Assessment and management of people with non-alcoholic fatty liver disease in primary care

This study will use an interrupted time-series design (before and after new pathway implementation). Practical NAFLD Pathway: Patients 18 years or older attending collaborating Metro South primary care practices with a diagnosis of NAFLD will be eligible for inclusion. Initial risk stratification will be performed using NAFLD Fibrosis Score (NFS) and Fibrosis-4 (Fib-4) tests. Both the Fib-4 and NFS provide cut off scores for low, indeterminate and high risk of advanced fibrosis. Patients with low FiB-4 (<1.3) and low NFS (<-1.455) are considered to have a low risk of advanced fibrosis and will remain in primary care, with ongoing assessment and management of metabolic cormorbidites (obesity, type 2 diabetes, hypertension, dyslipidemia) and reappraisal of fibrosis risk after 3 years. Patients with Fib-4>3.25 or NFS>0.675 are at high risk of advanced fibrosis and will be referred to secondary care for hepatology assessment. Patients with indeterminate FIB-4 or NFS scores will have second-line assessment with FibroScan and/or an ELF test in Primary Care, and will be referred to secondary care for further assessment if LSM>8.2 or ELF test>9.8. As many patients as possible in the indeterminate group will have both a Fibroscan and an ELF test. However some patients may not be suitable for Fibroscan due to body habitus/ rib spacing; other patients may be unable to provide a blood sample for the ELF test. Patients referred for secondary care will be reviewed by a Hepatologist as per standard of care and may have further investigations as deemed necessary to determine their level of fibrosis.