Stein L, Mittal R, Song H, Chung J, Sahota A. To scan or not to scan: Use of transient elastography in an integrated health system. World J Hepatol 2023; 15(3): 419-430 [PMID: 37034236 DOI: 10.4254/wjh.v15.i3.419]
Corresponding Author of This Article
Libby Stein, MD, Doctor, Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, Los Angeles, CA 90027, United States. libby.x.stein@kp.org
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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/
Libby Stein, Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, United States
Rasham Mittal, Amandeep Sahota, Department of Transplant Hepatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, United States
Hubert Song, Joanie Chung, Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA 91101, United States
Author contributions: Stein L, Mittal R and Sahota A designed the study; Song H and Chung J gathered the data and performed the statistical analysis; Stein L wrote the manuscript; all authors read, edited and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by the Kaiser Permanente Southern California Institutional Review Board (Approval No. #12674).
Informed consent statement: Because of the nature of a retrospective study, signed informed consent form is not needed. However, Kaiser Permanente Los Angeles Medical Center has given permission to conduct this study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Libby Stein, MD, Doctor, Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, Los Angeles, CA 90027, United States. libby.x.stein@kp.org
Received: October 21, 2022 Peer-review started: October 21, 2022 First decision: December 23, 2022 Revised: January 6, 2023 Accepted: March 1, 2023 Article in press: March 1, 2023 Published online: March 27, 2023 Processing time: 152 Days and 11.1 Hours
Abstract
BACKGROUND
Non-invasive tests, such as Fibrosis-4 index and transient elastography (commonly FibroScan), are utilized in clinical pathways to risk stratify and diagnose non-alcoholic fatty liver disease (NAFLD). In 2018, a clinical decision support tool (CDST) was implemented to guide primary care providers (PCPs) on use of FibroScan for NAFLD.
AIM
To analyze how this CDST impacted health care utilization and patient outcomes.
METHODS
We performed a retrospective review of adults who had FibroScan for NAFLD indication from January 2015 to December 2017 (pre-CDST) or January 2018 to December 2020 (post-CDST). Outcomes included FibroScan result, laboratory tests, imaging studies, specialty referral, patient morbidity and mortality.
RESULTS
We identified 958 patients who had FibroScan, 115 before and 843 after the CDST was implemented. The percentage of FibroScans ordered by PCPs increased from 33% to 67.1%. The percentage of patients diagnosed with early F1 fibrosis, on a scale from F0 to F4, increased from 7.8% to 14.2%. Those diagnosed with advanced F4 fibrosis decreased from 28.7% to 16.5%. There were fewer laboratory tests, imaging studies and biopsy after the CDST was implemented. Though there were more specialty referrals placed after the CDST was implemented, multivariate analysis revealed that healthcare utilization aligned with fibrosis score, whereby patients with more advanced disease had more referrals. Very few patients were hospitalized or died.
CONCLUSION
This CDST empowered PCPs to diagnose and manage patients with NAFLD with appropriate allocation of care towards patients with more advanced disease.
Core Tip: This was a retrospective study of nearly 1000 patients with non-alcoholic fatty liver disease who underwent FibroScan. The purpose of this study was to compare patients before and after a clinical decision support tool was implemented. This tool was designed to guide primary care providers on the management of non-alcoholic fatty liver disease. After the tool was released, we saw higher rates of early-stage fibrosis diagnosed by FibroScan. We saw appropriate allocation of care, whereby patients with advanced fibrosis had more labs, imaging studies and specialty referrals. These results suggest non-alcoholic fatty liver disease can feasibly be diagnosed and managed in the primary care setting.
