Assessing Clinician Engagement With a Passive Clinical Decision Support System for Liver Fibrosis Risk Stratification in a Weight Management Clinic.

Abstract

Objective: Metabolic dysfunction-associated steatotic liver disease is common in obesity. Guidelines recommend liver fibrosis risk stratification with tools such as Fibrosis-4 (FIB-4) index, liver stiffness measurement with vibration-controlled transient elastography (VCTE) and/or hepatology referral for elevated FIB-4. Despite recommendations, implementation remains limited. Using mixed methods, we evaluated a 3-strategy implementation bundle to improve fibrosis risk stratification-a FIB-4-based electronic health record embedded clinical decision support system (CDSS), educational outreach, and internal facilitation in a weight management clinic.

Methods: The primary outcome was penetration: the proportion of patients with elevated FIB-4 completing VCTE or hepatology referral. We compared rates, pre and postactivation of implementation bundle using Fischer's exact test. Semi-structured provider interviews, guided by the i-PARIHS framework, assessed acceptability and feasibility 3 months postimplementation.

Results: In the preactivation phase, 880 out of 3933 (22.4%) weight management visits had the necessary labs to calculate automated FIB-4 scores with 128 elevated scores. In the postactivation phase, 2513 of 4634 weight management visits (54.2%) had automated FIB-4 scores; with 234 elevated score. Preactivation, there were no VCTE and 2 hepatology referrals. Postactivation, there were 3 VCTE referrals and 2 hepatology referrals (Fischer's exact test P value = 1.00). Providers cited shared responsibility with primary care, low awareness and trust in risk-stratification tools, workflow challenges, and competing demands as barriers. Educational outreach and facilitation improved CDSS engagement, while technical issues reduced it.

Conclusion: This implementation strategy bundle did not achieve meaningful metabolic dysfunction-associated steatotic liver disease fibrosis risk stratification. Electronic health record-based CDSS shows promise but requires alignment with provider priorities, seamless workflow integration, and robust technical infrastructure.