Evidence-Based Medicine
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Feb 27, 2021; 13(2): 233-241
Published online Feb 27, 2021. doi: 10.4254/wjh.v13.i2.233
Awareness of non-alcoholic steatohepatitis and treatment guidelines: What are physicians telling us?
David Hermanus Wessels, Zeil Rosenberg
David Hermanus Wessels, Medical Office, A.E.S., Chorley PR7 1NY, Lancashire, United Kingdom
Zeil Rosenberg, Chief Medical Office, Accelerated Enrollment Solutions, Horsham, PA 19044, United States
Author contributions: All authors editing of this paper, and approved the final version of this study.
Conflict-of-interest statement: Dr. Wessels is an employee of AES, a clinical trials site management organization conducting clinical studies on NASH, which provided funding for this work. No other conflicts are reported.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: David Hermanus Wessels, MBChB, Chief Doctor, Medical Office, A.E.S., Sandringham House Ackhurst Park Foxhole Road, Chorley PR7 1NY, Lancashire, United Kingdom. dawie.wessels@globalaes.com
Received: November 23, 2020
Peer-review started: November 23, 2020
First decision: December 7, 2020
Revised: December 18, 2020
Accepted: December 28, 2020
Article in press: December 28, 2020
Published online: February 27, 2021

There is an acute need to raise awareness of non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH) among primary care physicians, endocrinologists and diabetologists to improve patient identification and address the current difficulties in NASH clinical trial enrollment. We examined the extent of knowledge and practice regarding NASH diagnosis and management guidelines. A randomized online convenience survey of 12869 physicians drawn from a national physician database of primary care physicians (PCPs), and gastroenterology and endocrinology specialists were queried via online survey. Our results, based on a cohort of 185 respondents, showed gaps in knowledge and practice between these three groups of practitioners, with primary care providers having the lowest adherence to published guidelines for diagnosis of NASH. Without clear knowledge and patient identification at the point of presentation - which is often in primary care or with specialties other than hepatology–many patients with NAFLD and NASH will remain undiagnosed and untreated, and clinical studies will continue to struggle with patient recruitment, hindering clinical development and optimal patient care.


To determine knowledge base concerning NASH diagnosis amongst gastroenterologists, endocrinologists and primary care physicians to improve referrals into clinical trials.


A randomized online convenience survey of 12869 physicians drawn from a national physician database of PCPs, and gastroenterology and endocrinology specialists was conducted yielding a sample of 185 respondents.


The survey revealed that many physicians are either unaware of testing options other than biopsy, or do not use them in practice. Only 46% of endocrinologists and 42% of primary care physicians indicated they would refer a patient for specialist workup if they suspected NASH. Risk (25%) and inconvenience to patients (18%) are given as reasons for not referring those with suspected NASH for biopsy. For standard diagnostic algorithms such as Fibrosis-4 score, 18% of PCPs, 30% of endocrinologists and 65% gastroenterologists reported using these tests in clinical practice.


Substantial gaps in knowledge of the differences between NAFLD and NASH exist between these physician groups, with knowledge being particularly low among primary care doctors and endocrinologists. The use of a simple non-invasive screening algorithm may help to identify the right patients for clinical trials, which in turn will be vital to the development of effective and well-tolerated treatments for this increasingly ubiquitous condition.

Keywords: Non-alcoholic steatohepatitis, Non-alcoholic fatty liver disease, Enrollment, Screening, Diagnostics, Guidelines

Core Tip: Primary care physician knowledge of non-alcoholic steatohepatitis (NASH) diagnostics guidelines is key for appropriate patient management. We conducted a national online survey of physicians regarding their awareness of NASH guidelines. Endocrinologists and primary care physicians were significantly less likely than gastroenterologists to understand the differences between NASH and non-alcoholic fatty liver disease, as well as undertake diagnostic testing and necessary referrals for NASH. Only 18% of primary care physicians and 30% of endocrinologists were familiar with common indices such as the Fibrosis-4 score. Better education of primary care physicians about NASH could also serve as one way to identify candidates for important NASH clinical trials.