Digestive Diseases and Sciences

, Volume 58, Issue 10, pp 2809–2816 | Cite as

Identifying Practice Gaps to Optimize Medical Care for Patients with Nonalcoholic Fatty Liver Disease

  • Amanda C. Wieland
  • Matthew Quallick
  • Aimee Truesdale
  • Pamela Mettler
  • Kiran M. Bambha
Original Article



Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease. Primary care providers (PCPs), in contrast to gastroenterology/hepatology (GI/Hep) providers, are the first medical contact for the majority of patients with, or at risk for, NAFLD. PCP awareness of and facility with NAFLD is critical for management of these patients.


The purpose of this study was to assess understanding and practice patterns of PCPs and non-GI/Hep subspecialty providers with respect to the diagnosis and management of NAFLD.


We administered an online, 61-question survey to 479 providers in internal medicine, family medicine, endocrinology, cardiology, and obstetrics and gynecology (ObGyn) across three health systems: academic medical center, safety-net health system and managed care health system.


There were 246 respondents (51 %), with the majority (87 %) being PCPs (internal medicine, family medicine, ObGyn). Only 31 % of providers identified NAFLD as a clinically important diagnosis in their practice. Although 65 % of providers reported some degree of facility in diagnosing NAFLD, less than half (47 %) were comfortable managing NAFLD. Only 33 % refer patients with suspected NAFLD to GI/Hep. Subspecialists in endocrinology and cardiology reported greater clinical concern over NAFLD and were more likely (67 %) to refer patients with suspected NAFLD to GI/Hep.


The majority of providers do not identify NAFLD as a clinically important diagnosis and do not refer to GI/Hep. However, 83 % expressed a need for education on NAFLD. Our data reveal practice gaps within NAFLD care and identify opportunities for targeted education to guide PCPs in the evaluation and management of NAFLD.


Liver Nonalcoholic fatty liver disease Physician perception Questionnaire 



We would like to thank Dr. Al Marcus, Dr. Lori Crane and Dr. Lisa Cicutto for their help with study design and survey formulation. This work was supported by NIH/NCATS Colorado CTSI Grant Number TL1 TR000155 and by NIH T32 DK07038 Gastrointestinal Diseases Training Grant. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

Conflict of interest



  1. 1.
    Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. Am J Gastroenterol. 2003;98:960–967.PubMedCrossRefGoogle Scholar
  2. 2.
    Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34:274–285.PubMedCrossRefGoogle Scholar
  3. 3.
    Brunt EM. Histopathology of non-alcoholic fatty liver disease. Clin Liver Dis. 2009;13:533–544.PubMedCrossRefGoogle Scholar
  4. 4.
    Ong JP, Younossi ZM. Epidemiology and Natural History of NAFLD and NASH. Clin Liver Dis. 2007;11:1–16.PubMedCrossRefGoogle Scholar
  5. 5.
    Charlton MR, Burns JM, Pedersen RA, Watt KD, Heimbach JK, Dierkhising RA. Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States. Gastroenterology. 2011;141:1249–1253.PubMedCrossRefGoogle Scholar
  6. 6.
    Angulo P, Keach JC, Batts KP, Lindor KD. Independent predictors of liver fibrosis in patients with nonalcoholic steatohepatitis. Hepatology. 1999;30:1356–1362.PubMedCrossRefGoogle Scholar
  7. 7.
    Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.Google Scholar
  8. 8.
    Ogden CL Carroll M, Kit DK, Flegal KM. Prevalence of obesity in the United States, 20092010. NCHS data brief. Vol no 82. Hyattsville, MD: National Center for Health Statistics; 2012.Google Scholar
  9. 9.
    Grattagliano I, D’Ambrosio G, Palmieri VO, et al. Improving nonalcoholic fatty liver disease management by general practitioners: a critical evaluation and impact of an educational training program. J Gastrointestin Liver Dis. 2008;17:389–394.PubMedGoogle Scholar
  10. 10.
    Ratziu V, Cadranel JF, Serfaty L, et al. A survey of patterns of practice and perception of NAFLD in a large sample of practicing gastroenterologists in France. J Hepatol. 2012;57:376–383.PubMedCrossRefGoogle Scholar
  11. 11.
    Bergqvist CJ, Skoien R, Horsfall L, Clouston AD, Jonsson JR, Powell EE. Awareness and opinions of non-alcoholic fatty liver disease by hospital specialists. Intern Med J. 2013;43:247–253.PubMedCrossRefGoogle Scholar
  12. 12.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.PubMedCrossRefGoogle Scholar
  13. 13.
    Mofrad P, Contos MJ, Haque M, et al. Clinical and histologic spectrum of nonalcoholic fatty liver disease associated with normal ALT values. Hepatology. 2003;37:1286–1292.PubMedCrossRefGoogle Scholar
  14. 14.
    Piton A, Poynard T, Imbert-Bismut F, et al. Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values, for selection of blood donors, and for patients with chronic hepatitis C. Hepatology. 1998;27:1213–1219.PubMedCrossRefGoogle Scholar
  15. 15.
    Prati D, Taioli E, Zanella A, et al. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med. 2002;137:1–10.PubMedCrossRefGoogle Scholar
  16. 16.
    Ruhl CE, Everhart JE. Upper limits of normal for alanine aminotransferase activity in the United States population. Hepatology. 2012;55:447–454.PubMedCrossRefGoogle Scholar
  17. 17.
    Diab DL, Yerian L, Schauer P, et al. Cytokeratin 18 fragment levels as a noninvasive biomarker for nonalcoholic steatohepatitis in bariatric surgery patients. Clin Gastroenterol Hepatol. 2008;6:1249.PubMedCrossRefGoogle Scholar
  18. 18.
    Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology. 2012;142:1592–1609.PubMedCrossRefGoogle Scholar
  19. 19.
    Sanyal AJ, Chalasani N, Kowdley KV, et al. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med. 2010;362:1675–1685.PubMedCrossRefGoogle Scholar
  20. 20.
    Boettcher E, Csako G, Pucino F, Wesley R, Loomba R. Meta-analysis: pioglitazone improves liver histology and fibrosis in patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2012;35:66–75.PubMedCrossRefGoogle Scholar
  21. 21.
    Rakoski MO, Singal AG, Rogers MAM, Conjeevaram H. Meta-analysis: insulin sensitizers for the treatment of non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2010;32:1211–1221.PubMedCrossRefGoogle Scholar
  22. 22.
    Adams LA, Lymp JF, St. Sauver J, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005;129:113–121.PubMedCrossRefGoogle Scholar
  23. 23.
    White DL, Kanwal F, El-Serag HB. Association between nonalcoholic fatty liver disease and risk for hepatocellular cancer, based on systematic review. Clin Gastroenterol Hepatol. 2012;10:1342–1359.e1342.PubMedCrossRefGoogle Scholar
  24. 24.
    Charlton M. Nonalcoholic fatty liver disease: a review of current understanding and future impact. Clin Gastroenterol Hepatol. 2004;2:1048–1058.PubMedCrossRefGoogle Scholar
  25. 25.
    Baffy G, Brunt EM, Caldwell SH. Hepatocellular carcinoma in non-alcoholic fatty liver disease: an emerging menace. J Hepatol. 2012;56:1384–1391.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Amanda C. Wieland
    • 1
  • Matthew Quallick
    • 2
  • Aimee Truesdale
    • 3
  • Pamela Mettler
    • 4
  • Kiran M. Bambha
    • 1
  1. 1.Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CampusAuroraUSA
  2. 2.Division of GastroenterologyKaiser Permanente ColoradoLafayetteUSA
  3. 3.Division of Gastroenterology and HepatologyDenver Health Medical CenterDenverUSA
  4. 4.Department of Biostatistics and Informatics, Colorado Biostatistics ConsortiumColorado School of Public HealthAuroraUSA

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