Increasing Utilization of the FIB-4 Score to Improve Appropriate NAFLD Consultation to the Orlando VA GI/Hepatology Service

From the 2022 HVPA National Conference

Omar Masarweh MD (UCF/HCA), Teayoung Kim MD, Mohammed Rahhal MD, Fanny Stampfli MD, Stephanie Lopez MD, Feras Al-Moussally MD, George Alvarez DO, Ashwini Komarla MD


Nonalcoholic fatty liver disease (NAFLD) is increasingly common, affecting more than one-third of American adults1. NAFLD often presents asymptomatically. Optimal timing of treatment depends on the accurate staging of fibrosis, so risk factor screening at the primary care level is critical together with timely, evidence-based, and accessible management processes. To achieve this, the American Gastroenterology Association (AGA) developed a clinical care pathway [KA1] providing guidelines for screening, diagnosis, and treatment of NAFLD that rely on the noninvasive fibrosis index for assessing liver fibrosis staging (FIB-4). Multiple studies have shown that a FIB-4 score <1.3 can reliably exclude advanced fibrosis in patients with NAFLD, with a negative predictive value >90%2,3. At our institution, we noticed a large number of gastroenterology (GI) consults for NAFLD without appropriate workup based on the AGA’s recommendation as well as a lack of awareness of non-invasive risk stratification tools such as the FIB-4. By using the FIB-4 score, a provider can accurately screen for patients with underlying liver disease, determine whether further invasive testing is needed, or if referral to a hepatologist is warranted.


We developed a quality improvement (QI) project aimed at increasing the utilization of the FIB-4 score for suspected NAFLD to reduce the number of inappropriate GI consults.


We surveyed 48 residents about their knowledge of the FIB-4 score to gain insight into possible areas to intervene. We conducted a retrospective chart review of all GI/hepatology consults that were placed from 1/1-11/16/2021. All consults placed for suspected NAFLD (204/1644) were included. For each consult, we searched if a Fib-4 score was calculated, who placed the consult, and if a fibroscan was completed.


From our initial resident survey, 23% (11/48) had knowledge of the Fib 4 score, 9% (9/48) have used it in practice, and 68% (33/48) have not heard of the Fib-4. Of all the GI consults 12% (204/1644) were determined to be for suspected NAFLD with only 5% (11/204) including Fib-4 scores, 98% (201/204) of the consults were placed by primary care. 0/204 had a fibroscan prior to consultation. Based on the AGA recommendations, only 37% (76/204) of consults were considered appropriate.


A large number of consults placed to GI/hepatology for evaluation of NAFLD may be considered inappropriate. A lack of knowledge of non-invasive scoring systems that aid in risk stratifying patients may be a significant contributing factor.

Clinical Implications

Currently, GI consults are being placed for further evaluation for suspected NAFLD with underutilization of screening and risk stratification tools such as the FIB-4. This leads to increased cost and delays in care for patients that truly need a referral to GI. [FA2] Our data suggest a general lack of knowledge of the AGA recommendations for the management of NAFLD. By educating all PCPs through grand rounds and changing the ordering menu for consults to include the clinical care pathway, we hope to decrease the number of inappropriate GI consults and empower primary care to begin the initial workup. This will increase patient satisfaction, decrease costs to the system, and avoid delays in treatment.

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