Cost‐Effectiveness of Noninvasive Screening for Alcohol‐Related Liver Fibrosis

Abstract

on behalf of the GALAXY ConsortiumBaCKgRoUND aND aIMS: Alcohol-related liver disease is often undetected until irreversible late-stage decompensated disease manifests. Consequently, there is an unmet need for effective and economically reasonable pathways to screen for advanced alcohol-related fibrosis. appRoaCH aND ReSUltS: We used real-world data from a large biopsy-controlled study of excessive drinkers recruited from primary and secondary care, to evaluate the cost-effectiveness of four primary care initiated strategies:(1) routine liver function tests with follow-up ultrasonography for test-positives, (2) the enhanced liver fibrosis (ELF) test with hospital liver stiffness measurement (LSM) for positives, (3) a three-tier strategy using the Forns Index to control before strategy 2, and (4) direct referral of all to LSM. We used linked decision trees and Markov models to evaluate outcomes short term (cost-per-accurate diagnosis) and long term (quality-adjusted life-years [QALYs]). For lowprevalence populations, ELF with LSM follow-up was most cost-effective, both short term (accuracy 96%, $196 per patient) and long term (incremental cost-effectiveness ratio [ICER] $5,387-$8,430/QALY), depending on whether diagnostic testing had lasting or temporary effects on abstinence rates. Adding Forns Index decreased costs to $72 per patient and accuracy to 95%. The strategy resulted in fewer QALYs due to more false negatives but an ICER of $3,012, making this strategy suited for areas with restricted access to ELF and transient elastography or lower willingness-to-pay. For high-prevalence populations, direct referral to LSM was highly cost-effective (accuracy 93%, $297 per patient), with ICERs between $490 and $1,037/QALY. CoNClUSIoNS:Noninvasive screening for advanced alcoholrelated fibrosis is a cost-effective intervention when different referral pathways are used according to the prevalence of advanced fibrosis. Patients in the primary health care sector should be tested with the ELF test followed by LSM if the test was positive, whereas direct referral to LSM is highly cost-effective in high-prevalence cohorts. (Hepatology

Results of liver and spleen endoscopic ultrasonographic elastography predict portal hypertension secondary to chronic liver disease

“…A cost-effectiveness analysis evaluating screening methods for alcohol-related liver fibrosis demonstrated that direct liver stiffness measurement via transient elastography is a highly cost-effective procedure, with 93 % accuracy and incremental cost-effectiveness ratios of $ 490 to $ 1,037 per quality-adjusted life-year in high-prevalence populations 23 . Nonetheless, there is a lack of studies evaluating the cost-effectiveness of EUS in the diagnostic workup of chronic liver disease, and its implications given the additional features found during EUS evaluation of patients with cirrhosis.…”

Noninvasive diagnosis in alcohol‐related liver disease

“…Additionally, these biomarkers (in particular, the ELF test) are highly cost-effective and should be tested in primary health care settings. 37,38 Lastly, advanced fibrosis can be ruled out in primary health care patients with an ELF value <10.5 or an FT < 0.58. 32 Therefore, these tests might be helpful in reducing the need for liver biopsy.…”

“…Although patented biomarkers are considered to have lower applicability compared with nonpatented ones given their higher cost, two recent studies 37,38 have found that the ELF score is cost-effective in primary health care 38…”

“…Altogether, despite their higher cost compared with nonpatented and other patented serum biomarkers, the FT and ELF tests provide the best diagnostic and prognostic performance to date in the identification of advanced liver fibrosis. Additionally, these biomarkers (in particular, the ELF test) are highly cost‐effective and should be tested in primary health care settings . Lastly, advanced fibrosis can be ruled out in primary health care patients with an ELF value <10.5 or an FT < 0.58 .…”

“…For low prevalence populations, such as patients in the primary health care sector, serum biomarkers with high negative predictive value (>94%), such as the ELF score and FT, should be used as a first‐line method to rule out advanced fibrosis. Although patented biomarkers are considered to have lower applicability compared with nonpatented ones given their higher cost, two recent studies have found that the ELF score is cost‐effective in primary health care for fibrosis assessment in patients with ALD. Patients with low risk of advanced fibrosis (ELF < 10.5, FT < 0.58) should be offered interventions aiming to reduce, and eventually withdraw, alcohol consumption.…”