P2836 - Calling Attention to Inadequate Workup of Elevated Transaminase Levels in Primary Care

Luis Hernandez, MD, MBA¹, Zain Raza, MD², Samantha Zarro, MD³, Scott McHenry, MD^2
1Washington University in St. Louis, St. Louis, MO; ²Washington University School of Medicine in St. Louis, St. Louis, MO; ³Barnes-Jewish Hospital at Washington University in St. Louis, St. Louis, MO

Introduction: Elevated transaminase levels are commonly encountered by primary care physicians, many times after follow up from recent hospital admissions. Given limited timely access to hepatology follow up, optimal evaluation of elevated transaminases should be performed by primary care providers. Given how common conditions including NAFLD, alcohol hepatitis, and viral hepatitis are seen in primary care, we wanted to analyze if proper evaluation was being performed.

Methods: Consecutive unique patients with ALT greater than 40 U/L (06/2019 – 10/2019) seen at a resident-run outpatient primary care medicine clinic were reviewed. Manual chart review was performed to evaluate if sufficient lab work was performed before or within 3 months of index ALT elevation according to current practice guidelines, including HBV, HCV, autoimmune testing (including ANA/AMA/ASMA), metabolic testing (including ferritin, A1A, ceruloplasmin) and liver ultrasound. Exclusion criteria included patients with previously diagnosed liver disease. Multivariate analysis was then performed to determine statistical differences between workup among the 3 categories of ALT elevation (table 1).

Results: 115 patients with an abnormal ALT were included. Using the ACG criteria (upper limit of normal [ULN] 40 IU/L), the peak ALT was less than 2 times the ULN (borderline) in 50 (43%), 2 to 5 times the ULN (mild) in 50 (43%) and greater than 5 times the ULN (moderate/severe) in 15 (14%). After removing patients referred to hepatology, only 60% in the borderline and 58% in the mild groups had HCV testing, 54% in the borderline and 47% in the mild had HBV testing, 22% of the mild and 36% of the moderate/severe had autoimmune testing, and 42% of the mild and 36% of the moderate/severe had any metabolic testing. There was no statistically significant difference between the 3 categories.

Discussion: We showed that the workup of abnormal ALT is inadequate in primary care and is detrimental to patient quality healthcare, leading to an increased risk of missed diagnoses and interventions, inability to determine the value of future hepatology visits, and inability to triage appropriate time until hepatology visits. Future QI initiatives should be aimed at improving guideline recommended workup, differentiating “borderline” from “mild ALT” elevations prior to early hepatology referral and differentiating the importance for autoimmune workup with moderate/severe aminotransferase elevations for early detection and intervention for autoimmune hepatitis


Figure: Table 1


Disclosures:
Luis Hernandez indicated no relevant financial relationships.
Zain Raza indicated no relevant financial relationships.
Samantha Zarro indicated no relevant financial relationships.
Scott McHenry indicated no relevant financial relationships.


Luis Hernandez, MD, MBA¹, Zain Raza, MD², Samantha Zarro, MD³, Scott McHenry, MD². P2836 - Calling Attention to Inadequate Workup of Elevated Transaminase Levels in Primary Care, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.