TABLE 3.

Quotations coded into themes 6 to 8, under the topic of NAFLD management

Theme 6: Diagnosing NAFLD does not change management
T6Q1	E3	The issue is how do you treat it, and we treat it the same way we treat everything else, and it usually doesn't work.
T6Q2	E3	Because I think all of the patients we tell them to lose weight, use metformin, use GLP−1 analogues and SGLT−2 inhibitors and we treat their lipids, we treat their hypertension. So we're kind of doing all the stuff.
T6Q3	E1	What are you gonna do about it because my thought is, telling the GP to send them to Joe Average down the road to get a FibroScan done with someone who does 2 FibroScans a year on your XL probe‐requiring patient is a dead loss. So it's the “what do I do about this at the end” ‐ is this going to change anything?
T6Q4	E2	I find that things like liver disease and cancer risk are quite triggering for a lot of patients and they may act if they were high risk of those things.. then that may actually be some form of other motivation.
T6Q5	GP3	We do need a group [lifestyle intervention group]. We make the diagnosis, but it's weight loss, and weight loss, the bariatric surgery, all of those things.
T6Q6	GP5	Because I suppose from our point of view there's so many things. But the management really is quite similar to the management that we are doing for these other things ‐ the weight loss. I suppose you are wanting to assess who are at higher risk, but the management is not that you would be doing anything particularly different.
T6Q7	E6	I think, a lot of our treatment for diabetes overlaps with treatment for NAFLD. I think all of us are pretty diet focused and all would give out lots of hand‐outs about diet. And I would often favour a GLP−1 agonist if I know or suspect they've got NAFLD.
T6Q8	GP7	I think in the ones who aren't a type 2 diabetic just yet, it's something they can see. They can see there's an abnormality. Maybe it's not something so dramatic that you have to start treatment, but they can see that things are not right and they've got the ability to improve it. So, I think the diagnosis is important for that reason. That it's telling them that things, you know, there's some damage that will continue if you don't do something about it. And there's an indication with other things as well and correlation with type 2 diabetes and cardiovascular disease and probably other things I should know about but can't remember.
T6Q9	GP8	You know in terms of, because they're usually going to have metabolic syndrome as well, someone's got metabolic syndrome and fatty liver. So that sort of covers the basis of all of them because really the fatty liver itself is almost the one that there's not much ‐ from the patient's perspective, we don't even, as far as I know, we don't even have a way of monitoring it, to say—hey your fatty liver has gotten way better! Unless we're doing serial ultrasounds or something. I don't know. So, they might not even know it's getting better. Is that true?
Theme 7: Time and resource constraints in clinical practice mean other issues are prioritised above NAFLD
T7Q1	E3	I don't even know how to get a FibroScan, I thought it was a research tool that we couldn't actually order.
T7Q2	E1	That's the thing ‐ they're not transplantable and they're probably going to die of their other metabolic associated bits and pieces first.
T7Q3	GP4	So I can understand why the NHS has done that (recommended the ELF test). I just think it's easier, it's just another test. And when you've got an ELF that comes back and it says you know this is probably elevated, then there's really this trigger ‐ I must refer now. Whereas the problem with an indeterminate NAFLD score, for example, is you know the vast majority of the indeterminate ones are going to be fine. And it's like, is it just indeterminate or is it nearly at the upper level. So I think being able to do something like an ELF would be helpful. Because the truth is, <Name of doctor> is currently sending you all of hers [NAFLD patients]. I send you some of mine but if every GP starts doing this you'll be completely overwhelmed and you know that and we know that.
T7Q4	GP5	I don't think it matters so much if it is a radiological or serum test, but one maybe that we could do [in the community]. Because that is the thing‐ because of the expense of the radiological study at the moment, it is not MediCare rebatable for sure. That is why we end up referring a lot through hepatology… If we could refer to it (fibrosis test) and then do a risk assessment then [we can] decide do they need HCC surveillance.
T7Q5	E5	I think probably the liver side of it does not get as much prominence as some of the other routine bits and bobs. Probably it is one of those things that is so common yet only a relatively small number of people would, over a long period of time, would get really sick directly due to this and there is probably more concentration on the cardiovascular side.
T7Q6	GP5	That is just the things that come up in the shorter term for us‐ the patients are presenting with heart attacks and bleeds. It is a bigger percentage of our patients, the cardiovascular things, but I mean they are tied in, like I have said, if they've got advanced liver disease then they are much more likely to have advanced cardiovascular disease as well, but I suppose just in terms of that monitoring.
T7Q7	E5	… so the ones we see are all the worse end of diabetes, so we probably should do more with them but there are a lot of other things to do I think. And referring them all to the liver clinic would fairly rapidly overwhelm the liver clinic.
T7Q8	GP5	Well HCC possibly, but probably more commonly cardiovascular.
T7Q9	GP8	I think that what you said about the risk of there being another, another in the big, long list of diagnoses that's sort of siloed, I think really applies here. And so, if a lot of the messaging you're giving them, overlaps with the messaging we want to, because really, we're trying to tell them about all the ways that you can undo or reverse this process that's happening in your body through mostly lifestyle changes and also maybe taking the tablets that you've been given. So, I think if it's integrated into something that's more broad that might be more useful to me as a thing to dedicate time to show the patient.
T7Q10	GP 1, 2, 3	“But they've already got a bad knee, they've already used up all of their GPMP (GP Management Plans*) on all the other things. You know, like the podiatry.” ‐ GP3 *[GP Management Plans allow a person with a complex and/or chronic illness to claim a Medicare rebate for up to five visits (in total) to certain allied health professionals within a calendar year.] “There's no space for the dietician.”‐ GP2 “And [the podiatry is] actually a practical thing that [patients] want.”—GP1 “Sure, I’d love to refer everyone to a dietician, but it's not possible.”—GP2
Theme 8: Healthcare providers favour an integrated approach in primary care
T8Q1	E4	The other issue comes into, say that person moves overseas or interstate or we discharge them from the clinic and they turn up to their FibroScan but they're not following up with anyone ‐ who's going to see the result?
T8Q2	E2	And it's ordered by a registrar, not copied into a consultant and the registrar no longer works there ‐ I don't know what happens to the result.
T8Q3	E3	I wanted to talk about the role of primary care. I understand this is a research project so you want as many coming through as we can get and that's great. But in the future, the future isn't going to be in hospital, it's going to be putting this into the primary care setting and having the facilities there. And primary care does a good job ‐ look what they've done with cervical cancer before we had the vaccine. Screening for cancer and chronic consequences is one of the things primary care does really quite well.
T8Q4	GP2	We really really really do need something in the community that we can access, so we can avoid the referral [to hepatology].
T8Q5	GP5	I would say it's not rocket science because it's the lifestyle stuff and then, I didn't say it before, but yeah the HCC monitoring. Like anything, it would just be an algorithm we would put into our review, our care plan reviews, that we need to be doing this at this point. So I think most GPs who do chronic disease would be comfortable.
T8Q6	GP5	We do our set care plan reviews for diabetics in general practice, not so much in the diabetes clinic. Every 3 months we are doing a review of their HbA1c, checking renal function, and just running past have they had their urine albumin check—all those tick box things at our three‐month review or on some of them they come up 12 monthly or the eye checks two yearly. At the moment I don't think there is a liver part to that, so that could be added to a typical diabetes clinic disease review that is done at practices.
T8Q7	E5	I think the thing that people have not done much is integrated all into one pathway so you don't have your eye pathway, heart pathway and your liver. If you had that as one, you are saying a lot of therapeutic goals are the same, with intensive respect to management.
T8Q8	E6	Diabetes has changed a lot in the last 10 years with the advent of newer agents which prevent other comorbid conditions, like the SGLT−2 and GLP−1 [agents]. So diabetes isn't about numbers and A1Cs anymore, it's about prevention of other things. You don't die from diabetes you die from heart attacks and cirrhosis… So I think there's good space for it [management of NAFLD].

Abbreviations: E, endocrinologist; EAT, endocrinology advanced trainee; GP, general practitioner; T1Q1, theme 1, quote 1.