Leveraging electronic health records to explore documentation of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in New York City practices

Background:

Non-alcoholic fatty liver disease (NAFLD) is characterized by metabolic liver injury and can progress to non-alcoholic steatohepatitis (NASH), greatly increasing risk of cirrhosis. According to the World Gastroenterology Organization, estimated NAFLD prevalence in U.S. adults is 27-34%. Exact population rates are difficult to obtain because NAFLD is often asymptomatic. The NYC Department of Health’s Primary Care Information Project (PCIP) enables evaluation of NAFLD/NASH documentation at the city level through a query tool (the Hub) that returns aggregate count data from NYC ambulatory practices in real time.

Objective:

To analyze NAFLD/NASH documentation in NYC ambulatory practices from 2011-2014 among adult patients by patient and practice characteristics.

Methods:

To be eligible, PCIP practices had to be actively using an electronic health record (EHR) from 2011-2014, defined as having seen at least 50 patients and having documentation rates of 80% for diagnoses, 50% for vitals and 20% for medications. Of the 507 practices that returned all Hub queries, 396 met inclusion criteria (n=1,053 providers, 839,430 patients in 2014). Median and mean practice documentation rate of NAFLD/NASH were reported for 2011-2014 by patient race, age, sex, neighborhood poverty and practice characteristics. The highly skewed data failed normality tests, and Wilcoxon signed-rank tests were used to assess significance of change from 2011 to 2014.

Results:

From 2011 to 2014, NAFLD/NASH documentation at the median practice moderately improved, from 0 to 6 cases/100,000 patients. However, the average practice documentation rate increased from 358 to 732 cases/100,000 patients, reflecting increases among the top quartile of practices. The percent of practices documenting at least one NAFLD/NASH case increased from 35.6% to 49.7%. Documentation increased significantly across all demographic sub-groups (p<0.05), except among Asians and patients without a documented race. The largest increases were seen among ages 40-59, Hispanics, males, and residents of neighborhoods with a moderate poverty rate (20-29.9%). Documentation increased significantly in small practices and primary care practices. No significant differences were seen in community health centers and hospitals, or specialty practices.

Discussion:

While average documentation doubled from 2011 to 2014, NAFLD/NASH was dramatically under-documented compared to estimated prevalence. This may reflect both a lack of an established testing recommendation and lack of awareness about the disease among providers and patients. More research is needed to understand barriers to identification of NAFLD/NASH in ambulatory care.