Patton Heather, Burchette Raoul, Tovar Stephanie, Pio Jose, Shi Jiaxiao, Nyberg Lisa M
Southern California Permanente Medical Group, Division of Gastroenterology, Garfield Specialty Center, 5893 Copley Drive, San Diego, CA, 92111, USA.
Section of Gastroenterology, VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA.
BMC Gastroenterol. 2020 Oct 31;20(1):362. doi: 10.1186/s12876-020-01492-9.
A care pathway for nonalcoholic fatty liver disease (NAFLD) in Kaiser Permanente San Diego, California was instituted in August 2017 to improve efficiency of disease staging and promote lifestyle modification.
The NAFLD Care Pathway includes: (1) patient education (2) vibration controlled transient elastography (VCTE) examination (3) hepatology consultation for VCTE ≥ 8 kPa and (4) referral to weight management (WM). Patients referred to the pathway during the first 6 months of its implementation were studied for adherence to its components and impact on weight change and ALT values in the 12 months following referral. Retrospective assessment of WM participation, change in weight, and change in ALT were evaluated in the 12-months following referral and compared to changes 12-months prior. Student's t-test or Wilcoxon signed rank test were used as appropriate (p < 0.05).
632 patients were included. 575 (91.0%) completed VCTE examination with mean liver stiffness 8.5 kPa (SD 9.2). 52 patients had mean liver stiffness ≥ 15 kPa. 180/632 (28.5%) attended NAFLD education. 153/632 (24.2%) were offered hepatology clinic and 136/153 (88.9%) completed at least 1 appointment. Participation in WM was 24/632 (3.8%) prior to referral and 67/632 (10.6%) after referral and increased among patients who attended NAFLD education. Mean weight change following referral was - 0.69 kg (SD 6.58 kg) among patients without WM and - 7.78 kg (SD 13.43 kg) with WM. Overall, 44.2% of participants experienced weight gain after referral, 40.8% had weight loss < 5% and 15% had weight loss ≥ 5%. Variables associated with weight loss included WM (p < 0.0001) and higher liver stiffness (p = 0.0066). Mean ALT change was - 15.2 (SD 38.5) U/L without WM and - 28.8 (SD 29.6) U/L with WM.
A care pathway for NAFLD within a large, integrated healthcare system provides non-invasive disease staging and minimizes hepatology clinic utilization to those with more advanced disease. Referral was associated with increased enrollment in WM, weight loss, and decreased ALT. Given its impact on healthcare resources, strategies to improve NAFLD identification, staging, and promotion of lifestyle modification are imperative.
2017年8月，加利福尼亚州圣地亚哥的凯撒医疗机构制定了非酒精性脂肪性肝病（NAFLD）护理路径，以提高疾病分期效率并促进生活方式改变。
NAFLD护理路径包括：（1）患者教育；（2）振动控制瞬时弹性成像（VCTE）检查；（3）VCTE≥8 kPa时的肝病学咨询；（4）转介至体重管理（WM）。对在该路径实施的前6个月内转介至该路径的患者进行研究，以了解其对各组成部分的依从性以及在转介后的12个月内对体重变化和ALT值的影响。在转介后的12个月内对WM参与情况、体重变化和ALT变化进行回顾性评估，并与转介前12个月的变化进行比较。根据情况使用学生t检验或Wilcoxon符号秩检验（p<0.05）。
纳入632例患者。575例（91.0%）完成了VCTE检查，平均肝脏硬度为8.5 kPa（标准差9.2）。52例患者的平均肝脏硬度≥15 kPa。180/632（28.5%）参加了NAFLD教育。153/632（24.2%）被安排到肝病门诊就诊，136/153（88.9%）至少完成了1次就诊。转介前参与WM的比例为24/632（3.8%），转介后为67/632（10.6%），且在参加NAFLD教育的患者中有所增加。未参加WM的患者转介后的平均体重变化为-0.69 kg（标准差6.58 kg），参加WM的患者为-7.78 kg（标准差13.43 kg）。总体而言，44.2%的参与者在转介后体重增加，40.8%的人体重减轻<5%，15%的人体重减轻≥5%。与体重减轻相关的变量包括WM（p<0.0001）和较高的肝脏硬度（p=0.0066）。未参加WM的患者平均ALT变化为-15.2（标准差38.5）U/L，参加WM的患者为-28.8（标准差29.6）U/L。
大型综合医疗系统内的NAFLD护理路径提供了非侵入性疾病分期，并将肝病门诊的使用降至对病情更严重患者的最低限度。转介与WM参与度增加、体重减轻和ALT降低相关。鉴于其对医疗资源的影响，必须制定改善NAFLD识别、分期和促进生活方式改变的策略。
