Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score.

Elliot B Tapper,Nezam H Afdhal,Michelle Lai,M G Myriam Hunink,Neil Sengupta,Pavel Strnad

doi:10.1371/journal.pone.0147237

Abstract

BackgroundThe 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.MethodsWe 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.ResultsRisk-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.ConclusionRisk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice.

Highlights

Nonalcoholic fatty liver disease (NALFD) is increasingly common, afflicting no less than 1 in 5 people living in Western nations. [1,2,3] In America, the respective prevalence of steatosis and steatohepatitis is 46% and 12% and rising[4,5] and outpatient visits for the primary purpose of Nonalcoholic Fatty Liver Disease (NAFLD) management have doubled of late.[3,6] The contemporary management of patients with NAFLD is defined by two key features
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
Nonalcoholic fatty liver disease (NALFD) is increasingly common, afflicting no less than 1 in 5 people living in Western nations. [1,2,3] In America, the respective prevalence of steatosis and steatohepatitis is 46% and 12% and rising[4,5] and outpatient visits for the primary purpose of NAFLD management have doubled of late.[3,6]

Summary

Introduction

Nonalcoholic fatty liver disease (NALFD) is increasingly common, afflicting no less than 1 in 5 people living in Western nations. [1,2,3] In America, the respective prevalence of steatosis and steatohepatitis is 46% and 12% and rising[4,5] and outpatient visits for the primary purpose of NAFLD management have doubled of late.[3,6] The contemporary management of patients with NAFLD is defined by two key features. [7,8] a major focus of clinical care for patients with NAFLD should be the determination of those at highest risk for the complications of advanced liver disease.[1,4]. The optimal strategy for the management of NAFLD would benefit from a multidisciplinary approach to prioritize patients for specialists referral. Primary care physicians would recognize and manage early disease while gastroenterologists are referred patients with advanced liver disease. 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

Results

Conclusion