NCQA White Paper: Improving Coordinated Care for People With Nonalcoholic Steatohepatitis
May 16, 2022 · Matt Brock
About one in every four or five Americans has a chronic disease that, particularly when diagnosed late and not optimally managed, has significant individual, clinical, public health and health care cost implications.
Nonalcoholic fatty liver disease (NAFLD) is characterized by accumulation of fat in the liver (hepatic steatosis) among people who do not consume significant amounts of alcohol. NAFLD increases the risk of advanced liver disease, and is a leading cause of liver transplants in the United States. Patients with NAFLD fall into two categories: those with nonalcoholic fatty liver (NAFL) and those with nonalcoholic steatohepatitis (NASH), indicating severe liver damage and often fibrosis.
A new white paper from NCQA, A Rallying Cry: Improving Coordinated Care for People With Nonalcoholic Steatohepatitis, calls for expanded awareness of NASH and increased identification of patients at risk. The paper summarizes a September 2021 roundtable discussion, facilitated by NCQA, that included panelists with expertise in primary care, nutrition, gastroenterology, hepatology, endocrinology and patient advocacy.
The white paper provides recommendations for primary care providers (PCPs), specialty clinicians, payers, and patients, including guidance on overcoming barriers to ideal care and providing culturally-appropriate patient education. Given the widespread occurrence of NASH – as many as 6.5% of Americans, including 30-40% of people with type 2 diabetes mellitus (T2DM) – the panelists agreed that it is important to equip primary care practitioners (PCPs) with guidance and tools, as these clinicians are the gateway into the health care system for most patients.
Identifying patients with NASH early in the disease process is essential to optimized care, including patient engagement in nutrition and lifestyle counseling to achieve and maintain weight loss goals. Panelists stressed that NASH education should be as available as it is for T2DM, and patients should be empowered to be active partners in their care.
“There are not going to be enough providers to take care of this.”
The costs of fatty liver disease are considerable. NASH increases the risk of advanced liver disease that can lead to liver failure, making it the second most common cause of liver transplants in the U.S. Research shows that NASH is associated with a diminished quality of life, significantly higher health care costs, and higher mortality rates.
The American Association for the Study of Liver Diseases advises that there should be a “high index of suspicion” of NAFLD and NASH among patients with T2DM. Panelists agreed that ordering additional noninvasive assessments is indicated upon suspicion of NASH, in order to determine the likelihood of fibrosis and need for referral to a specialist. Yet, while PCPs are familiar with the risks associated with T2DM and obesity, and are experienced in appropriate management of these conditions, panelists expressed concern that patients with T2DM are not sufficiently appreciated as at elevated risk for NASH.
Even those providers aware of how common fatty liver disease is may not appreciate the seriousness of short- and long- term consequences when diagnosis is delayed. Primary care clinicians order few non-invasive screening tests for patients at risk of NASH – particularly those with T2DM – to determine if advanced fibrosis is likely to be present, and if a patient may benefit from referral to a gastroenterologist or hepatologist.
Roundtable panelists recommended that clinician education on NASH be shared alongside other obesity-related conditions, including a greater leadership role by professional societies, and within medical school curricula. One study based on data from 10 U.S. medical schools found that only 8.4% of third- and fourth-year medical students had dedicated exposure to chronic liver disease training.
As awareness of NASH and familiarity with existing screening tools expands, clinicians will begin to identify more at-risk patients. More specialty physicians, nurse practitioners, physician assistants, nutritionists, behavioral care professionals and other care providers will be needed. One panelist warned, “There are not going to be enough providers to take care of this.”
Health Disparities Add Additional Challenges to Optimal Care
It is well-known that vulnerable and underserved populations face many challenges in receiving appropriate care for their health needs, including lack of a regular source of primary care. Thus, those with NASH – especially non-English-speaking patients who need specialist care – are at higher risk of disease progression and late-stage complications.
The white paper offers guidance on overcoming barriers to ideal care, including recommendations for culturally appropriate patient education and best practices for overcoming disparities in care, such as the strategies discussed in NCQA’s new Health Equity Resource Center.
What’s Next For NASH?
The white paper closes by looking ahead to new ways of identifying and treating the increasingly common conditions. These include electronic clinical decision support tools to diagnose and treat patients with NAFLD and NASH, expanded practice guidelines, greater use of noninvasive testing and new medications.
The approval of new drugs will have a significant impact. At the time of the NASH Roundtable, nearly 100 companies were developing therapies to treat NASH. As treatments evolve, guideline developers will consider whether medication should be the standard of care, insurers will need to determine if and how to include these drugs in their formularies, and professional societies will need to quickly educate their members on these new medicines.
You can read A Rallying Cry: Improving Coordinated Care for People With Nonalcoholic Steatohepatitis on our web site. NCQA thanks the Roundtable panelists for sharing their expertise and recommendations. The NASH Roundtable, and production and distribution of this paper, were generously funded by Novo Nordisk.