Impact of pharmacist-led fibrosis-4 screening in veterans with high-risk alcohol use

Background Heavy alcohol use is linked to numerous negative health outcomes. Regular assessment of high-risk drinking, along with timely psychotherapy, pharmacotherapy, and specialty care, is essential for preventing or managing alcohol-related conditions, such as liver disease. The fibrosis-4 (FIB-4) score is a useful tool for identifying patients who may be at an increased risk for advanced liver fibrosis. Objectives The objective of this project was to incorporate pharmacist-led FIB-4 screening into care and then provide targeted recommendations based on fibrosis risk to improve access to health care resources, such as gastroenterology (GI) referral and treatment engagement, among veterans with self-reported heavy alcohol use. Methods This quality improvement project identified veterans at a single veterans affairs health care system with documented heavy alcohol consumption, defined as an alcohol use disorders identification test-consumption score of 8 or greater, for potential clinical pharmacist intervention. Veterans were excluded if they were already receiving pharmacologic treatment to reduce alcohol intake, were currently engaged in psychotherapy, or had previously been evaluated by GI for high-risk alcohol use. For eligible veterans, clinical pharmacists calculated the FIB-4 score. Veterans with a FIB-4 score of 3 or greater were classified as being at high risk of liver fibrosis, and pharmacist recommendations were made to the primary care provider (PCP) for immediate referral to GI specialty care. Those with a FIB-4 score less than 3 were classified as being at low risk of liver fibrosis, and pharmacist recommendations were made to the PCP for treatment options such as pharmacotherapy to support reduced alcohol use or psychotherapy. Results A total of 26 veterans met the criteria for clinical pharmacist intervention. Out of those, 4 veterans (15.4%) had a FIB-4 score of 3 or greater and received recommendations for urgent GI referral for further evaluation. The remaining 22 veterans, all with FIB-4 scores less than 3, had their PCPs alerted to their AUDIT-C and FIB-4 scores, with suggested treatment options including pharmacotherapy and psychotherapy. Following the pharmacist's recommendations, 22 of 26 (76.9%) veterans had action taken by their PCP, including 9 veterans (35%) who were offered pharmacotherapy. Conclusion The use of the FIB-4 score as a screening tool by clinical pharmacists may lead to increased access to health care resources, such as GI referral and pharmacotherapy, for veterans with high-risk alcohol consumption.