Lost in Stratification: The Underutilization of FIB-4-Guided MASLD Screening in the Primary Care Setting

Authors

• Sanjna Shelukar, MD, Thomas Jefferson University HospitalFollow
• Ananya Venkatesh, MD, Thomas Jefferson University HospitalFollow
• Breanne McDermott, BS, Thomas Jefferson UniversityFollow
• Julietta Gervase, BA, Thomas Jefferson UniversityFollow
• Maria Winte, MD, Thomas Jefferson University HospitalFollow
• Rebecca Loh, MD, Thomas Jefferson University HospitalFollow
• Dina Halegoua-De Marzio, MD, Thomas Jefferson University HospitalFollow

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a leading contributor to chronic liver disease worldwide. Early identification of MASLD and hepatic fibrosis in the primary care setting is essential for timely and effective management. The Fibrosis-4 (FIB-4) index is recommended as a first-line, non-invasive tool to screen at-risk patients for advanced fibrosis. This study aims to determine FIB-4 screening rates in at-risk patients in an urban resident-led primary care clinic.

A retrospective chart review was conducted in a single Internal Medicine resident-led primary care clinic. Patients aged 36 to 65 years were included, and FIB-4 scores were calculated. Patients were stratified into low-risk (FIB-4 < 1.3), indeterminate-risk (FIB-4 1.3-2.67), and high-risk (FIB-4 > 2.67) groups. For patients in the indeterminate and high-risk groups, secondary risk assessments in the form of elastography orders and hepatology referrals, respectively, were assessed.

172 patients with BMI >36 were identified. Of these, 108 were female (63%) with a median age of 53 years. 69% of patients had hypertension, 67% had hyperlipidemia, and 46% had diabetes. 144 patients were classified as low-risk FIB-4, 26 as indeterminate-risk, and 2 as high-risk. Among the indeterminate-risk group, only 3 (12%) patients had elastography ordered; 2 patients completed the test with values of 5.8 and 6.9 kPA (F0-F1 fibrosis). None of the high-risk patients were referred to a hepatologist. Documentation of FIB-4 scores in patient charts was rare.

Our findings show that FIB-4 is infrequently utilized in the primary care setting, and patients with indeterminateor high-risk FIB-4 scores often do not receive appropriate secondary evaluation for MASLD. This underuse may contribute to delayed diagnosis and progression of liver fibrosis. Increased education of primary care providers and FIB-4 integration into the electronic health record can increase incorporation of the FIB-4 index into routine screening for patients with metabolic risk factors.

Recommended Citation

Shelukar, MD, Sanjna; Venkatesh, MD, Ananya; McDermott, BS, Breanne; Gervase, BA, Julietta; Winte, MD, Maria; Loh, MD, Rebecca; and Halegoua-De Marzio, MD, Dina (2026) "Lost in Stratification: The Underutilization of FIB-4-Guided MASLD Screening in the Primary Care Setting," The Medicine Forum: Vol. 27, Article 15.
Available at: https://jdc.jefferson.edu/tmf/vol27/iss1/15