OBJECTIVES: Both the American Association of Clinical Endocrinology and the American Association for the Study of Liver Diseases recently adopted blood-based non-invasive testing strategies for screening metabolic dysfunction-associated steatotic liver disease (MASLD) in their clinical pathways. We assessed the cost-effectiveness of these testing strategies in a cohort of adult patients with Type 2 diabetes mellitus (T2DM), a risk factor of MASLD, in the endocrinology setting at a Veteran Affairs Palo Alto (VAPA) healthcare system in Palo Alto, CA.

METHODS: A decision analytic model was developed to project health care costs and lifetime quality-adjusted life years (QALYs) for adult patients at risk of MASLD. Patients identified to be at risk for MASLD using electronic medical records at VAPA underwent fibrosis 4 (FIB-4) and enhanced liver fibrosis (ELF) testing. Costs and quality-of-life values were estimated from published research. A cost-effectiveness analysis (CEA) was conducted to compare 6 testing strategies in this population, including FIB-4 alone at a 1.3 cut-off, ELF alone with 9.0 and 9.8 cut-offs, and FIB-4 followed by ELF with 7.7, 9.0 and 9.8 cut-offs.

RESULTS: Patients (N=254) were enrolled with a mean age 65.3+/-9.3 years, and a mean body mass index (BMI) of 31.7+/-6. Of these patients, 87.4% were male, 78.3% non-Hispanic, and 96.5% had T2DM. Total costs per person were lowest for the FIB-4/ELF with the 9.8 cut-off ($28,387) and highest for the ELF alone strategy with the 9.0 cut-off ($35,078). Lifetime QALYs were lowest for ELF alone strategy with 9.0 cut-off (13.49) and highest for FIB-4/ELF with the 9.8 cut-off strategy (14.23). The CEA revealed that the FIB-4/ELF with 9.8 cut-off strategy dominated all other blood-based non-invasive strategies.

CONCLUSIONS: FIB-4 followed by ELF strategy with the 9.8 cut-off can be a cost-effective gatekeeping tool in veteran patients at risk for MASLD in the United States in endocrinology setting.