EHR-based clinical pathway may improve care for advanced liver disease in type 2 diabetes
A trial in Asia found that automated calculation of fibrosis scores and electronic reminder messages to clinicians increased referrals of patients with abnormal results to appropriate care, although subsequent diagnosis of advanced liver disease was uncommon.
Use of automatically calculated fibrosis scores and electronic reminder messages to clinicians may increase appropriate care in patients with type 2 diabetes and indications of advanced liver disease.
Researchers in Hong Kong and Malaysia performed a pragmatic randomized controlled trial at five general medicine or diabetes clinics. Patients with type 2 diabetes were assigned to an intervention group, in which Fibrosis-4 Index and aspartate aminotransferase-to-platelet ratio index were automatically calculated based on routine blood tests and clinicians received electronic reminder messages about abnormal results, or to usual care. The study's primary outcome was the proportion of patients with elevated fibrosis scores who received appropriate care, defined as referral to a hepatologist or for specific fibrosis assessment, within a year. The results were published Aug. 7 by Gut.
Five hundred thirty-three and 528 patients were assigned to the intervention and control groups, respectively, between May 2020 and October 2021. The mean age was 59.4 years, and 47.4% were women. Overall, 33.3% of patients with elevated fibrosis scores received appropriate care in the intervention group versus 3.1% in the control group (difference, 30.2% [95% CI, 22.4% to 38%]; P<0.001). To ensure one additional case of appropriate management, the number needed to screen was 11 (95% CI, 9 to 15). Advanced liver disease was confirmed in 2.1% of patients in the intervention group and 0.2% of patients in the control group (difference, 1.9% [95% CI, 0.61% to 3.5%]; P=0.006).
The researchers noted that they only included patients in Asia, that fibrosis score was calculated based on a single rather than periodic assessments, and that the study was underpowered to detect the effect of the intervention on such clinical outcomes as cirrhotic complications and death. They concluded that automated calculation of fibrosis scores and electronic reminders of abnormal results can increase referral of patients with type 2 diabetes and abnormal fibrosis scores to appropriate care. “However, over half of the patients with increased fibrosis scores did not receive appropriate care, and only a minority of referred patients actually had advanced liver disease,” they wrote. “The findings of this trial shed light on how to refine the clinical care pathway.”