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

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

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UCL Institute for Liver and Digestive Health, Royal Free Campus, London, NW3 2PF, UK.
Science Based Business, Leiden University, Snellius Building, Niels Bohrweg 1, 2333 CA, Leiden, Netherlands.
Health Economist, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
Department of Primary care and Population Health, Upper 3rd Floor, Royal Free Hospital, London, NW3 2PF, UK.
Camden Clinical Commissioning Group, 75 Hampstead Rd, London, NW1 2PL, UK.
Islington Clinical Commissioning Group Laycock St, London, N1 1TH, UK.
UCL Institute for Liver and Digestive Health, Royal Free Campus, London, NW3 2PF, UK.
Department of Applied Health Research, UCL 1-19 Torrington Place, London, WC1E7HB, UK.
Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK.



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.


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.


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.


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.


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

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