Cost Effectiveness of Different Strategies for Detecting Cirrhosis in Patients With Nonalcoholic Fatty Liver Disease Based on United States Health Care System

Abstract

Several strategies are available for detecting cirrhosis in patients with nonalcoholic fatty liver disease (NAFLD), but their cost effectiveness is not clear. We developed a decision model to quantify the accuracy and costs of 9 single or combination strategies, including 3 noninvasive tests (fibrosis-4 [FIB-4], vibration-controlled transient elastography [VCTE], and magnetic resonance elastography [MRE]) and liver biopsy, for the detection of cirrhosis in patients with NAFLD. Data on the diagnostic accuracy, costs, adverse events, and cirrhosis outcomes over a 5-year period were obtained from publications. The diagnostic accuracy, per-patient cost per correct diagnosis of cirrhosis, and incremental cost-effectiveness ratios (ICERs) were calculated for each strategy for base cirrhosis prevalence values of 0.27%, 2%, and 4%. The combination of the FIB-4 and VCTE identified patients with cirrhosis in NAFLD populations with a 0.27%, 2%, and 4% prevalence of cirrhosis with the lowest cost per person ($401, $690, and $1024, respectively) and highest diagnostic accuracy (89.3%, 88.5%, and 87.5% respectively). The combination of FIB-4 and MRE ranked second in cost per person ($491, $781, and $1114, respectively) and diagnostic accuracy (92.4%, 91.6%, 90.6%, respectively). Compared with the combination of FIB-4 and VCTE (least costly), the ICERs were lower for the combination of FIB-4 and MRE ($2864, $2918, and $2921) than the combination of FIB-4 and liver biopsy ($4454, $5156, and $5956) at the cirrhosis prevalence values tested. When the goal was to avoid liver biopsy, FIB-4+ VCTE and FIB-4+ MRE had similar diagnostic accuracies, ranging from 87.5% to 89.3% and 90.6% to 92.4% for a cirrhosis diagnosis, respectively, although FIB-4+ MRE had a slightly higher cost. In our cost-effectiveness analysis based on the US health care system, we found that results from FIB-4, followed by either VCTE, MRE, or liver biopsy, detect cirrhosis in patients with NAFLD with a high level of accuracy and low cost. Compared with FIB-4+ VCTE, which was the least costly strategy, FIB-4+ MRE had a lower ICER than FIB-4+ LB.