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08-10-2019

Authors
Lars Asphaug,  Maja Thiele,  Aleksander Krag,  Hans Olav Melberg on behalf of the GALAXY Consortium

Abstract
Background and Aims
Alcohol‐related liver disease is often undetected until irreversible late‐stage decompensated disease manifests. Consequently, there is an unmet need for effective and economically reasonable pathways to screen for advanced alcohol‐related fibrosis.

Approach and Results
We used real‐world data from a large biopsy‐controlled study of excessive drinkers recruited from primary and secondary care, to evaluate the cost‐effectiveness of four primary care initiated strategies: (1) routine liver function tests with follow‐up ultrasonography for test‐positives, (2) the enhanced liver fibrosis (ELF) test with hospital liver stiffness measurement (LSM) for positives, (3) a three‐tier strategy using the Forns Index to control before strategy 2, and (4) direct referral of all to LSM. We used linked decision trees and Markov models to evaluate outcomes short term (cost‐per‐accurate diagnosis) and long term (quality‐adjusted life‐years [QALYs]). For low‐prevalence populations, ELF with LSM follow‐up was most cost‐effective, both short term (accuracy 96%, $196 per patient) and long term (incremental cost‐effectiveness ratio [ICER] $5,387‐$8,430/QALY), depending on whether diagnostic testing had lasting or temporary effects on abstinence rates. Adding Forns Index decreased costs to $72 per patient and accuracy to 95%. The strategy resulted in fewer QALYs due to more false negatives but an ICER of $3,012, making this strategy suited for areas with restricted access to ELF and transient elastography or lower willingness‐to‐pay. For high‐prevalence populations, direct referral to LSM was highly cost‐effective (accuracy 93%, $297 per patient), with ICERs between $490 and $1,037/QALY.

Conclusions
Noninvasive screening for advanced alcohol‐related fibrosis is a cost‐effective intervention when different referral pathways are used according to the prevalence of advanced fibrosis. Patients in the primary health care sector should be tested with the ELF test followed by LSM if the test was positive, whereas direct referral to LSM is highly cost‐effective in high‐prevalence cohorts.

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