Letters to the Editor

Abstract

Noninvasive diagnosis of liver fibrosis: The importance of being reimbursed To the Editor: With great interest, we read the article by Kan et al (1) in the March 2015 issue of the Journal, reporting the results of a survey of 422 patients evaluating the preference and willingness to pay for transient elastography versus liver biopsy in British Columbia. The topic explored by these authors is sound given that, despite both liver biopsy and transient elastography are approved in Canada for liver fibrosis staging, only liver biopsy is covered under all provincial health care plans. As of 2013, Quebec is the only province reimbursing transient elastography (Fibroscan, Echosens, France) in Canada. In a recent study (2), we showed that liver fibrosis diagnosis is systematically required by the majority of Canadian physicians managing patients with chronic liver diseases. However, 46.2% of Canadian physicians still use liver biopsy as primary diagnostic tool. In France, where Fibroscan and Fibrotest (LabCorp, USA) have been reimbursed since 2007, liver biopsy is still systematically performed by only 4% of hepatologists (3). Major obstacles for Canadian physicians to implement noninvasive methods include difficult access to transient elastography (42.3%) and concerns about reimbursement policies (14.4%). On the other hand, most Canadian physicians (82.6%) consider noninvasive diagnostic tools for liver fibrosis to be accurate and reliable (2). The study by Kan et al (1) has the invaluable merit of providing the patient's perspective in terms of discomfort experienced and acceptability of transient elastography versus liver biopsy. Importantly, almost onehalf of the respondents were also liver biopsy experienced. The vast majority (95.4%) of patients prefer transient elastography to liver biopsy if both tests are available at no cost. Moreover, 75.3% of patients are willing to pay for transient elastography instead of undergoing a liver biopsy at no cost. The results of our survey conducted among physicians and of the current survey among patients point toward the same direction: the necessity of harmonizing common reimbursement policies for liver fibrosis diagnosis across Canada. There are several other reasons supporting the implementation of transient elastography instead of liver biopsy. First, liver biopsy is an invasive procedure with risks for complications. A population-based study involving 4275 patients conducted in Canada showed that significant biopsy-related complications occurred in 0.75% of patients and the median direct cost of a hospitalization for complications was $4,579 (4). Second, liver biopsy results are often limited by methodological flaws, including sampling variability, and intra-and interobserver variation. Mehta et al (5) argued that the ideal surrogate will never attain the maximal diagnostic accuracy, expressed as area under the curve (AUC), because of the intrinsic limitations of the reference standard. By considering a spectrum of accuracies of the biopsy plus a spectrum of prevalence of ...