Early Detection of **Liver Disease in Community Health Centers Enhances Patient Engagement, Improves Outcomes **
*Author: Robert G. Gish, M.D., Medical Director, Hepatitis B Foundation Doylestown, PA *
Community health centers deliver exceptional care to medically underserved populations and share a common goal of providing coordinated community-directed primary and preventive health care services to 29 million people across the country.
Physicians at community health centers play a critical role in not only helping to educate patients about the importance of liver for overall health, but also identifying the best approaches for preventing the progression of non-alcoholic fatty liver disease (NAFLD), a condition characterized by different hepatic abnormalities, ranging from simple liver steatosis to cirrhosis. Therefore, it’s important to understand the connection between disease and cardio-metabolic disorders, as well as the growing and critical need for early detection, prevention and treatment of liver disease.
As early adopters of new, non-invasive tools for liver health examination, Federally Qualified Health Care (FQHC) clinics are moving toward a care model that provides more specialty care in-house, usually through consultant contracts, to create a more highly integrated team to facilitate care. This is important given the alarming rise in liver disease, which impacts a significant number of adult FQHC patients.
Liver Disease and Cardio-Metabolic Disorders
Recent clinical evidence suggests that NAFLD is tied to an increased risk of cardio-metabolic disorders. NAFLD patients usually die of extra-hepatic causes, frequently for cardiovascular diseases (CVD), which points to the importance of an early diagnosis. NAFLD has also been directly linked to multiple cardio-metabolic disorders, including ischemic stroke, insulin resistance, hypertension, chronic kidney disease (CKD) and cardiac arrhythmias.
Tied to the increased prevalence of obesity and metabolic syndrome worldwide, it’s no surprise that NAFLD has reached epidemic levels in the last few decades, with a global prevalence of about 24%. This condition poses an enormous challenge for community health centers and other health systems because of the high prevalence of cardio-metabolic comorbidities and high liver-related mortality.
A significant percentage of the NAFLD conditions evolve to liver fibrosis via non-alcoholic steatohepatitis (NASH). In some cases, NASH may lead to cirrhosis, liver cancer, liver transplant and death. NASH, which is associated with nonspecific symptoms, and is often underdiagnosed and underreported, recently became the most common reason for a liver transplant in women and older patients.
Most patients with NASH experience few specific symptoms, especially in the early stages of the disease. When a patient feels well or has vague symptoms, it can be challenging for physicians and caregivers to convince the patient that they may have a dangerous condition.
Who is at Risk?
People most at risk for developing NAFLD or NASH have obesity, Type 2 diabetes, hyperlipidemia and/or metabolic syndrome. Hispanic and Latino populations are disproportionately affected by NAFLD, depending on genetic factors, access to health care or the prevalence of chronic diseases.
Health center patients have higher rates of chronic conditions than the general population. This is important to note because the presence of Type 2 diabetes accelerates the progression of liver disease in patients with NAFLD, and NAFLD is an independent predictor associated with a > 2x increase in developing Type 2 diabetes.
Researchers have found NAFLD, hepatitis C, liver cancer and liver transplants are prevalent in 40-80% of people who have Type 2 diabetes and in 30-90% of people who are obese. Being overweight or obese is responsible for about 85% of fatty liver disease.
Patient Engagement is Critical
Because NAFLD and NASH are so tightly intertwined with obesity, diabetes and lifestyle, a “whole person” approach to patient engagement is required to support behavioral changes that will result in better outcomes across the co-morbid conditions affecting the individual patient.
Early detection is needed because lifestyle modifications and strict control of metabolic risk factors are the most effective treatment. Because disease progression is typically slow, patients can be managed well by primary care physicians, although NAFLD patients with advanced liver fibrosis should be referred to specialist care for further assessment. While finding and managing fibrotic NASH is an important component to addressing liver disease, patients with steatosis alone are at a greater risk of cardiovascular mortality and morbidity.
Role of Early Detection
Physicians should consider integrating non-invasive, point-of-care liver examinations as a way of improving patient intake and outcomes, lowering costs and enhancing income stream.
At La Maestra, a Federally Qualified Health Care (FQHC) clinic in San Diego, every patient who has elevated liver tests and diabetes undergoes a liver examination with a point-of-care, non-invasive specialized ultrasound machine that measures fibrosis (scarring) and steatosis (fatty change) in the liver. This tool, FibroScan, is an FDA cleared technology for the diagnosis and monitoring of adult patients as part of an overall evaluation of liver health.
Unlike blood tests that measure circulating markers of inflammation, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), this tool directly and non-invasively measures physical properties of stiffness and liver fat. It provides reproducible results, allowing for both diagnosis and monitoring of liver stiffness and liver fat, and has been recognized as a cost-effective tool for screening and also identifying cirrhosis in people with NAFLD. This information can support care management across key components of the metabolic syndrome – diabetes and hyperlipidemia.
This examination can validate the determination of elastography with CAP as an essential part of a patient’s workup, along with a full abdominal ultrasound that includes special liver cancer biomarkers, a liver panel that includes liver enzymes and liver function, chemistry panel and a CBC as well as APRI, FIB4 NAFLD score calculations.
How Non-Invasive Tests Work
It can be particularly useful to share the patient’s liver health score and CAP with patients who have NAFLD to illustrate the change in liver fat and the need for adjusting their treatment and calculation of the FAST score. The liver assessment is simple and accurate – without requiring a clinician that has 100 hours of training. At La Maestra, one technician performs all the exams as part of a team approach for improving the liver health of its patients.
These free examinations use FIB-4 and the APRI score (AST to Platelet Ratio Index). The patient may also require Enhanced Liver Fibrosis Test™ (ELF) test, a new blood test for fibrosis – all of which saves spending thousands of dollars on laboratory testing. These innovative tools represent the standard approach to evaluating the extent of liver disease in a FQHC population, regardless of the demographics.
Patients with elevated liver tests should get a full work up for hepatitis B, C, NASH, iron, alcohol and medications. At La Maestra, this is called the “six rules” – six tests, $60 in 6 minutes. FibroScan should be performed on anyone with elevated liver tests and diabetes to establish fibrosis scores and fat quantity.
Collectively, these tests provide inputs and integrated specimens – and then the outputs provide guidance for managing the patient. It’s also important for clinicians to consult or contract with a consultant liver specialist.
Education and Treatment
When it comes to treating NAFLD, diet and exercise interventions are the first line of therapy, with the goal of decreasing body weight and modifying cardio-metabolic risk factors related to metabolic syndrome. In the early stages of NAFLD, a healthy diet and weight loss of at least 7% might be sufficient. Patients are often treated with vitamin E as well. Aggressive management of hypertension, diabetes and lipid disorder is also key.
Physician practices working in the community health center setting can play a significant role in helping to reverse the nation’s liver disease epidemic through early detection and monitoring of NAFLD/NASH. Ultimately, having a non-invasive tool at the point of care to examine liver health provides quantifiable information that can improve individual health outcomes, lower payer costs by avoiding expensive, invasive interventions and enhance the financial performance of a physician practice.
Patient engagement is the key to successful treatment. This involves a liver specialist sitting down with the patient for at least 15 minutes, and the rest of the care team spending another 15-30 minutes with the patient. The idea is to educate patients through the use of models, diagrams, figures and pictures to give them a better understanding of cirrhosis and liver cancer, as well as the five risk factors of metabolic syndrome.
Patients also learn if they are at increased risk for stroke, heart attack, cirrhosis, liver cancer, bone, spinal, knee and hip disease, degenerative joint disease, renal disease and at least 13 different cancers. In addition, they learn about the impact on their health if they don’t follow treatment and sign a weight loss contract. A follow-up visit ensures that they are following the weight loss program, consulting with a dietician or nutritionist and adhering to the program.
It’s also useful to share the patient’s liver exam score with them to illustrate the change in liver fat and the need for adjusting their treatment. Patients should also take vitamin E at 800 IU’s per day. Clinicians should treat diabetes aggressively and try to stop insulin therapy, if possible. In addition, every patient should be prescribed with metformin for renal function. Significantly, aggressive diabetes management can improve NASH.