Brief Report|Articles in Press, 104483

Implementing Screening for Nonalcoholic Fatty Liver Disease in Endocrinology Clinics

Published:December 01, 2022DOI:


      • Approximately 25% of the world population is affected by nonalcoholic fatty liver disease (NAFLD).
      • Practice guidelines on screening for NAFLD are available.
      • Identifying NAFLD is important so that necessary interventions can be initiated.
      • An evidence-based algorithm using FIB-4 risk stratifies patients with type 2 diabetes and NAFLD.


      Nonalcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes (T2D) remains underrecognized by health care providers. The primary purpose of this quality improvement project was to increase identification of NAFLD among patients with T2D followed in an endocrinology practice using an evidence-based algorithm to risk stratify patients. Pre- and post-intervention analysis revealed a significant 36% increase in screening for NAFLD post-intervention (P < 0.001).


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        • Younossi Z.M.
        Non-alcoholic fatty liver disease—a global public health perspective.
        J Hepatol. 2019; 70: 531-544
        • Younossi Z.M.
        • Corey K.E.
        • Alkhouri N.
        • et al.
        Clinical assessment for high-risk patients with non-alcoholic fatty liver disease in primary care and diabetology practices.
        Aliment Pharmacol Ther. 2020; 52: 513-526
        • Estes C.
        • Razavi H.
        • Loomba R.
        • Younossi Z.
        • Sanyal A.J.
        Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease.
        Hepatology. 2018; 67: 123-133
        • Allen A.M.
        • Van Houten H.K.
        • Sangaralingham L.R.
        • Talwalkar J.A.
        • McCoy R.G.
        Healthcare cost and utilization in nonalcoholic fatty liver disease: real-world data from a large U.S. claims database.
        Hepatology. 2018; 68: 2230-2238
        • Gordon S.C.
        • Kachru N.
        • Parker E.
        • Korrer S.
        • Ozbay A.B.
        • Wong R.J.
        Health care use and costs among patients with nonalcoholic steatohepatitis with advanced fibrosis using the Fibrosis-4 score.
        Hepatol Commun. 2020; 4: 998-1011
        • Younossi Z.M.
        • Tampi R.P.
        • Racila A.
        • et al.
        Economic and clinical burden of nonalcoholic steatohepatitis in patients with type 2 diabetes in the U.S.
        Diabetes Care. 2020; 43: 283-289
        • Cusi K.
        • Isaacs S.
        • Barb D.
        • et al.
        American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD).
        Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2022; 28: 528-562
        • Kanwal F.
        • Shubrook J.H.
        • Adams L.A.
        • et al.
        Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease.
        Gastroenterology. 2021; 161: 1657-1669
        • European Association for the Study of the Liver, European Association for the Study of Diabetes, European Association for the Study of Obesity
        EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease.
        Obes Facts. 2016; 9: 65-90
        • American Diabetes Association
        4. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2021.
        Diabetes Care. 2021; 44: S40-S52
        • LaBrecque D.R.
        • Abbas Z.
        • Anania F.
        • et al.
        World Gastroenterology Organisation global guidelines: nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.
        J Clin Gastroenterol. 2014; 48: 467-473
        • Alexander M.
        • Loomis A.K.
        • Fairburn-Beech J.
        • et al.
        Real-world data reveal a diagnostic gap in non-alcoholic fatty liver disease.
        BMC Med. 2018; 16: 130
        • Casler K.
        • Trees K.
        • Bosak K.
        Readiness for the epidemic: the adult nonalcoholic fatty liver disease toolkit for primary care nurse practitioners.
        J Am Assoc Nurse Pract. 2020; 32: 323-331
        • Pandyarajan V.
        • Gish R.G.
        • Alkhouri N.
        • Noureddin M.
        Screening for nonalcoholic fatty liver disease in the primary care clinic.
        Gastroenterol Hepatol. 2019; 15: 357-365
        • Yadav Y.
        • Syn W.K.
        • Basu R.
        Evolving Management strategies for nonalcoholic fatty liver disease-targeting primary care physicians.
        Diabetes Technol Ther. 2019; 21: 611-618
        • Djulbegovic B.
        • Hozo I.
        • Dale W.
        Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies.
        J Eval Clin Pract. 2018; 24: 1247-1254
        • Chalasani N.
        • Younossi Z.
        • Lavine J.E.
        • et al.
        The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases.
        Hepatology. 2018; 67: 328-357
        • Anstee Q.M.
        • Lawitz E.J.
        • Alkhouri N.
        • et al.
        Noninvasive tests accurately identify advanced fibrosis due to NASH: baseline data from the STELLAR trials.
        Hepatology. 2019; 70: 1521-1530
        • El-Gohary M.
        • Moore M.
        • Roderick P.
        • et al.
        Local care and treatment of liver disease (LOCATE)—A cluster-randomized feasibility study to discover, assess and manage early liver disease in primary care.
        PLoS OneE. 2018; 13e0208798
        • Shaheen A.A.
        • Riazi K.
        • Medellin A.
        • et al.
        Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study.
        CMAJ Open. 2020; 8: E370-E376
        • Siddiqui M.S.
        • Yamada G.
        • Vuppalanchi R.
        • et al.
        Diagnostic accuracy of noninvasive fibrosis models to detect change in fibrosis stage.
        Clin Gastroenterol Hepatol. 2019; 17: 1877-1885.e5
        • Srivastava A.
        • Gailer R.
        • Tanwar S.
        • et al.
        Prospective evaluation of a primary care referral pathway for patients with non-alcoholic fatty liver disease.
        J Hepatol. 2019; 71: 371-378
        • Sterling R.K.
        • Lissen E.
        • Clumeck N.
        • et al.
        Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection.
        Hepatology. 2006; 43: 1317-1325
        • Castera L.
        • Friedrich-Rust M.
        • Loomba R.
        Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease.
        Gastroenterology. 2019; 156: 1264-1281.e4
        • Ando Y.
        • Jou J.H.
        Nonalcoholic fatty liver disease and recent guideline updates.
        Clin Liver Dis. 2021; 17: 23-28
        • Marjot T.
        • Sbardella E.
        • Moolla A.
        • et al.
        Prevalence and severity of non-alcoholic fatty liver disease are underestimated in clinical practice: impact of a dedicated screening approach at a large university teaching hospital.
        Diabet Med J Br Diabet Assoc. 2018; 35: 89-98
        • Rodriguez-Araujo G.
        Nonalcoholic fatty liver disease: implications for endocrinologists and cardiologists.
        Cardiovasc Endocrinol Metab. 2020; 9: 96-100
        • North F.
        • Fox S.
        • Chaudhry R.
        Clinician time used for decision making: a best case workflow study using cardiovascular risk assessments and Ask Mayo Expert algorithmic care process models.
        BMC Med Inform Decis Mak. 2016; 16: 96


      Dawn L. Piercy, DNP, FNP-BC


      Andrea Coviello, MD, MSc, MMCi


      Yuval A. Patel, MD, MHS


      Julie A. Thompson, PhD.;


      and Kathryn E. Kreider, DNP, FNP, BC-ADM, are all associated with Duke University, Durham, NC. The corresponding author, Dawn Piercy, may be contacted at [email protected]