Cost-effectiveness analysis: risk stratification of nonalcoholic fatty liver disease (NAFLD) by the primary care physician using the NAFLD fibrosis score
Open accessAbstract
BACKGROUND: The complications of Nonalcoholic Fatty Liver Disease (NAFLD) are dependent on the presence of advanced fibrosis. Given the high prevalence of NAFLD in the US, the optimal evaluation of NAFLD likely involves triage by a primary care physician (PCP) with advanced disease managed by gastroenterologists. METHODS: We compared the cost-effectiveness of fibrosis risk-assessment strategies in a cohort of 10,000 simulated American patients with NAFLD performed in either PCP or referral clinics using a decision analytical microsimulation state-transition model. The strategies included use of vibration-controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care by a specialist only). NFS and VCTE performance was obtained from a prospective cohort of 164 patients with NAFLD. Outcomes included cost per quality adjusted life year (QALY) and correct classification of fibrosis. RESULTS: Risk-stratification by the PCP using the NFS alone costs $5,985 per QALY while usual care costs $7,229/QALY. In the microsimulation, at a willingness-to-pay threshold of $100,000, the NFS alone in PCP clinic was the most cost-effective strategy in 94.2% of samples, followed by combination NFS/VCTE in the PCP clinic (5.6%) and usual care in 0.2%. The NFS based strategies yield the best biopsy-correct classification ratios (3.5) while the NFS/VCTE and usual care strategies yield more correct-classifications of advanced fibrosis at the cost of 3 and 37 additional biopsies per classification. CONCLUSION: Risk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice.
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One study modelling the primary care setting suggests that screening with the NAFLD fibrosis score is not cost-effective.
“However, one study modelling the primary care setting suggests that screening with the NAFLD fi brosis score (NFS) is not cost-effective.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [133]
The Abstract Results report that, among simulated patients with NAFLD, NFS alone in primary care was the most cost-effective strategy in 94.2% of samples. The Discussion likewise calls PCP use of NFS alone the most cost-effective strategy. The model assessed fibrosis risk-stratification in patients with NAFLD, rather than population-wide NAFLD screening. (LLM, conf=0.95)
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- Authors
- Tapper, E. B., Hunink, M. G. M., Afdhal, N. H., Lai, M., & Sengupta, N.
- Affiliations
- Beth Israel Deaconess Medical Center (US)
- Harvard University (US)
- University of Chicago (US)
- Corresponding author
- Tapper, Elliot B.
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2016-02-23
- Volume
- 11
- Issue
- 2
- Pages
- e0147237
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC4764354
- OpenAlex
- W2293460727
- Cited by
- 68
- References
- 47
- Citations by year
- 2026: 5 · 2025: 6 · 2024: 7 · 2023: 8 · 2022: 4 · 2021: 10 · 2020: 10 · 2019: 8 · 2018: 6 · 2017: 4
- FWCI
- 5.62
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion, other-oa)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Knowledge@UChicago (University of Chicago) (submittedVersion, cc-by-nc-nd)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion, other-oa)
- RePub (Erasmus University Rotterdam) (submittedVersion, other-oa)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- RePub (Erasmus University Rotterdam) (submittedVersion)
- University of Chicago (cc-by)
- Funders
- National Institutes of Health (UL1TR000430)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Health Sciences › Medicine › Hepatology › Liver Diseases and Immunity
- Keywords
- non-alcoholic fatty liver disease, NAFLD fibrosis score, vibration-controlled transient elastography, liver biopsy, primary care triage, cost-effectiveness, quality-adjusted life years
- MeSH terms
- Cost-Benefit Analysis, Humans, Liver, Liver Cirrhosis, Middle Aged, Referral and Consultation, Risk Assessment, Elasticity Imaging Techniques, Physicians, Primary Care, Non-alcoholic Fatty Liver Disease
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