Transient elastography for screening of liver fibrosis: Cost-effectiveness analysis from six prospective cohorts in Europe and Asia

J Hepatol. 2019 Dec;71(6):1141-1151. doi: 10.1016/j.jhep.2019.08.019. Epub 2019 Aug 27.


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.

Keywords: Alcohol-related liver disease; Liver fibrosis; Non-alcoholic fatty liver disease; Stratified screening; Transient elastography.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Asia / epidemiology
  • Cost-Benefit Analysis
  • Elasticity Imaging Techniques* / economics
  • Elasticity Imaging Techniques* / methods
  • Elasticity Imaging Techniques* / statistics & numerical data
  • Europe / epidemiology
  • Female
  • Humans
  • Liver / diagnostic imaging
  • Liver Cirrhosis* / diagnosis
  • Liver Cirrhosis* / epidemiology
  • Liver Cirrhosis* / etiology
  • Liver Diseases, Alcoholic* / complications
  • Liver Diseases, Alcoholic* / epidemiology
  • Male
  • Mass Screening* / economics
  • Mass Screening* / methods
  • Middle Aged
  • Non-alcoholic Fatty Liver Disease* / complications
  • Non-alcoholic Fatty Liver Disease* / epidemiology
  • Primary Health Care* / economics
  • Primary Health Care* / methods
  • Risk Assessment / methods