Reply: more questions than answers: response to the POP-NEXT project.

Berry and Kotha correctly emphasize the numerous issues raised by NAFLD, which is both a liver disease and part of a larger clinical phenotype of metabolic dysfunction. They argue that a multisystem assessment would be best performed by primary care physicians, as liver or gastroenterology specialists lack familiarity with the management of nonhepatic conditions or the medications to manage these conditions, and the time commitment for such an assessment would be too onerous. However, given the considerable variability between countries in the way that healthcare systems operate, what is appropriate for the United Kingdom may not be applicable elsewhere. For instance, in parts of France, general practitioners are overburdened with clinical work (high demand for general medicine, low visit costs, and generous coverage by social security being the main reasons), which translates into long waiting times for an appointment and limited time for each patient visit. In other parts of the country, there is a severe shortage of general practitioners (medical “deserts”). In many instances, complex multiorgan workups would further burden primary care physicians. In our view, the crucial point is that a diagnosis of NAFLD should entail a thorough evaluation of the main interconnected comorbidities, regardless of the most appropriate setting. In countries where general practitioners are overbooked and specialized medicine is highly fragmented in the cardiometabolic field, hepatologists could share the medical burden and avoid unnecessary delays by adopting first-line screening for several medical comorbidities or by assessing cardiovascular risk and initiating prescription of lipid-lowering medication when necessary. Ideally, this should be done in multidisciplinary clinics1,2 that colocate and coordinate care, thereby reducing the risk of overlooked diagnosis and mismanagement, and increasing patient compliance.3 In the absence of such structures and particularly in patients first diagnosed with NAFLD, hepatologists should strive to save unnecessary hospital visits by initiating a holistic diagnostic workup themselves. The POP-NEXT project highlights inadequacies and shortcomings of the current exploration of NAFLD patients, which are even more revealing since responders were, as Berry and Kotha point out, highly committed specialists, probably with a vested interest in NAFLD. Additional surveys adapted to address issues raised in primary care by suspected NAFLD will certainly complement the current work and enhance the broader understanding of the healthcare burden of NAFLD.