Date of Award
Spring 5-24-2025
Document Type
Doctor of Nursing Practice Final Manuscript
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Lilian Canamo Chan, DNP, RN, PCCN-K
Second Advisor
Michelle Hughes, PharmD
Abstract
Abstract
Background: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly non-non-alcoholic fatty liver disease (NAFLD), affects over 1 in 3 adults with type 2 diabetes mellitus (T2DM) and is a leading cause of advanced liver fibrosis. Despite guideline support from the American Diabetes Association (ADA) and American Association for the Study of Liver Diseases (AASLD), screening practices remain inconsistent in primary care. The Fibrosis-4 (FIB-4) index is a validated, low-cost, noninvasive tool for fibrosis risk stratification, yet it remains underutilized despite its availability in many electronic health record (EHR) systems.
Purpose: This Doctor of Nursing Practice (DNP) evidence-based practice (EBP) project aimed to implement a phased, system-wide FIB-4 based screening initiative in a Federally Qualified Health Center (FQHC) system to increase provider knowledge, improver referral alignment, and integrate evidence-based MASLD triage into routine care for patients with T2DM.
Methods: Guided by the Iowa Model of Evidence-Based Practice and the Iowa Implementation for Sustainability Framework (IISF), this evidence-based project used a two-phase implementation design. Phase I included a live Grand Rounds session with paired pre/post provider surveys (n=9), while Phase II expanded outreach through digital and printed education materials (n=54). Retrospective EHR data (n=9,869) were analyzed to evaluate hepatology referral alignment with FIB-4 risk tiers (low < 1.3, intermediate 1.3-2.67, high >2.67).
Results: Statistically significant improvements were observed in provider knowledge, confidence, and FIB-4 interpretation across both phases (Cohen’s d > 1.0). High-risk referral alignment increased from 25.7% to 28.4%, reflecting a 10.5% relative improvement. Intermediate- and low-risk referral increased modestly, suggesting cautious adoption. A cost-benefit analysis estimated a 208.2% return on investment (ROI), with $13,342.50 in net savings. Sensitivity analysis showed continued fiscal viability under conservative assumptions.
Conclusion: FIB-4 screening embedded in the EHR alone is insufficient for practice change. DNP-led education, interdisciplinary collaboration, and clinical decision support are critical to translating evidence into real-world outcomes. This project highlights a scalable, equity-oriented model for MASLD screening in high-risk primary care populations.
Keywords: diabetes mellitus, type 2, MASLD, NAFLD, FIB-4 index, liver fibrosis, diabetes, primary care, DNP project, implementation science, population health, hepatology referral
Digital USD Citation
Montillano, Robert I., "Implementing the FIB-4 Tool for Liver Fibrosis Screening in Diabetic Patients in Primary Care" (2025). Doctor of Nursing Practice Final Manuscripts. 302.
https://digital.sandiego.edu/dnp/302
Copyright
Copyright held by the author
Creative Commons License
This work is licensed under a CC BY-NC License
Included in
Endocrine System Diseases Commons, Endocrinology, Diabetes, and Metabolism Commons, Family Practice Nursing Commons, Hepatology Commons, Nutritional and Metabolic Diseases Commons, Preventive Medicine Commons, Primary Care Commons
