Identifying and Linking Patients At Risk for MASLD with Advanced Fibrosis to Care in Primary Care

Abstract Background and Aims Severity of fibrosis is the driver of liver-related outcomes in metabolic dysfunction-associated steatotic liver disease (MASLD), and non-invasive testing such as fibrosis-4 (FIB-4) score is utilized for risk stratification. We aimed to determine if primary care patients at risk for MASLD and advanced fibrosis were evaluated with subsequent testing. A secondary aim was to determine if at-risk patients with normal aminotransferases had advanced fibrosis. Methods Primary care patients at increased risk for MASLD with advanced fibrosis ( n = 91,914) were identified using previously established criteria. Patients with known alternative/concomitant etiology of liver disease or cirrhosis were excluded. The study cohort included patients with calculated FIB-4 score in 2020 ( n = 52,006), and stratified into low, indeterminate, and high likelihood of advanced fibrosis. Among those at indeterminate/high risk, rates of subsequent testing were measured. Results Risk stratification with FIB-4 characterized 77% ( n = 40,026) as low risk, 17% ( n = 8847) as indeterminate, and 6% ( n = 3133) as high risk. Among indeterminate/high-risk patients ( n = 11,980), 78.7% ( n = 9433) had aminotransferases within normal limits, 0.95% ( n = 114) had elastography, and 8.2% ( n = 984) were referred for subspecialty evaluation. Conclusion In this cohort of primary care patients at risk for MASLD with fibrosis, the FIB-4 score identified a substantial proportion of indeterminate/high-risk patients, the majority of which had normal aminotransferase levels. Low rates of subsequent testing were observed. These data suggest that a majority of patients at increased risk for liver-related outcomes remain unrecognized and highlight opportunities to facilitate their identification.