Transient elastography for screening of liver fibrosis: cost-effectiveness analysis from six prospective cohorts in Europe and Asia

Serra-Burriel, Miquel; Graupera, Isabel; Torán, Pere; Thiele, Maja; Roulot, Dominique; Wai-Sun Wong, Vincent; Neil Guha, Indra; Fabrellas, Núria; Arslanow, Anita; Expósito, Carmen; Hernández, Rosario; Lai-Hung Wong, Grace; Harman, David; Darwish Murad, Sarwa; Krag, Aleksander; Pera, Guillem; Angeli, Paolo; Galle, Peter; Aithal, Guruprasad; Caballeria, Llorenç; Castera, Laurent; Ginès, Pere; Lammert, Frank

Abstract

Background & Aims: Nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) pose an important challenge to current clinical healthcare pathways due to a large number of at-risk patients. Therefore, we aimed to explore the cost-effectiveness of transient elastography (TE) as a screening method to detect liver fibrosis in a primary care pathway.
Methods: Cost-effectiveness analysis using real-life individual patient data from six independent prospective cohorts (five from Europe and one from Asia). A diagnostic algorithm with conditional inference trees was developed to explore the relationships between liver stiffness, socio-demographics, comorbidities, and hepatic fibrosis, the latter assessed by fibrosis scores (FIB-4, NFS) and liver biopsy in a subset of 352 patients. We compared the incremental cost-effectiveness of a screening strategy against standard of care alongside the numbers needed to test to diagnose a patient with fibrosis stage ≥F2.
Results: The data set encompassed 6,295 participants (mean age 55±12 years, BMI 27±5 kg/m2, liver stiffness 5.6±5.0 kPa). A 9.1 kPa TE cut-off provided the best accuracy for the diagnosis of significant fibrosis (≥F2) in general population settings, whereas a threshold of 9.5 kPa was optimal for populations at-risk for alcoholic liver disease. TE with the proposed cut-offs outperformed fibrosis scores in terms of accuracy. Screening with TE was cost-effective with mean incremental cost-effectiveness ratios ranging from 2,570 €/QALY (95% CI 2,456 - 2,683) for a population at-risk for alcoholic liver disease (age ≥45 years) to 6,217 €/QALY (95% CI 5,832 - 6,601) in the general population. Overall, there was a 12% chance of TE screening being cost-saving across countries and populations.
Conclusions: Screening for liver fibrosis with transient elastography in primary care is a cost-effective intervention for European and Asian populations and may even be cost-saving.
Lay summary:
The lack of optimized public health screening strategies for the detection of liver fibrosis in adults without known liver disease presents a major healthcare challenge. Analyses from six independent international cohorts with transient elastography measurements based on economic modelling shows that a community-based risk-stratification strategy for alcoholic and non-alcoholic fatty liver diseases is cost-effective through earlier identification of patients and potentially cost-saving for our healthcare systems.
Highlights:
• Optimal liver stiffness thresholds for community-based screening in populations with metabolic risk factors and alcoholic is between 9.1 and 9.5 kPa for the diagnosis of significant fibrosis (stages ≥F2)
• Transient elastography is a cost-effective intervention for identifying patients with liver fibrosis in primary care. Healthcare systems would need to invest between 2,500 (at-risk population) to 6,500 (general population) purchasing power parity-adjusted euros to gain an extra year of life, adjusted per quality of life.
• The survival effect of screening is most pronounced for the identification of significant (≥F2) fibrosis.

Citation

Serra-Burriel, M., Graupera, I., Torán, P., Thiele, M., Roulot, D., Wai-Sun Wong, V., Neil Guha, I., Fabrellas, N., Arslanow, A., Expósito, C., Hernández, R., Lai-Hung Wong, G., Harman, D., Darwish Murad, S., Krag, A., Pera, G., Angeli, P., Galle, P., Aithal, G., Caballeria, L., …Lammert, F. (2019). Transient elastography for screening of liver fibrosis: cost-effectiveness analysis from six prospective cohorts in Europe and Asia. Journal of Hepatology, 71(6), 1141-1151. https://doi.org/10.1016/j.jhep.2019.08.019

• Journal Article Type: Article
• Acceptance Date: Aug 22, 2019
• Online Publication Date: Aug 27, 2019
• Publication Date: 2019-12
• Deposit Date: Sep 6, 2019
• Publicly Available Date: Aug 28, 2020
• Journal: Journal of Hepatology
• Print ISSN: 0168-8278
• Electronic ISSN: 1600-0641
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 71
• Issue: 6
• Pages: 1141-1151
• DOI: https://doi.org/10.1016/j.jhep.2019.08.019
• Keywords: Alcoholic Liver Disease; Liver Fibrosis; Non-Alcoholic Fatty Liver Disease; Stratified Screening; Transient Elastography
• Public URL: https://nottingham-repository.worktribe.com/output/2580909
• Publisher URL: https://www.sciencedirect.com/science/article/pii/S0168827819304866?via%3Dihub
• Contract Date: Sep 6, 2019