Miquel Serra-Burriel1, Isabel Graupera2, Pere Torán3, Maja Thiele4, Dominique Roulot5, Vincent Wai-Sun Wong6, Indra Neil Guha7, Núria Fabrellas8, Anita Arslanow9, Carmen Expósito3, Rosario Hernández10, Grace Lai-Hung Wong6, David Harman7, Sarwa Darwish Murad11, Aleksander Krag4, Guillem Pera3, Paolo Angeli12, Peter Galle13, Guruprasad P Aithal7, Llorenç Caballeria3, Laurent Castera14, Pere Ginès2, Frank Lammert15. 1. Centre de Recerca en Economia I Salut - UPF, Universitat Pompeu Fabra, Spain. 2. Liver Unit Hospital Clínic, Institut D'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd), Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain. 3. USR Metropolitana Nord, IDIAP Jordi Gol, ICS Institut Català de la Salut, Spain. 4. Odense University Hospital, University of Southern Denmark and Odense, Patient data Exploratory Network (OPEN), Department of Gastroenterology and Hepatology, Odense, Denmark. 5. Department of Hepatology, AP-HP, Hopital Avicenne, Bobigny, France; Université Paris 13, Sorbonne Paris Cité, France. 6. The Chinese University of Hong Kong, Dept. of Medicine and Therapeutics, Hong Kong. 7. NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK. 8. Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona, Institut D'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd), Barcelona, Spain. 9. Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany. 10. CAP La Marina, Institut Català de la Salut de Barcelona, Barcelona, Spain. 11. Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands. 12. Of Internal Medicine and Hepatology; of Medicine (Dimed), University and General Hospital of Padova, Italy. 13. Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany. 14. Hôpital Beaujon, Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Université Paris VII, Inserm Umr 1149, Centre de Recherche Sur L'inflammation, Paris, France. 15. Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany. Electronic address: frank.lammert@uks.eu.
Abstract
BACKGROUND & AIMS: Non-alcoholic fatty liver disease and alcohol-related liver disease pose an important challenge to current clinical healthcare pathways because of the 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 was performed using real-life individual patient data from 6 independent prospective cohorts (5 from Europe and 1 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 biopsies 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 screen 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 of alcohol-related 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 of alcohol-related 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 TE 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 6 independent international cohorts, with transient elastography measurements, show that a community-based risk-stratification strategy for alcohol-related and non-alcoholic fatty liver diseases is cost-effective and potentially cost saving for our healthcare systems, as it leads to earlier identification of patients.
BACKGROUND & AIMS: Non-alcoholic fatty liver disease and alcohol-related liver disease pose an important challenge to current clinical healthcare pathways because of the 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 was performed using real-life individual patient data from 6 independent prospective cohorts (5 from Europe and 1 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 biopsies 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 screen 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 of alcohol-related 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 of alcohol-related 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 TE 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 6 independent international cohorts, with transient elastography measurements, show that a community-based risk-stratification strategy for alcohol-related and non-alcoholic fatty liver diseases is cost-effective and potentially cost saving for our healthcare systems, as it leads to earlier identification of patients.
Authors: Isabel Graupera; Maja Thiele; Ann T Ma; Miquel Serra-Burriel; Judit Pich; Núria Fabrellas; Llorenç Caballeria; Robert J de Knegt; Ivica Grgurevic; Mathias Reichert; Dominique Roulot; Jörn M Schattenberg; Juan M Pericas; Paolo Angeli; Emmanuel A Tsochatzis; Indra Neil Guha; Montserrat Garcia-Retortillo; Rosa M Morillas; Rosario Hernández; Jordi Hoyo; Matilde Fuentes; Anita Madir; Adrià Juanola; Anna Soria; Marta Juan; Marta Carol; Alba Diaz; Sönke Detlefsen; Pere Toran; Céline Fournier; Anne Llorca; Phillip N Newsome; Michael Manns; Harry J de Koning; Feliu Serra-Burriel; Fernando Cucchietti; Anita Arslanow; Marko Korenjak; Laurens van Kleef; Josep Lluis Falcó; Patrick S Kamath; Tom H Karlsen; Laurent Castera; Frank Lammert; Aleksander Krag; Pere Ginès Journal: BMC Public Health Date: 2022-07-19 Impact factor: 4.135
Authors: Wolf Peter Hofmann; Peter Buggisch; Lisa Schubert; Nektarios Dikopoulos; Jeannette Schwenzer; Marion Muche; Gisela Felten; Renate Heyne; Patrick Ingiliz; Anna Schmidt; Kerstin Stein; Heiner Wedemeyer; Thomas Berg; Johannes Wiegand; Frank Lammert; Stefan Zeuzem; Jörn M Schattenberg Journal: JHEP Rep Date: 2020-08-04