The increasing burden of NAFLD fibrosis in the general population: Time to bridge the gap between hepatologists and primary care
Authors: Marloes van Asten, Pauline Verhaegh, Ger Koek, Jef Verbeek
Journal: Hepatology (2016)

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. TO THE EDITOR: It is with great interest that we read the article by Koehler et al.1 in Hepatology. This elegant study demonstrates the high prevalence of liver fibrosis in the context of nonalcoholic fatty liver disease (NAFLD) in a large, population‐based cohort in the Netherlands. As discussed in the accompanying Editorial, these results confront us with the challenge to adequately detect and manage these patients at the general population level.2 As the gatekeepers of our health care system, general practitioners (GPs) may play a major role in this health issue. In this light, we performed a survey among 64 GPs (mean age, 45 years) in the area of Maastricht, Netherlands, to obtain a snapshot of their knowledge and practices concerning NAFLD. Strikingly, the acronyms NAFLD and NASH (nonalcoholic steatohepatitis) were not known by 34% and 53% of the GPs, respectively. Although 63% of the GPs acknowledged NAFLD as an important health problem, 96% of the GPs never or rarely screened for its presence. In addition, although 80% of the GPs acknowledged the importance of differentiating simple steatosis from NASH, only 47% of the questioned GPs did this in daily practice using liver tests (never, 24%; rarely, 24%; often, 34%; always, 18%) or liver ultrasound (never, 20%; rarely, 36%; often, 28%; always, 16%). Noninvasive serum markers/scores were never (73%) or rarely (22%) used for this purpose. Similarly, referral to specialist care was highly dependent on increased liver tests. Patients with liver steatosis on ultrasound and normal liver tests were never (53%) or rarely (47%) referred. Patients with liver steatosis and abnormal liver tests were never (4%), rarely (39%), often (47%), or always (10%) referred by the GPs. In cases of referral, the majority of GPs (95%) referred their patients to gastro‐enterologists or hepatologists. GPs are not familiar with the clinical practice guidelines on NAFLD developed by our hepatology medical societies. Only one of the questioned GPs consulted the clinical practice guidelines of the European Association for the Study of the Liver or the American Association for the Study of Liver Diseases. However, 86% of the GPs consulted the Dutch general practitioners guidelines for liver diseases. The need for increased awareness and knowledge on NAFLD in the field of primary care was endorsed by 84% of the GPs. Our findings, in conjunction with those of Koehler et al., demonstrate the urgent need for the hepatology societies to reach out. In dialogue with GPs, we should develop, validate, and communicate noninvasive tools and algorithms for the detection, referral, and (parallel) follow‐up of high‐risk individuals in the primary care setting, taking into account cost‐effectiveness. Only close harmony between primary care and hepatologists will decrease the number of patients with undiagnosed NAFLD/NASH and insufficient referral.