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FIB-4 Risk-Stratification Algorithm for MASLD Improved Primary Care Practice Patterns, According to New Research


TLM 2023: Primary care clinicians exposed to a FIB4-based risk stratification algorithm reported applying it routinely for patients with elevated LFTs after the introduction.

FIB-4 Risk-Stratification Algorithm for MASLD Improved Primary Care Practice Patterns / Image credit: ©Jo Panuwat D/AdobeStock

©Jo Panuwat D/AdobeStock

Implementing a fibrosis-4 index (FIB-4) risk-stratification algorithm in primary care substantially impacted primary care clinician management of metabolic-dysfunction associated steatotic liver disease (MASLD), according to new research.

Specifically, findings showed that after implementing the American Association for the Study of Liver Disease’s (AASLD’s) FIB-4 risk-stratification algorithm, 46% of primary care clinicians reported that their likelihood of managing patients with MASLD with low FIB-4 in primary care and/or appropriately referring patients with high FIB-4 to a hepatologist had increased.

The study abstract was presented at The Liver Meeting (TLM) 2023, November 10-14, in Boston, MA. TLM is the annual scientific meeting of the AASLD.

“Nearly 25% of US adults have MASLD with 1 in 4 having at least moderate fibrosis at diagnosis,” wrote presenting author Max Goldman, MD, of Kaiser Permanente Northern California, and colleagues. “Early detection in the primary care (PC) setting is ideal in order to implement early interventions to prevent advanced progression.”

According to Goldman and coauthors, AASLD guidance recommends that primary care clinicians perform FIB-4 risk assessment to determine the need for specialist referral, however, few primary care clinicians “are aware of or use FIB-4 in managing those at risk of MASLD” and it is unclear whether clinicians would adopt FIB-4 in their practice.

To gain a deeper understanding of primary care clinician knowledge and use of FIB-4 before and after implementation of AASLD’s FIB-4 risk-stratification algorithm, they conducted a 3-part study at a large, diverse health system. The 3-part design included a preintervention survey and assessment to ascertain clinician knowledge of MASLD and management patterns, an intervention implementation, and a postintervention survey after 1 year.

In the intervention implementation phase, primary care clinicians received an electronic medical record notification for each patient aged 18-75 years with diabetes (DM) and either a low-risk FIB-4 (ie, <1.3) or a high-risk Fib-4 (ie, >2.67). The electronic notification recommended that low-risk patients be managed in primary care and those at high-risk be referred to hepatology, according to the abstract. The intervention was implemented over 18 months and excluded patients with other common liver diseases.

In total, researchers surveyed 115 primary care clinicians preintervention and 119 postintervention treating 26 602 adult PC patients actively receiving care. Among the patients actively receiving care, 3297 had DM, with 269 excluded for hepatitis B virus (HBV), hepatitis C virus (HCV), ethyl alcohol (ETOH), yielding 3028 PC patients with DM without other liver disease.


The authors reported 88 of an original 115 preintervention and 69 of an original 119 postintervention primary care clinician survey respondents. Among postintervention respondents, 64% received messages for low-FIB-4 patients and 54% for high-FIB-4 patients during the intervention, according to researchers.

When investigators compared postintervention survey responses to preintervention responses, they observed the following:

  • Primary care clinician knowledge of fibrosis as a predictor of cirrhosis improved (86% vs 76%; P=.02).
  • Primary care clinician knowledge of FIB-4 components increased (46% vs 25%; P=.003).
  • Significantly more primary care clinicians reported applying FIB-4 for patients with elevated liver function tests (59% vs 16%; P<.001).

Results also showed that 46% of primary care clinicians reported postintervention that their likelihood of managing patients with MASLD with low FIB-4 in primary care and/or appropriately referring patients with high FIB-4 to hepatology had increased.

“This study provides evidence that [primary care clinicians] introduced to FIB-4-based risk stratification adopt the strategy, resulting in improved practice patterns,” concluded Goldman and colleagues.

Source: Goldman ML, Fox RK, Brandman D, et al. Improving primary care provider awareness and use of FIB-4 risk-stratification for metabolic-dysfunction associated steatotic liver disease (MASLD). Abstract presented at The Liver Meeting 2023; November 10-14, 2023; Boston, MA.

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