Liver disease and cirrhosis now outpace diabetes and stroke as the leading cause of mortality in people aged 25 to 54 years. However, data from the Liver Health Annual Trends Report indicate shortfalls in adoption of national treatment guidelines.

In this second annual survey, nurse practitioners (NPs) and PAs were added to the list of providers as these providers are “very critical” even within subspecialty care and inpatient management, said study coauthor Nancy Reau, MD, section chief of hepatology at Rush University Medical Center. “Some of our patients really do find that the bulk of their care is provided by APPs [advance practice practitioners], and so if we don’t survey them, we don’t really understand this critical component in our patients’ management,” Dr Reau said in an interview with the American Journal of Managed Care

The shortage of gastroenterologists in the US is predicted to reach 1630 by 2025, according to the US Department of Health and Human Services (HHS). However, HHS also predicts a surplus of 980 PAs specializing in gastroenterology. “The gastroenterologist shortage may provide PCPs, NPs, and PAs an opportunity to potentially impact patient outcomes,” according to the report authors.

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The report authors also pointed to the value of APPs in the care of patients with liver disease. Data from a large nationally representative commercial claims database show that compared with those not treated by APPs, patients treated by APPs had:

  • Higher rates of hepatocellular carcinoma screening (adjusted odds ratio [OR]: 1.23; 95% CI: 1.19, 1.27)
  • Higher rates of varices screening (OR: 1.20; 95% CI: 1.13, 1.27)
  • Higher use of antibiotic after a discharge for hepatic encephalopathy (OR: 2.09; 95% CI: 1.80, 2.43)
  • Reduced risk of 30-day readmission (OR: 0.68; 95% CI: 0.66, 0.70)
  • Reduced risk of death (adjusted HR: 0.57; 95% CI: 0.55, 0.60)

Key Survey Findings

The trends report is based on a survey of 400 health care providers (HCPs) who treat patients with chronic liver disease. Survey respondents included 100 community-based gastroenterologists, 100 institution-based specialists, 100 primary care physicians, and 100 NPs/PAs.

Notable findings from the report include the following:

  • 34% of gastroenterologists report increases in patient hospitalizations due to alcoholic cirrhosis of the liver during the past year
  • 38% of the respondents were unaware of and/or could not name national guidelines for the management of CLD
  • 18% of PCPs and 20% of NPs/PAs report that they are interested in the American Association for the Study of Liver Diseases (AASLD) guidelines but do not know how to incorporate them into daily practice
  • 55% of PCPs and 49% of NPs/PAs said they are not comfortable treating overt hepatic encephalopathy and seek a consult
  • 50% of providers surveyed report a patient’s ability to pay out-of-pocket expenses is very or extremely important to CLD patient outcomes
  • A 3-fold projected increase in mortality from liver disease associated with nonalcoholic fatty liver disease (NAFLD) progression is expected from 2015 to 2030
  • The rate of liver disease-related mortality is highest among non-Hispanic American Indians or Alaska Natives (5.97%) followed by Hispanic adults (3.24%) compared with 1.46% in non-Hispanic White patients; the lowest rate was found among non-Hispanic Black adults (0.09%)
  • Perceived issues with prior authorization rejections/complexity were among the leading factors negatively affecting treatment initiation or continuity

NP/PA Perspectives on Liver Disease Management

In in-depth interviews, PCPs and NPs/PAs spoke of their desire for better patient management resources. One PA respondent said: “Our nearest specialist is 45 minutes away, so we [APPs] do all the follow-up care. Our biggest challenge beyond managing a complicated disease is securing treatment and tests for the uninsured or underinsured, which is half of our patient population.”

“I think early detection of fatty liver disease [via ultrasound] is the key given the obesity epidemic,” said an NP respondent. “You are not going to see evidence of it on lab work. We should be screening for it like any other type of condition—diabetes, for example.”

The report includes a list of resources and tools for chronic liver disease management.


Salix Pharmaceuticals. Liver Health: Annual Trends Report, Second Edition. Accessed November 10, 2022.