title: Nonalcoholic fatty liver disease is underrecognized in the primary care setting.
abstract: OBJECTIVE
  The prevalence and disease burden of nonalcoholic fatty liver disease (NAFLD) are increasing. Nonetheless, little is known about the processes related to identification, diagnosis, and referral of patients with NAFLD in routine clinical care.
  
  
  METHODS
  Using automated data, we isolated a random sample of patients in a Veterans Administration facility who had ≥2 alanine transaminase (ALT) values >40 IU/ml >6 months apart in the absence of any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use. We conducted a structured medical record review to confirm NAFLD and abstracted data from the primary care providers' notes for (i) recognition of abnormal ALT levels, (ii) mention of NAFLD as a possible diagnosis, (iii) recommendations for diet or exercise, and (d) referral to a specialist for further NAFLD evaluation. Using a multilevel logistic regression model, we identified patient demographic, clinical, comorbidity, and health-care utilization factors associated with recognition and receipt of early NAFLD care.
  
  
  RESULTS
  Of 251 patients identified with NAFLD by our methods, 99 (39.4%) had documentation in medical record notes of abnormal ALT, 54 (21.5%) had NAFLD mentioned as a possible diagnosis, 37 (14.7%) were counseled regarding diet and exercise, and 26 (10.4%) were referred to a specialist. Only the magnitude of ALT elevation (adjusted odds ratio (OR) for ALT >80 IU/ml vs. <80 IU/ml=4.4, 95% confidence interval (CI)=2.65-7.30) and proportion of elevation (adjusted OR for >50% vs. <50% of ALT values >40 IU/ml=1.8, 95% CI=1.03-3.14) were associated with receiving specified NAFLD care. Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists.
  
  
  CONCLUSIONS
  Most patients in care who may have NAFLD are not being recognized and evaluated for this condition. Our data suggest that providers may be using an incorrect heuristic in delivering NAFLD care by concentrating on those with high ALT levels.
authors.affiliation: Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Pierre
authors.initials: P
authors.lastname: Blais
authors.affiliation: 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
authors.forename: Nisreen
authors.initials: N
authors.lastname: Husain
authors.affiliation: 1] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Kramer
authors.affiliation: 1] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [2] Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Kowalkowski
authors.affiliation: 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [3] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
authors.forename: Hashem
authors.initials: H
authors.lastname: El-Serag
authors.affiliation: 1] Department of Medicine, Baylor College of Medicine, Houston, Texas, USA [2] Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA [3] Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000410:Alanine Transaminase / Q000097:blood; D015992:Body Mass Index; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000175:diagnosis* / Q000453:epidemiology; D015995:Prevalence; D011320:Primary Health Care; D012017:Referral and Consultation; D012307:Risk Factors; D014481:United States; D055815:Young Adult
chemical_list: D000410:Alanine Transaminase