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

Serra-Burriel, Miquel; Graupera, Isabel; Torán, Pere; Thiele, Maja; Roulot, Dominique; Wong, Vincent Wai‐Sun; Guha, Indra Neil; Fabrellas, Núria; Arslanow, Anita; Expósito, Carmen Barranco; Hernández, Rosario; Wong, Grace Lai–Hung; Harman, D. J.; Murad, Sarwa Darwish; Krag, Aleksander; Pera, Guillem; Angeli, Paolo; Galle, Peter R.; Aithal, Guruprasad P.; Caballería, Llorenç; Castéra, Laurent; Ginès, Pere; Lammert, Frank

doi:10.1016/j.jhep.2019.08.019

Cited by 115 publications

(90 citation statements)

References 52 publications

(58 reference statements)

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“…Therefore, validated surrogate scores of advanced fibrosis are used to stage the disease severity. The most accurate non-invasive identification of NAFLD patients with advanced fibrosis has been studied extensively, and in addition to LSM, NAFLD fibrosis score and the FIB-4 index perform best 15,18 ; however, cut-off values to rule out significant fibrosis may vary between different chronic liver diseases and populations. By the use of the recently proposed FIB-4 cut-off (>2.67 for advanced fibrosis), 64%, 26%, and 10% of our cohort were classified to have no significant fibrosis, an indeterminate stage, or advanced fibrosis, respectively.…”

Section: Discussionmentioning

confidence: 99%

The Fatty Liver Assessment in Germany (FLAG) cohort study identifies large heterogeneity in NAFLD care

et al. 2020

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A German real world NAFLD cohort Standard of care intervention Highlights This is the first report on NAFLD from a secondarycare real-world cohort in Germany. In this outpatient cohort, diagnostics rely heavily on non-invasive surrogate scores and elastography to stage NAFLD. Every 10th patient presents with advanced fibrosis at baseline. Management of NAFLD in Germany consists predominantly of general lifestyle recommendations and best supportive care. The study underlines the applicability of noninvasive tests to identify patients at risk of advanced fibrosis in secondary care in Germany. Lay summary FLAG is a real-world cohort study that examined the liver disease burden in secondary and tertiary care. Herein, 10% of patients referred to secondary care for NAFLD exhibited advanced liver disease, whilst 64% had no significant liver scarring. These findings underline the urgent need to define patient referral pathways for suspected liver disease.

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Section: Discussionmentioning

confidence: 99%

The Fatty Liver Assessment in Germany (FLAG) cohort study identifies large heterogeneity in NAFLD care

et al. 2020

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“…A particularity of the German guideline is the implementation of VCTE in the screening algorithm, which was indicated in about 75% of our patients. LSM-based approaches were recently evaluated from a health economics standpoint and found to be potentially cost-saving in populations at risk 41 . However, universal access to this method would require large investments 21 and modifications to the reimbursement system in most European countries, depending on national health care.…”

Section: Discussionmentioning

confidence: 99%

“…Hence, our single centre study should be reproduced in a multi-centre approach, ideally in primary care. Such a study should be accompanied by a detailed health-economics analysis to verify potential cost benefits of such screening strategies 41 .…”

Section: Discussionmentioning

confidence: 99%

Current NAFLD guidelines for risk stratification in diabetic patients have poor diagnostic discrimination

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et al. 2020

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Patients with type 2 diabetes (T2D) are at risk for non-alcoholic fatty liver disease (NAFLD) and associated complications. This study evaluated the performance of international (EASL-EASD-EASO) and national (DGVS) guidelines for NAFLD risk stratification. Patients with T2D prospectively underwent ultrasound, liver stiffness measurement (LSM) and serum-based fibrosis markers. Guideline-based risk classification and referral rates for different screening approaches were compared and the diagnostic properties of simplified algorithms, genetic markers and a new NASH surrogate (FAST score) were evaluated. NAFLD risk was present in 184 of 204 screened patients (age 64.2 ± 10.7 years; BMI 32.6 ± 7.6 kg/m2). EASL-EASD-EASO recommended specialist referral for 60–77% depending on the fibrosis score used, only 6% were classified as low risk. The DGVS algorithm required LSM for 76%; 25% were referred for specialised care. The sensitivities of the diagnostic pathways were 47–96%. A simplified referral strategy revealed a sensitivity/specificity of 46/88% for fibrosis risk. Application of the FAST score reduced the referral rate to 35%. This study (a) underlines the high prevalence of fibrosis risk in T2D, (b) demonstrates very high referral rates for in-depth hepatological work-up, and (c) indicates that simpler referral algorithms may produce comparably good results and could facilitate NAFLD screening.

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“…With a rise in recognition of NAFLD, strategies to reduce pressure on secondary services and costs for the health care system will be crucial. A recent evaluation of a large data set (n = 6,295 participants) from Europe and Asia demonstrated that community‐based screening for liver fibrosis with transient elastography was cost‐effective through earlier identification of patients, and the authors suggested that it could represent a valuable public health strategy . However, in the current cohort of patients with NAFLD, availability of transient elastography or the ELF test in primary care centers may not have avoided the need for hepatology referral, as most of the patients (88.5%) were referred with a request for an opinion regarding other clinical concerns.…”

Section: Discussionmentioning

confidence: 99%

Nonalcoholic Fatty Liver Disease: Interface Between Primary Care and Hepatology Clinics

et al. 2020

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Primary care physicians (PCPs) have the primary role in the diagnosis and management of nonalcoholic fatty liver disease (NAFLD), and in selecting patients for referral to a hepatologist for further evaluation. This study aimed to characterize PCP referrals for patients diagnosed with NAFLD at a major referral hospital, and to determine the severity of liver disease and patient pathway following evaluation in secondary care. New patients seen in the hepatology outpatient clinic (HOC) with a secondary care diagnosis of NAFLD were identified from the HOC scheduling database. PCP referrals for these patients were retrieved from the electronic medical records and reviewed by study clinicians, along with the hepatologists’ clinic notes and letters. Over a 14‐month period, 234 new PCP referrals received a diagnosis of NAFLD, accounting for 20.4% of the total number of new cases (n = 1,147) seen in the HOC. The 234 referrals were received from 170 individual PCPs at 135 practices. Most patients with NAFLD (88.5%) were referred for investigation of abnormal liver enzymes or other clinical concerns, including abnormal iron studies, hepatomegaly, and abdominal pain. Only 27 (11.5%) referrals included an assessment of liver disease severity. Following evaluation in the liver clinic, 175 patients (74.8%) were found to have a low risk of advanced fibrosis, and most (n = 159; 90.9%) were discharged back to their PCP for ongoing follow‐up in primary care. Conclusion: In addition to better access to noninvasive fibrosis tests, educational strategies to enhance awareness and recognition of NAFLD as a cause for many of the initial concerns prompting patient referral might improve risk stratification and increase the appropriateness of PCP referrals.

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

Cited by 115 publications

References 52 publications

The Fatty Liver Assessment in Germany (FLAG) cohort study identifies large heterogeneity in NAFLD care

The Fatty Liver Assessment in Germany (FLAG) cohort study identifies large heterogeneity in NAFLD care

Current NAFLD guidelines for risk stratification in diabetic patients have poor diagnostic discrimination

Nonalcoholic Fatty Liver Disease: Interface Between Primary Care and Hepatology Clinics

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