Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA.
Division of Hospital Medicine, Department of Medicine, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, CA; Department of Gastroenterology, Kaiser Permanente San Francisco, CA.
Am J Med. 2024 Feb;137(2):172-177.e2. doi: 10.1016/j.amjmed.2023.10.002. Epub 2023 Oct 27.
Nonalcoholic fatty liver disease (NAFLD) is a leading cause of cirrhosis but is underrecognized in primary care. Cirrhosis management requires complex monitoring, and the quality of care (QoC) for NAFLD cirrhosis patients in primary care may be inadequate.
In this retrospective-prospective cohort study of primary care patients with diabetes mellitus, we identified patients with NAFLD cirrhosis by 1) evidence of cirrhosis from abdominal imaging identified by natural language processing, or 2) existence of International Classification of Diseases code for cirrhosis. A finding of either was followed by manual chart review for confirmation of both cirrhosis and NAFLD. We then determined if cirrhosis care measures were up-to-date, including hepatitis A and B vaccination, Model for End-Stage Liver Disease score components, esophagogastroduodenoscopy, and hepatocellular carcinoma screening. We created a composite score quantifying overall QoC (scale 0-8), with high QoC defined as ≥6 points.
Among 3,028 primary care patients with diabetes mellitus, we identified 51 (1.7%) with NAFLD cirrhosis. Although 78% had ≥3 average primary care visits/year, only 24% completed hepatocellular carcinoma screening at least annually in at least 75% of years since diagnosis. The average QoC composite score was 4.9 (SD 2.4), and less than one-third had high QoC.
NAFLD cirrhosis is prevalent but underdiagnosed in primary care, and receipt of comprehensive QoC was suboptimal. Given the rising incidence of NAFLD cirrhosis, primary care providers need improved awareness and mechanisms to ensure high QoC for this population.
非酒精性脂肪性肝病（NAFLD）是肝硬化的主要原因，但在初级保健中未得到充分认识。肝硬化的管理需要进行复杂的监测，初级保健中 NAFLD 肝硬化患者的护理质量（QoC）可能不足。
在这项针对患有糖尿病的初级保健患者的回顾性前瞻性队列研究中，我们通过以下两种方法之一来确定患有 NAFLD 肝硬化的患者：1）通过自然语言处理识别出腹部影像学检查提示肝硬化的证据，或 2）存在肝硬化的国际疾病分类代码。如果发现这两种方法中的任何一种，都将通过手动病历审查来确认肝硬化和 NAFLD 的存在。然后，我们确定肝硬化的护理措施是否是最新的，包括甲型肝炎和乙型肝炎疫苗接种、终末期肝病模型评分成分、上消化道内镜检查和肝细胞癌筛查。我们创建了一个综合评分，用于量化整体 QoC（范围 0-8），高 QoC 定义为≥6 分。
在 3028 名患有糖尿病的初级保健患者中，我们发现 51 名（1.7%）患有 NAFLD 肝硬化。尽管 78%的患者每年平均有≥3 次初级保健就诊，但只有 24%的患者在确诊后至少每年有 75%的时间进行了肝细胞癌筛查。平均 QoC 综合评分为 4.9（SD 2.4），不到三分之一的患者具有高 QoC。
NAFLD 肝硬化在初级保健中普遍存在但诊断不足，全面的 QoC 接受情况并不理想。鉴于 NAFLD 肝硬化的发病率不断上升，初级保健提供者需要提高认识，并建立机制，以确保这一人群的高 QoC。
