Thursday, July 2, 2015

Inadequate screening for non-alcoholic fatty liver disease among pediatric patients with type 2 diabetes: Role of provider knowledge and barriers to screening

Erica Reynolds, MD, MEd
Cincinnati Children's Hospital Medical Center

Background: Most pediatric patients with type 2 diabetes (T2DM) should be screened at least once every 2 years for non-alcoholic fatty liver disease (NAFLD) based on published guidelines for co-morbidity screening in patients with obesity. However, diabetes providers may lack knowledge about these guidelines and NAFLD in general.

Objective: To improve pediatric diabetes providers’ knowledge and confidence regarding screening for NAFLD.

We hypothesized that screening rates for NAFLD in obese pediatric patients with T2DM at a tertiary diabetes center are low, and that lack of provider knowledge about NAFLD is a barrier to screening. We also hypothesized that a simple educational intervention could improve provider knowledge.

Design/Methods: A pre-test/post-test intervention study design was used to measure pediatric diabetes providers’ knowledge retention, confidence in NAFLD screening, and perceived barriers to screening before and after a brief educational intervention. The survey was administered again a year later to measure knowledge retention.
We also performed a retrospective chart review of all obese T2DM patients seen over a 2 year period to determine the rate of NAFLD screening (AST, ALT, or GGT).

Results: Of 59 patients, only 37 were screened (63%). Pre- and post-tests were completed by 77% or 17 of all 22 providers. Confidence in screening (p=0.0003) and knowledge scores increased (mean change SD: 15% 5%, p=0.02). However, the knowledge increase was not sustained at one year. Initially all providers cited lack of knowledge about screening guidelines as a barrier to screening; lack of knowledge about management (53%) and difficulty remembering to screen (71%) were also cited as significant barriers. Knowledge about management, insufficient time and patient non-compliance with follow-up visits were seen as significantly greater barriers after the training than before (p=0.03).

Conclusions: Screening for NAFLD in obese pediatric patients with T2DM is suboptimal, due in part to a lack of provider knowledge about NAFLD risk factors, screening and management. Provider knowledge can be improved with a brief educational session; however, knowledge retention is poor. Perceived barriers should be addressed and future studies should investigate how to optimize long-term retention of learning.