2	3.9	3.7
Obesity	3.7	3.9	3.8	3.7
Fatigue	2.8	2.3	2.4	2.4
Upper abdominal pain	3.4	2.6	2.6	3.1
A family member with NAFLD	3.4	3.1	2.7	3.2
Case: A 47-year-old woman presents for follow-up with persistently elevated liver transaminases, fatigue, obesity, and type 2 diabetes treated with metformin. She does not take any other medications or consume any alcohol. Her family history is unremarkable. On exam, her BMI is 39 kg/m^2 and there is mild tenderness with right upper abdominal palpation. Lab testing is notable for Hb A1c 8.5%, AST 70 U/L, and ALT 90 U/L. Total bilirubin, albumin, hemoglobin, platelet count, iron, TIBC, ferritin, and INR are within normal range. A lipid panel shows elevated triglycerides at 350 mg/dL and LDL cholesterol at 180 mg/dL. Additional testing rules out infectious hepatitis, Wilson’s disease, alpha-1 antitrypsin deficiency, and autoimmune liver disease.
Which of the following would you order next?
Ultrasound	87%	82%	84%	73%
Elastography	11%	65%	53%	28%
Serologic markers for NASH	46%	28%	37%	30%
Liver biopsy	4%	5%	10%	10%
CT	8%	7%	1%	2%
MRI	2%	7%	4%	4%
Referral to gastroenterologist or hepatologist^†	19%	-	-	17%
Begin treatment without additional testing/referral	3%	0%	0%	8%
Case (continued): A liver ultrasound is performed and indicates moderate fatty liver. The patient’s FIB-4 score is in the indeterminant range for advanced fibrosis. Liver stiffness by vibration-controlled transient elastography is 11 kPa.
How likely are you to suggest a liver biopsy in this patient?
Unsure	5%	2%	1%	5%
Not at all likely	21%	25%	37%	27%
Slightly likely	23%	18%	22%	19%
Moderately likely	29%	18%	22%	30%
Very likely	20%	26%	16%	14%
Extremely likely	3%	12%	3%	5%

Notes: *Means of 1–5 scale: 1 = not at all likely, 5 = extremely likely. ^†Only an option for primary care and endocrinology clinicians.

Table 3 Management Goals

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Management goal for patient with confirmed NASH via liver biopsy*
Weight loss	1.9	1.7	1.5	1.6
Improved control of diabetes	2.3	2.4	2.2	2.3
Improved lipid profile	3.3	3.4	3.3	3.5
NASH downstaging or regression in liver fibrosis	3.4	3.0	3.3	3.0
Symptom improvement	4.1	4.5	4.7	4.5
Weight loss of what percent body weight is your goal for this patient as a component of NASH management?
Less than 5%	0%	0%	0%	0%
5% to 10%	48%	72%	51%	60%
11% to 20%	35%	21%	41%	30%
21% to 30%	11%	7%	5%	4%
No weight loss goal at this time	3%	0%	1%	4%
Other	1%	0%	1%	1%
Unsure	3%	0%	1%	1%
What would your hemoglobin A1c goal be for management of this patient’s NASH?
Less than 6.5%	42%	53%	67%	40%
6.5% to 7.4%	53%	39%	29%	52%
7.5% to 8.4%	2%	4%	2%	4%
8.5% or greater	0%	0%	0%	0%
No A1c goal at this time	1%	2%	0%	0%
Other	1%	4%	1%	3%
Unsure	1%	0%	1%	1%

Notes: *Choices were ranked 1 through 5, where 1 is the most important and 5 is the least important goal. Mean responses shown.

Table 4 Management Approach for a Patient with Confirmed NASH via Liver Biopsy

	PCP (n = 221)	Hepatology (n = 48)	Gastroenterology (n = 126)	Endocrinology (n = 83)
How likely are you to recommend each of the following initially?*
Drug therapy for diabetes control	4.3	4.1	4.1	4.6
Drug therapy for dyslipidemia	4.2	4.1	4.0	4.4
Drug therapy for NASH	2.6	2.8	2.4	2.9
Drug therapy for weight loss	2.3	2.4	2.0	3.4
Bariatric surgery	2.2	2.4	2.3	2.7
How likely are you to recommend each of the following 12 months of unsuccessful diet and exercise?*
Drug therapy for diabetes control	4.3	4.1	4.1	4.5
Drug therapy for dyslipidemia	4.2	4.1	4.0	4.3
Drug therapy for NASH	3.1	3.1	2.8	3.2
Drug therapy for weight loss	2.8	2.8	2.4	3.9
Bariatric surgery	2.9	3.3	3.2	3.4
Difference between initial recommendation and 12 months following unsuccessful lifestyle modifications
Drug therapy for diabetes control	0	0	0	−0.1
Drug therapy for dyslipidemia	0	0	0	−0.1
Drug therapy for NASH	0.5	0.3	0.4	0.3
Drug therapy for weight loss	0.5	0.4	0.4	0.5
Bariatric surgery	0.7	0.9	0.9	0.7

Notes: *Means of 1–5 scale: 1 = not at all likely, 5 = extremely likely. Respondents indicating “unsure/defer to another specialist” were removed from analysis.

Table 5 Barriers to Optimally Managing Patients with NASH

	PCP (n = 295)	Hepatology (n = 56)	Gastroenterology (n = 151)	Endocrinology (n = 92)
How significant are each of the following barriers to optimal management of your patients with NASH?*
Difficulty in establishing a diagnosis without biopsy	2.6	2.0	2.3	2.8
Lack of approved therapies for NASH treatment	3.2	3.7	3.8	3.7
Difficulty managing patients with co-morbidities	3.1	2.7	3.2	2.9
Difficulty in coordinating care between multiple clinicians	2.5	2.6	2.6	2.4
Limited time to spend educating patients about lifestyle modifications and treatment options	3.0	2.8	2.9	2.9
Poor patient adherence to lifestyle modifications and treatments	3.8	3.6	3.9	3.8

Notes: *Means of 1–5 scale: 1 = not at all significant, 5 = extremely significant. Respondents indicating “unsure/defer to another specialist” were removed from analysis.

Table 6 Multidisciplinary Teams and Referral

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Would you involve any other clinicians or medical specialists in the initial management of a patient diagnosed with NASH? (select all that apply)
Yes, dietitian or nutritionist	59%	72%	54%	50%
Yes, endocrinologist	21%	47%	33%	–
Yes, gastroenterologist/ hepatologist	64%	–	–	67%
Yes, obesity specialist or bariatrician	21%	39%	21%	17%
Yes, primary care physician	8%	51%	30%	19%
Yes, other	2%	2%	2%	1%
No	15%	16%	33%	24%
Unsure	8%	7%	8%	5%
Which of the following patients would you refer to a gastroenterologist or hepatologist for further workup or management of NAFLD/NASH? A patient with … ?* (select all that apply)
Any risk factors for NAFLD/NASH	19%			14%
Elevated liver enzymes in the context of risk factors for NAFLD/NASH	53%			55%
Any evidence of fatty liver by imaging	22%	–	–	25%
Fatty liver on imaging after other causes have been excluded	40%			40%
NAFLD at high risk for advanced fibrosis or cirrhosis	91%			88%
Other	2%			1%
None of these	1%			1%
What is your role in the ongoing management of a patient’s NAFLD/NASH after referral to a specialist?* (select all that apply)
Ordering diagnostic testing based on the specialist’s recommendations	61%			43%
Discussing treatment options with the patient	52%			51%
Oordinating care between multiple specialists	80%	–	–	47%
Reinforcing or modifying lifestyle management recommendations	88%			82%
Monitoring for treatment side effects and disease complications	71%			56%
Educating on tests or treatments for NASH	60%			51%
Monitoring for and managing drug side effects	63%			60%
Other	0%			4%
No ongoing role	1%			2%

Note: *Only on primary care and endocrinology clinician surveys.

Table 7 Guideline Use and Utility

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Which guidelines do you use to inform or guide your management decisions for patients with suspected or diagnosed NASH? (select all that apply)
AASLD/ACG/AGA Joint Guideline	34%	86%	84%	22%
EASL-EASD-EASO Clinical Practice Guidelines	16%	33%	18%	30%
World Gastroenterology Organization (WGO) Global Guideline	15%	5%	7%	6%
Coverage policies or guidelines from healthcare payors	18%	7%	7%	14%
Guidelines developed by my institution or practice	30%	5%	6%	16%
Other	5%	0%	1%	8%
None	24%	4%	7%	33%
How useful do you find clinical practice guidelines to be in managing your patients with suspected or diagnosed NASH?
Not Applicable/have not used	13%	4%	1%	14%
Not at all useful	2%	5%	3%	10%
Slightly useful	22%	19%	24%	22%
Moderately useful	33%	40%	40%	29%
Very useful	23%	26%	26%	22%
Extremely useful	6%	5%	6%	2%

Table 8 Clinician Knowledge of Disease Pathophysiology and Emerging Therapies

	PCP (n = 318)	Hepatology (n = 57)	Gastroenterology (n = 156)	Endocrinology (n = 98)
Which of the following processes are involved in the pathophysiology of NASH? (select all that apply)
Insulin resistance	68%	95%	89%	84%
Oxidative stress	45%	81%	71%	75%
Proinflammatory cytokine production	54%	79%	72%	73%
Impaired GLP-1 secretion	43%	56%	51%	34%
Increased glucagon levels	35%	26%	31%	30%
De novo hepatic lipogenesis	35%	60%	45%	55%
Other	0	4%	1%	0%
Unsure	19%	0%	6%	7%
How useful do you think GLP-1 receptor agonists are for each of the following?*
Improving glycemic control	4.0	4.0	3.7	4.4
Improving cardiovascular outcomes	3.6	3.4	3.4	4.1
Improving microvascular outcomes	3.6	3.5	3.3	3.7
Assisting in weight loss	3.4	3.2	3.2	4.1
Decreasing mortality	3.5	3.2	3.2	3.8
Improving liver histology in NASH	3.2	3.1	3.1	3.5
How familiar are you with each of the following investigational therapies for NASH? †
Aldafermin	1.2	1.9	1.4	1.2
Aramchol	1.2	2.0	1.4	1.3
Belapectin	1.2	1.7	1.4	1.3
Cenicriviroc	1.2	2.6	1.7	1.3
Cilofexor	1.2	2.3	1.5	1.4
Efruxifermin	1.2	1.7	1.4	1.3
Firsocostat	1.2	1.9	1.4	1.4
Lanifibranor	1.2	2.3	1.6	1.4
Obeticholic acid	1.5	3.8	3.2	1.8
Resmetirom	1.2	2.2	1.6	1.4
Semaglutide	2.2	3.2	2.3	4.0

Notes: *Means of 1–5 scale: 1 = not at all useful, 5 = extremely useful. Respondents selecting unsure were excluded. †Means of 1–5 scale: 1 = not at all familiar, 5 = extremely familiar.