Cost-comparison analysis of FIB-4, ELF and fibroscan in community pathways for non-alcoholic fatty liver disease

BMC Gastroenterol. 2019 Jul 11;19(1):122. doi: 10.1186/s12876-019-1039-4.


Background: The identification of patients with advanced liver fibrosis secondary to non-alcoholic fatty liver disease (NAFLD) remains challenging. Using non-invasive liver fibrosis tests (NILT) in primary care may permit earlier detection of patients with clinically significant disease for specialist review, and reduce unnecessary referral of patients with mild disease. We constructed an analytical model to assess the clinical and cost differentials of such strategies.

Methods: A probabilistic decisional model simulated a cohort of 1000 NAFLD patients over 1 year from a healthcare payer perspective. Simulations compared standard care (SC) (scenario 1) to: Scenario 2: FIB-4 for all patients followed by Enhanced Liver Fibrosis (ELF) test for patients with indeterminate FIB-4 results; Scenario 3: FIB-4 followed by fibroscan for indeterminate FIB-4; Scenario 4: ELF alone; and Scenario 5: fibroscan alone. Model estimates were derived from the published literature. The primary outcome was cost per case of advanced fibrosis detected.

Results: Introduction of NILT increased detection of advanced fibrosis over 1 year by 114, 118, 129 and 137% compared to SC in scenarios 2, 3, 4 and 5 respectively with reduction in unnecessary referrals by 85, 78, 71 and 42% respectively. The cost per case of advanced fibrosis (METAVIR ≥F3) detected was £25,543, £8932, £9083, £9487 and £10,351 in scenarios 1, 2, 3, 4 and 5 respectively. Total budget spend was reduced by 25.2, 22.7, 15.1 and 4.0% in Scenarios 2, 3, 4 and 5 compared to £670 K at baseline.

Conclusion: Our analyses suggest that the use of NILT in primary care can increases early detection of advanced liver fibrosis and reduce unnecessary referral of patients with mild disease and is cost efficient. Adopting a two-tier approach improves resource utilization.

Keywords: Cirrhosis detection; Cost savings; Enhanced Liver fibrosis (ELF); Fibroscan; |NAFLD.

Publication types

  • Evaluation Study

MeSH terms

  • Computer Simulation
  • Costs and Cost Analysis
  • Critical Pathways / economics*
  • Decision Support Techniques
  • Elasticity Imaging Techniques / economics*
  • Elasticity Imaging Techniques / methods
  • Extracellular Matrix Proteins / analysis
  • Humans
  • Liver Cirrhosis / diagnosis
  • Liver Cirrhosis / economics*
  • Liver Cirrhosis / etiology
  • Liver Function Tests / economics*
  • Liver Function Tests / methods
  • Non-alcoholic Fatty Liver Disease / complications
  • Non-alcoholic Fatty Liver Disease / economics*


  • EFEMP2 protein, human
  • Extracellular Matrix Proteins