Defining comprehensive models of care for NAFLD Liver health specialists

NAFLD places a substantial burden on healthcare systems and receives little attention from public health authorities. Ambitious measures are needed to improve preparedness globally. Prof Lazarus, Spain, discusses how to establish care pathways tailored to meet patients needs but also that optimally use existing resources. Modifiable risks factors are particularly important in a comprehensive strategy.
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My name is Professor Jeffrey Lazarus from the Barcelona Institute for Global Health in Spain. I’m also the vice chair of the EASL International liver foundation. Today I’ll be presenting defining comprehensive models of care for NAFLD Liver Health Specialists. The key points I will be focusing on are centered around the fact that NAFLD places a substantial burden on Healthcare Systems, yet It’s been given little attention within National Public Health agendas with few countries prepared to address the challenge through appropriate policies and strategies and specifically for the design and implementation of efficient and effective models of care. NAFLD has resulted in substantial economic losses and healthcare costs as well as impaired health related quality of life. 

National differences in best practices 

National preparedness is to allow for effective public health measures aimed at preventing disease in NAFLD preparedness means having adequate policies and civil society engagement, guidelines, epidemiology and care management. Such preparedness was found to be efficient in all 29 countries studied in a paper. We carried out focusing on European countries last year. However, there are differences between countries and changes for improvements are clearly needed. Eight recommendations that I’m going to detail contribute to Philly the Earth of guidance on NAFLD models of care and help address the increasing need for the provision of best practice care for patients. 

Requirements of NAFLD patients 

So what services do NAFLD patients require? We need to establish care pathways tailored to their needs. The European pathway association defines a care pathway as a complex intervention for the mutual decision-making and organization of care processes for a well-defined group of patients during the well-defined period. In our paper, we published examples of naphobi models of care and experts’ opinions to develop a series of recommendations for policymakers, healthcare providers and other stakeholders looking to improve the clinical management of this condition. 

What patients need moving forward 

In the years to come we’re seeking to increase the need for the provision of NAFLD practice care pathways. The needs of NAFLD patients vary widely depending on the disease stage and the presence of comorbidities which are very common as we all know. The majority of people living with NAFLD can be managed for now in primary care settings, clearing pathways that direct patients to the appropriate clinical services are essential for managing NAFLD, both for patients and healthcare providers with efficient and effective utilization of resources. 

Primary care plays an essential role in identifying and referring NAFLD patients to specialist care, they have competing priorities and often very limited resources. So they should be engaged and involved early in the guideline development process along with patient organization, representatives, modifiable risk factors such as diets, body weight and physical activity and management of associated comorbidities remain the cornerstones of treatment in all patients right now. For patients with advanced disease, we need more aggressive management, including with pharmacotherapy. If cirrhosis, we need surveillance. How about cellular carcinoma? Now five of the amount rules we identified explicitly addressed common comorbid conditions, like cardiovascular disease and diabetes here.

You see a summary of the seven comprehensive models of care for patients with NAFLD. That doesn’t mean there aren’t other care pathways out there that aren’t working. Well, this is what we were able to identify in a review of the literature. And when we looked specifically at 29 countries surveyed and 2019, none had a strategy for diet and lifestyle interventions that mentioned fatty liver disease or NASH specifically, so I’d encourage you to take a look at these studies specifically, I won’t run through all of them right now in the interest of time. 

The roadmap to optimal care for patients 

So the road to comprehensive models of care for an NAFLD. Well I can assure you that unfortunately it is going to be very long and very windy. What do we need to do to have these kinds ofIt models? Well a model of care needs to focus on four issues. What services are provided? where are they provided? How are they coordinated and integrated within healthcare systems? and who is offering them? So in terms of what services are provided I recommend that we need to develop guidance on screening and testing with non-invasive tests. We need to establish patient-centered pathways tailored to the disease stage. We need to outline actions to prevent disease progression and we need to develop guidance on treatment strategies related to the disease stage. So here you see on the right before concrete recommendations that the study group came up with through a long series of literature review, discussions, meetings, revision and consultation. Where are the models of care provided? What we need to articulate and Define the roles and interactions between primary secondary and tertiary care providers as I already mentioned many people can be managed primary care, but we need to make sure that those that need secondary care and tertiary care receive it at the same time that only those specialists with that those specialists only receive the patients in need of their care. Otherwise, their services will become overwhelmed. Our sixth recommendation was to establish where services for NAFLD can be co-located with services for the treatment of common comorbidities. Most obvious would be diabetes but also cardiovascular disease and other conditions co-location or a very tight referral system or team care is essential. 

Coordination and implementation in the healthcare system

How are they coordinated and integrated within health care systems? We need to establish effective systems for coordinating and integrating care across a healthcare system. Now for the non-alcoholic fatty liver disease NAFLD hepatitis, these are going to be new issues for some healthcare systems around the world and we know with the high and increasing awareness of the high prevalence of these conditions. Healthcare systems are going to need to address them at all levels and therefore we need to have better coordination and integration. Finally, who’s offering the care? We need to define the composition and structure of the multidisciplinary team responsible for managing patients that may mean that those received in specialist care, go back to primary care, later go back  to specialist care and they might even need to be some joint care provided but in the in the presence of comorbidities and there will be comorbidities for sure. Team approaches need to be facilitated to the extent possible. So these are the eight recommendations I went through and that are available in the paper. I won’t go through them again, but as you can see this will take a whole of system approach with clinicians.from many different specialties along with the primary care specialists and other stakeholders within the healthcare system from hospital administrators to payers and insurance companies getting involved in order to make sure that models of care are fit for purpose. 

Prevention of disease progression 

So how can we prevent disease progression for the best possible outcomes? Comprehensive models of care outlining patients management from diagnosis to treatment. Some countries have strong guidelines. In our review, we found that many countries do not have guidelines, some will use international associations guidelines. Some are simply not able to address fatty liver disease at all right now due to competing priorities or lack of awareness. We focus on the importance of these care pathways and early diagnosis as the first step in the care system. We know from other liver diseases such as hepatitis B and hepatitis C, that late diagnosis is a major problem for those conditions and we believe that will be the same or is already the same for fatty liver disease. 

The role of primary care 

Primary care, specialist care play key roles and the identification of patients and linking them to appropriate care.The integration and coordination within different healthcare systems is critical including effective communication between specialists, primary care and patients and that isn’t always easy. Patients won’t always understand the specialists, specialists won’t always understand the patients and primary care addressing so many other issues, may simply not have the time to communicate properly. So this needs to all be addressed and facilitated in a structured fashion, and it’s essential to have close collaboration and effective communication. I mentioned between service providers and collaborative approaches, that includes patient organizations and individual patients along care pathways. Most fatty liver disease patients do not require intensive special slight interventions to manage the addict component of the disease. 

Efficient and effective systems are needed for patients

For the identified models, we found that the role of primary care not requiring specialist care monitoring liver disease progression systems and specific systems and specific population groups and ensuring linkage to care are beneficial. I would stay essential and access to high quality primary care prevented interventions and is critical to reduce the burden of non-communicable diseases more broadly and addressing the inherent inequalities associated with these diseases. That means looking at the social determinants of health as we start to gain a broader picture of the profile of NAFLD patients for feasible primary care interventions. Efficient and effective systems are needed for patients who would benefit and link them to development. Primary care or even community service-structured disease management programs are likely to deliver more benefit than general. In this context, established management programs for high-risk patient populations, for example patients with diabetes can serve as examples, integrating other health professionals namely dietitians should be considered. I would say it is essential in decentralizing the provision of care including the community-based care models that can also be an effective approach regarding the dietitians. Of course, we do know that there is not obese or what we call lean NASH, but for the majority of cases, dietitians will play an important role. Adequate training and resourcing are key to the implementation of effective programs and primary care. Right now, there are major shortfalls in care for fatty liver disease and even the factors leading to fatty liver disease. Poor diet and lack of physical activity are simply under addressed and we need to ensure synergies between stakeholders with mutual goals, developing local communities of practice that go beyond healthcare providers to include other stakeholders such as community groups, businesses and sports bodies. This can be an effective approach. As previously noted, a lack of consensus remains among professional bodies on the effectiveness of systematic screening and high-risk populations, however, growing evidence of the cost-effectiveness of NAFLD screen patients with diabetes and growing calls from experts to routinize screening in this group is becoming available. 

Health Information technology and opportunities for further improving the coordination and integration of services for patients

Health Information technology provides opportunities for further improving the coordination and integration of services for patients with chronic disease and enabling greater levels of collaboration between patients and providers. Nevertheless, given the increasing prevalence of NAFLD and the low percentage of diagnosed cases, health systems need to start reorienting to ensure that care can be delivered efficiently and effectively. To address this progressive condition and reduce its wide reach.

Conclusion 

So in conclusion, the eight recommendations that I set out in this presentation contribute to filling the depth of guidance on how best to address the gaps in care for patients with NAFLD. I’d like to thank and acknowledge the many co-authors of the paper on models of care published in reviews, guests and groups earlier this year who helped review the literature to refine and develop these recommendations together with these co-authors and 218 from around the world. We’re currently developing a large global public health consensus statement that will start to provide a roadmap to how these recommendations and many others can be taken forward as we start to address fatty liver disease, NAFLD and NASH from a whole system approach and perspective. Thank you very much.

 

Prof. Jeffrey V. Lazarus

Prof. Jeffrey V. Lazarus

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