S2744 Underrecognized and Underreferred: Gaps in MASLD Risk Management Among Patients With Type 2 Diabetes

Introduction: Patients with type 2 diabetes mellitus (T2DM) are at increased risk for metabolic dysfunction-associated steatotic liver disease (MASLD) and advanced hepatic fibrosis. While FIB-4-based risk stratification is guideline-endorsed, the role of provider-level practice patterns in implementing this approach has not been systematically evaluated. Understanding how provider characteristics influence MASLD screening and referral behavior is critical to ensuring equitable liver care. Methods: We conducted a retrospective cohort study of adult patients with T2DM who received outpatient care in 2021. Provider types were categorized as Resident, Attending, NP/PA. We assessed: 1) Completion of screening labs (CBC + LFTs), 2) Proportion of patients with FIB-4 score >1.3, and 3) GI referral rates among high-risk individuals. Multivariable logistic regression was used to evaluate whether provider type independently predicted missed referral, adjusting for age, A1c, body mass index, and race. Results: Among 1,149 patients with an assigned provider type, laboratory completion rates varied by provider, ranging from 30.8% among residents to 50.0% among other providers. A total of 163 patients (14.2%) had a FIB-4 score >1.3. Gastroenterology referral rates among high-risk patients were low across all groups: 5.5% (4/73) for residents, 1.3% (1/75) for attendings, and 0.0% for NP/PAs. In adjusted models, provider type was not a statistically significant independent predictor of referral. Despite this, referral rates remained consistently low regardless of provider type, suggesting that barriers to MASLD risk pathway activation may be driven more by system-level factors than individual provider decision-making. Conclusion: MASLD risk stratification and GI referral remain underutilized across provider types in the outpatient management of T2DM. While individual performance varied, no provider group consistently met referral expectations for high-risk patients. These results highlight a system-wide opportunity to standardize FIB–4–guided workflows through automated alerts, care pathways, and multidisciplinary collaboration, rather than attributing gaps to any single role.