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Real-world implementation studies further highlight both the feasibility and the challenges of applying this algorithm at scale: in a large retrospective cohort of 14,814 adults undergoing abdominal ultrasound, 3,052 (20.6%) met MASLD criteria, and age-adjusted FIB-4 stratification classified 15.2% as high-risk and 18.0% as indeterminate, yet more than half of patients in these elevated-risk categories did not receive appropriate hepatology referral or secondary testing, revealing persistent gaps in real-world care pathways [99]