Approaching NAFLD Management With a Multidisciplinary Clinic Model

The complexity of non-alcoholic fatty liver disease (NALFD), associated with metabolic disease, cardiac and diabetic complications, and lifestyle factors, makes it ideal for multidisciplinary care. According to a study published in Hepatology, multidisciplinary care can help prevent progression, which is key as NAFLD becomes more prevalent.

Researchers reviewed current models of multidisciplinary care teams and introduced a framework to build a comprehensive NAFLD program. Multidisciplinary clinics (MDCs) are already used in oncology, type 2 diabetes, and women’s health to improve patient satisfaction, as well as clinical and financial outcomes.

“While traditional health care delivery models consist of physicians assessing patients independently, MDCs promote coordinated care by integrating consultations and centralizing into a single clinic space,” the authors explained.

Although data are scarce on NAFLD multidisciplinary care, there are studies on MDCs for the comorbidities associated with NAFLD:

• A cardiovascular disease–focused MDC reduced coronary heart disease risk profiles and central obesity by utilizing cardiologists, nurse coordinators, dietitians, and physiotherapists to initiate lifestyle changes and appropriate drugs.
• Diabetes MDCs have utilized physicians, pharmacists, nurses, and dietitians to improve glycated hemoglobin.
• A weigh management MDC with family physicians, social workers, dietitians, and bariatric surgeons using behavioral therapy achieved a total body weight loss of at least 5% in 1 year for one-third of patients

However, for NAFLD, few guidelines on multidisciplinary care have been published. The Division of Gastroenterology and Hepatology at Weill Cornell Medicine developed the Innovation Center for Health and Nutrition in Gastroenterology (ICHANGE), which targets patients with NAFLD and disease progression.

“ICHANGE employs concepts previously published in successful MDC models and can guide development of other NAFLD MDCs,” the authors wrote.

ICHANGE is led by a hepatologist, but it utilizes an endocrinologist, cardiologist, and dietitian to manage the associated comorbidities of NAFLD. The care team also includes gastroenterologists, endobariatricians, bariatric providers, and advanced practice providers, with a nurse navigator as the point of contact.

The nurse navigator introduces the patient to the program and the care team. All patients initially meet with a hepatologist and a registered dietitian, and a referral algorithm is used to schedule appointments with the ICHANGE providers. Patients with multiple risk factors for cardiovascular disease or risk-enhancing factors are offered a consultation with a preventive cardiologist.

During the initial consultation, the providers evaluate the associated comorbidities, assess stage of liver disease, review lifestyle practices, and formulate a treatment plan. Patients are stratified based on their fibrosis risk, which then determines frequency of follow-up and use of pharmacotherapy.

Patients receive diet and lifestyle counseling, exercise recommendations, and personalized meal planning. The follow-up occurs at 1- to 6-month intervals and focuses on weight and body composition tracking, food and activity review, maintenance of weight loss, disease monitoring, and treatment optimization.

The authors noted that the MDC streamlines the referral process and allows for specialty care to be provided in one setting. ICHANGE utilized concepts from other successful MDCs, highlighting that MDC concepts can be adapted according to the health care setting, they added.

“As NAFLD MDCs become more common, additional prospective evidence will guide long term efficacy and further define best practices,” the authors concluded.

Reference

Kumar S, Wong R, Newberry C, Yeung M, Peña JM, Sharaiha RZ. Multi-disciplinary clinic models: a paradigm of care for management of non-alcoholic fatty liver disease (NAFLD). Hepatology. Published online July 29, 2021. doi:10.1002/hep.32081