S2447 Missed Opportunities for Noninvasive Fibrosis Risk Stratification in MASLD: A Veteran Population Analysis

Introduction: Noninvasive fibrosis scores such as Fib-4 and the NAFLD fibrosis score are recommended by major guidelines for risk stratification in metabolic dysfunction-associated steatotic liver disease (MASLD). However, adherence to these recommendations is unclear, and predictors of missed risk stratification have not been well characterized. Understanding care gaps is essential to inform quality improvement initiatives and optimize patient outcomes. We sought to determine the prevalence and predictors of missed noninvasive fibrosis risk stratification in a Veteran MASLD cohort and to identify subpopulations at greatest risk for being overlooked. Methods: We conducted a retrospective cohort study of 80 adults with MASLD followed at a veteran's affairs hospital. EMR were reviewed for documentation of Fib-4 and/or NAFLD fibrosis score. “Missed risk stratification” was defined as the absence of both a Fib-4 and a NAFLD fibrosis score in the medical record. Clinical variables, including age, BMI, platelet count, alanine aminotransferase (ALT), A1c, ASCVD 10-year risk, and type 2 diabetes (T2DM) status, were extracted for all patients. Logistic regression was used to identify independent predictors of missed risk stratification. Results: Of 80 patients, 21 (26%) had no documented Fib-4 or NAFLD fibrosis score, representing a significant care gap in guideline-recommended MASLD management. Older age was independently associated with higher odds of missed risk stratification (OR per year: 1.14, 95% CI 1.06–1.24, P = 0.001), while T2DM was associated with a dramatically lower risk (OR: 0.02, 95% CI 0.001–0.38, P = 0.009). BMI, platelet count, and ALT were not significantly associated with missed risk stratification. Among patients without risk scores, 18% had laboratory or clinical findings suggestive of advanced fibrosis, indicating potential for missed diagnosis and delayed specialist referral. Conclusion: More than 1 in 4 MASLD patients did not undergo noninvasive fibrosis risk stratification, with older adults at the highest risk of being overlooked. In contrast, patients with T2DM were substantially more likely to have been appropriately risk stratified, possibly reflecting targeted screening efforts in this population. These findings highlight the need for system-level interventions to ensure that all MASLD patients receive guideline-recommended risk assessment. Proactive identification and management of care gaps may reduce missed opportunities for early diagnosis and improve long-term liver-related outcomes.