ArticleCMAJ open
Risk stratification of patients with nonalcoholic fatty liver disease using a case identification pathway in primary care: a cross-sectional study.
Article in CMAJ open. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 22 papers.
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Who cites it
22 citing papers in PubMed.
- Metabolic dysfunction-associated steatotic liver disease assessment and management: Clinical practice guidance from the Canadian Association for the Study of the Liver.Canadian liver journal · 2026Article
- Summary of Guidelines for Identifying and Risk-Stratifying Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease: A Primer for Family Physicians.Diagnostics (Basel, Switzerland) · 2026Review
- Diabetes and obesity reduce FIB-4 accuracy in MASLD referral pathways.JHEP reports : innovation in hepatology · 2026Article
- Care Pathways for Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A State-of-The-Art Review.Liver international : official journal of the International Association for the Study of the Liver · 2026Review
- Call to action: integrating steatotic liver disease into public health strategies in Canada.Lancet regional health. Americas · 2025Review
- FIB-4, APRI, and ALRI as Predictors of COVID-19 Outcomes: Insights from a Large-Scale Study.Diagnostics (Basel, Switzerland) · 2025Article
- Approach to steatotic liver disease in the office: Diagnosis, management, and proposed nomenclature.Canadian family physician Medecin de famille canadien · 2025Review
- Article
- Deploying a metabolic dysfunction-associated steatohepatitis consensus care pathway: findings from an educational pilot in three health systems.BMC primary care · 2024Article
- It's time for a unified North American guideline on the use of ultrasound and MRI in patients with MASLD.Abdominal radiology (New York) · 2024Article
- Evolutive Models, Algorithms and Predictive Parameters for the Progression of Hepatic Steatosis.Metabolites · 2024Article
- Evaluating the coding accuracy of type 2 diabetes mellitus among patients with non-alcoholic fatty liver disease.BMC health services research · 2024Article
- Projected Healthcare System Cost Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease in Canada.Gastro hep advances · 2024Article
- Comparison of different definitions of metabolic syndrome and their associations with non-alcoholic fatty liver disease: a retrospective study.Canadian liver journal · 2023Article
- Comparison of Pathway Referrals for Liver Fibrosis Risk Stratification Performed in Diabetology and Nutrition Clinics.Diabetes, metabolic syndrome and obesity : targets and therapy · 2023Article
- Ultrasound-Based Hepatic Elastography in Non-Alcoholic Fatty Liver Disease: Focus on Patients with Type 2 Diabetes.Biomedicines · 2022Review
- Two-Tier Care Pathways for Liver Fibrosis Associated to Non-Alcoholic Fatty Liver Disease in HIV Mono-Infected Patients.Journal of personalized medicine · 2022Article
- Advancing the global public health agenda for NAFLD: a consensus statement.Nature reviews. Gastroenterology & hepatology · 2022Review
- Current considerations for clinical management and care of non-alcoholic fatty liver disease: Insights from the 1st International Workshop of the Canadian NASH Network (CanNASH).Canadian liver journal · 2022Article
- Deep significance clustering: a novel approach for identifying risk-stratified and predictive patient subgroups.Journal of the American Medical Informatics Association : JAMIA · 2021Article
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Authors and funding
11 authors.
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Abstract
backgroundIdentification of patients with nonalcoholic fatty liver disease (NAFLD) with advanced liver fibrosis in primary care remains an unmet need. Our primary objective was to implement a pathway driven by shear wave elastography (SWE) to facilitate risk stratification of patients with NAFLD within primary care and evaluate whether SWE assessment can reduce referrals of patients with NAFLD at low risk for fibrosis to hepatology.
methodsA multidisciplinary NAFLD clinical care pathway was codeveloped by hepatologists, radiologists and primary care physicians in Calgary to provide access to SWE-based screening of patients with NAFLD risk factors in primary care. The study outcome measures were estimated NAFLD-related referrals to the hepatology service in Calgary after implementation of the NAFLD pathway and characteristics of patients with NAFLD at risk for advanced fibrosis. The NAFLD pathway was implemented in January 2018 and was made available to all primary care physicians in the Calgary Health Zone. Patients with NAFLD who had liver stiffness (SWE value ≥ 8.0 kPa) or an inconclusive assessment were referred to hepatology. A serum liver fibrosis score was also measured with the fibrosis-4 (FIB-4) index, and performance of an FIB-4 index score of 1.30 or greater to risk stratify patients with NAFLD was evaluated. Demographic, clinical and laboratory characteristics of study groups were compared.
resultsBetween March and October 2018, 2084 patients with suspected NAFLD were evaluated. Nonalcoholic fatty liver disease was confirmed by ultrasonography in 1958 (94.1%). A majority of the cohort had elevated liver enzyme values (1028 [52.5%]) and obesity (body mass index ≥ 30) (1063/1764 [60.3%]). Most patients with NAFLD (1791 [91.5%]) had an SWE value less than 8.0 kPa and were not referred to hepatology. Sixty-seven patients (3.4%) had an SWE value of 8.0 kPa or more, and 100 (5.1%) had an inconclusive SWE; these patients were referred to hepatology. Using an FIB-4 index score cut-off of 1.30 would have led to hepatology referral of 396/1251 patients (31.6%).
interpretationImplementation of a primary care-accessible SWE pathway for patients with NAFLD facilitated fibrosis risk stratification and greatly reduced hepatology referrals. Using the FIB-4 index score alone would led to higher rates of referral of patients with NAFLD.
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