title: Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score.
abstract: BACKGROUND
  The complications of Nonalcoholic Fatty Liver Disease (NAFLD) are dependent on the presence of advanced fibrosis. Given the high prevalence of NAFLD in the US, the optimal evaluation of NAFLD likely involves triage by a primary care physician (PCP) with advanced disease managed by gastroenterologists.
  
  
  METHODS
  We compared the cost-effectiveness of fibrosis risk-assessment strategies in a cohort of 10,000 simulated American patients with NAFLD performed in either PCP or referral clinics using a decision analytical microsimulation state-transition model. The strategies included use of vibration-controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care by a specialist only). NFS and VCTE performance was obtained from a prospective cohort of 164 patients with NAFLD. Outcomes included cost per quality adjusted life year (QALY) and correct classification of fibrosis.
  
  
  RESULTS
  Risk-stratification by the PCP using the NFS alone costs $5,985 per QALY while usual care costs $7,229/QALY. In the microsimulation, at a willingness-to-pay threshold of $100,000, the NFS alone in PCP clinic was the most cost-effective strategy in 94.2% of samples, followed by combination NFS/VCTE in the PCP clinic (5.6%) and usual care in 0.2%. The NFS based strategies yield the best biopsy-correct classification ratios (3.5) while the NFS/VCTE and usual care strategies yield more correct-classifications of advanced fibrosis at the cost of 3 and 37 additional biopsies per classification.
  
  
  CONCLUSIONS
  Risk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice.
authors.affiliation: Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, United States of America.
authors.forename: Elliot B
authors.initials: EB
authors.lastname: Tapper
authors.affiliation: Dept of Radiology, Dept of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands.|Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, United States of America.
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.affiliation: Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, United States of America.
authors.forename: Nezam H
authors.initials: NH
authors.lastname: Afdhal
authors.affiliation: Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, United States of America.
authors.forename: Michelle
authors.initials: M
authors.lastname: Lai
authors.affiliation: Division of Gastroenterology/Hepatology/Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Neil
authors.initials: N
authors.lastname: Sengupta
mesh_terms: D003362:Cost-Benefit Analysis; D054459:Elasticity Imaging Techniques; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology; D008103:Liver Cirrhosis / Q000150:complications*; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000150:complications* / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D058007:Physicians, Primary Care; D012017:Referral and Consultation; D018570:Risk Assessment / Q000191:economics*