Embedding metabolic dysfunction–associated steatotic liver disease fibrosis risk stratification within pharmacist-integrated diabetes comanagement in primary care

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent among patients with type 2 diabetes mellitus (T2DM) but remains underdiagnosed in primary care despite clinical guidelines. We investigated whether a multicomponent workflow that included expanding the role of ambulatory pharmacists, who already manage T2DM under collaborative care agreements to include MASLD risk stratification, is associated with improved detection of liver fibrosis. OBJECTIVE: To evaluate the feasibility of a pharmacist-integrated, multicomponent intervention and its association with MASLD fibrosis risk stratification, vibration-controlled transient elastography (VCTE) referral and completion, and detection of clinically significant fibrosis among patients with T2DM in a safety net primary care setting. METHODS: We conducted a 6-month pre-post feasibility and implementation pilot in a safety net family medicine clinic, with the pre-period serving as a baseline of usual care. The multicomponent intervention expanded MASLD risk stratification to pharmacists comanaging T2DM and incorporated targeted education, co-location of VCTE, and internal facilitation. Pharmacists calculated Fibrosis-4 index (FIB-4) scores during T2DM visits and referred patients with FIB-4 greater than or equal to 1.3 for VCTE. Outcomes included VCTE referral among patients with elevated FIB-4 scores, VCTE completion, detection of clinically significant fibrosis (liver stiffness measurement ≥8 kPa) or possible cirrhosis (liver stiffness measurement ≥12 kPa), and hepatology referral. RESULTS: In the pre-intervention period, 41% (52 of 127) of patients with available laboratory data had FIB-4 greater than or equal to 1.3, and none were referred for VCTE. In the post-intervention period, 45% (61 of 136) of such patients had FIB-4 greater than or equal to 1.3. Of these, 87% (53 of 61) were referred for VCTE, and 85% (45 of 53) completed testing. VCTE identified 8 new cases of clinically significant fibrosis, including 6 with possible cirrhosis, leading to 6 hepatology referrals. CONCLUSIONS: A pharmacist-integrated, multicomponent workflow was associated with increased VCTE referrals and completion, enabled identification of fibrosis, and facilitated specialist referrals among patients with T2DM in a safety net primary care setting. These findings support this pharmacist-integrated workflow as a feasible, patient-centered strategy to enhance MASLD detection, warranting further evaluation of scalability, sustainability, and impact.