Implementing MASLD Screening in Primary Care for Adults with Type 2 Diabetes: A Quality Improvement Initiative

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects over two-thirds of adults with type 2 diabetes (T2D), yet advanced fibrosis often remains undiagnosed. This quality improvement (QI) project implemented a standardized screening pathway to identify patients at risk for advanced fibrosis and guide appropriate follow-up.

A pre-post QI initiative was conducted from February to April 2026 in a primary care practice within a southeastern United States integrated health system. Adults aged 18-75 years with T2D underwent FIB-4 index risk stratification via electronic health record (EHR) SmartPhrase (auto text). The intervention included clinician education, EHR-based decision support, workflow redesign, and certified medical assistant supported pre-visit preparation. Patients with indeterminate or high-risk FIB-4 index scores were referred for transient elastography. Primary outcomes were FIB-4 index documentation and referral rates.

All eligible clinicians (7/7) completed pre-implementation education sessions. FIB-4 index screening documentation increased from 0.9% (1/115 encounters) at baseline to 14.4% (67/464 encounters) during the 12 weeks post-implementation (P < .001). Seven screened patients (10.4%) met criteria for additional fibrosis evaluation; 3 of 7 (42.9%) were referred. Only 3 of 7 patients (42.9%) had abnormal liver enzymes, indicating that 4 patients (57.1%) would not have been identified for further evaluation based on liver enzyme abnormalities alone.

A standardized MASLD screening pathway was associated with increased FIB-4 index screening among adults with T2D and identified fibrosis risk missed by liver enzymes alone. Additional implementation strategies are needed to optimize workflow integration and increase screening uptake in primary care.