Cost-effectiveness of various referral pathways to identify advanced fibrosis among type 2 diabetes mellitus patients with metabolic dysfunction-associated steatotic liver disease in primary care setting in Malaysia

by Wei Yoon Poh, Amirah Azzeri, Shamsul Mohd Zain, Rosmawati Mohamed, Kim Sui Wan, Xe Hui Lee, Maznah Dahlui, Fatiha Hana Shabaruddin Background and aim Most international guidelines recommend a two-step approach using the Fibrosis-4 index (FIB-4) and vibration-controlled transient elastography (VCTE) to identify advanced fibrosis, a key predictor of all-cause and liver-related mortality in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). However, VCTE is not available in most primary care settings in Malaysia, and there is scarce data on the cost-effectiveness of different approaches.

This study evaluated the cost-effectiveness of three referral pathways for identifying advanced fibrosis among type 2 diabetes mellitus(T2DM) patients with MASLD. Methods We developed a decision-analytical model from the healthcare provider’s perspective, using 1,000 simulated patients to compare: (i) Current Practice (direct referral based on elevated alanine transaminase), (ii) Clinical Practice Guidelines (CPG) Pathway using FIB-4 single-cutoff 1.3, and (iii) FIB-4 dual-cutoffs (1.3,3.25) followed by a gamma-glutamyl transferase (GGT) test for indeterminate cases (Sequential FIB-4/GGT Pathway).

Current practice served as the reference comparator.