Cost-Utility Analysis of Non-Invasive Tests to Initiate Hepatocellular Carcinoma Surveillance in Metabolic Dysfunction-Associated Steatotic Liver Disease

Background & Aims: Non-invasive tests (NITs), e.g. Fibrosis-4 Index (FIB-4) and vibration-controlled elastography (VCTE), have been used to identify metabolic dysfunction-associated steatotic liver disease (MASLD) patients at high risks for hepatocellular carcinoma (HCC). This study investigates the cost-effectiveness of NITs to identify MASLD patients with advanced liver fibrosis and initiate HCC surveillance. Methods: A cost-utility analysis using a Markov model compared no use of NITs with three NIT strategies: 1) FIB-4 and VCTE (FIB-4/VCTE), 2) FIB-4 alone, and 3) VCTE alone to identify advanced liver fibrosis and initiate HCC surveillance with biannual ultrasonography with alpha-fetoprotein in 4 MASLD populations: 1) general MASLD patients, 2) MASLD patients with body mass index (BMI) >30 kg/m 2 , 3) MASLD patients with diabetes, and 4) MASLD patients with three metabolic traits (diabetes, hypertension and BMI >30). Results: FIB-4/VCTE was the most cost-effective approach across all groups, showing the lowest ICER, followed by FIB-4 alone and VCTE alone. In the general MASLD population, both FIB-4/VCTE and FIB-4 alone were cost-effective in the US, while only FIB-4/VCTE was cost-effective in Thailand. For MASLD patients with BMI >30, all strategies were cost-effective in the US, while only FIB-4/VCTE was cost-effective in Thailand. In MASLD patients with diabetes or 3 metabolic traits, all strategies were cost-effective in the US, while FIB-4/VCTE and FIB-4 alone were cost-effective in Thailand. Conclusions: Using FIB-4/VCTE to initiate HCC surveillance is cost-effective for MASLD patients. If VCTE is unavailable, FIB-4 alone is a cost-effective alternative for MASLD patients with diabetes or 3 metabolic traits.