Utilization of the NAFLD Fibrosis Score for Screening Obese Patients in a Safety Net Internal Medicine Resident Clinic: A Quality Improvement Project

Introduction: As rates of obesity and type 2 diabetes mellitus (T2DM) have increased worldwide, non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease. The NAFLD fibrosis (NAFLD-F) score is commonly used in the outpatient setting to assess liver fibrosis and determine progression of NAFLD to non-alcoholic steatohepatitis (NASH) and ultimately cirrhosis. Our study aims to identify areas of improvement in the screening of obese patients and to determine associations with low-risk or high-risk NAFLD-F scores. Methods: This study comprised of obese patients from a safety net internal medicine resident clinic. Patients were categorized into low risk and intermediate/high risk based on their NAFLD-F scores. Descriptive statistics were used to summarize demographic and clinical variables. Logistic regressions identified variables that significantly differentiated between low risk and intermediate/high risk scores. Significant variables in the previous regressions were then entered into a single logistic regression to determine significant independent predictors of NAFLD-F category scores. Results: A total of 417 patients (61% female, 57% black) were included, with a median age of 49 years (IRQ = 37 – 59). BMIs ranged from 42.2 – 86.0 (M = 50.1±7.3), and HTN (68.1%) and HLD (43.9%) were the most common medical comorbidities. Variables that significantly differentiated between the low risk (< -1.455) and intermediate/high risk (≥ -1.455) scores included HTN, DM, HLD, HbA1C, ALP, platelets, and albumin. Regression analysis results indicated that age (β = 0.34, P = < .001), BMI (β = 0.43, P = < .001), platelet levels (β = -0.57, P = < .001), albumin levels (β = -0.21, P = < .001), and T2DM (β = 0.28, P = < .001) were significant independent predictors of NAFLD-F scores. Of note, patients in the intermediate/high-risk category had lower percentages of liver ultrasound screening and nutrition/obesity referrals. Conclusion: Our study highlights the importance of addressing risk factors and screening for NAFLD in obese patients in the outpatient setting. By identifying patients with statistically significant predictors of higher NAFLD-F scores, aggressively controlling their co-morbidities, screening with liver ultrasound, and referring to obesity specialists early in their course, disease progression can be minimized. Over 60% of patients were not referred to an obesity clinic. Our aim is to start an obesity clinic for NAFLD patients to prevent NASH and cirrhosis (Figure 1).Figure 1.: (A) Factors associated with low risk (< -1.455) vs intermediate/high risk (≥ -1.455) NAFLD Fibrosis scores, with highlighted variables demonstrating statistical significance. (B) Referrals, prescription, liver ultrasound and past bariatric surgeries by NAFLD low risk vs intermediate/high risk scores.