OBJECTIVES: The global metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence in the year 2040 is projected to be 55.7%. Characterized by the accumulation of excessive fat within liver cells unrelated to alcohol consumption, MASLD has received attention not only due to its potential to develop severe liver-related complications, but also due to its intricate connection with obesity and metabolic disorders such as type 2 diabetes mellitus.

METHODS: Consenting adult patients at risk of MASLD in the veteran administration (VA) healthcare system identified using electronic medical records underwent fibrosis 4 (FIB-4), enhanced liver fibrosis (ELF), transient elastography (TE), and magnetic resonance elastography (MRE) testing. Single- double- and triple-test strategies were evaluated for total costs. Costs of each NIT strategy were compared according to patient percentage remaining in primary care for management vs. referral to the hepatology clinic.

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 the 254 patients, 87.4% were male, 78.3% non-Hispanic/Latino, and 96.5% had type 2 diabetes mellitus (T2DM). Five out of ten strategies showed lower referral rate and lower costs compared to the FIB-4 only strategy. FIB-4/TE, FIB-4/MRE, FIB-4/ ELF/TE, TE only, and FIB-4/ELF strategies kept the highest proportion of patients within primary care at 91.9% (170/185), 87.9% (51/58), 81.7% (134/164), 81.1% (150/185), and 72.7% (165/227) respectively. These five strategies incurred the following costs per-patient: $172.92, $408.35, $292.11, $299.58, and $411.70 respectively. FIB-4 alone strategy resulted in 63.1% (93/252) patients kept within primary care and $445.35 per-patient costs.

CONCLUSIONS: Among ten strategies assessed, five strategies resulted in lower referral rates to hepatology clinics and lower costs compared to the FIB-4 only strategy. These five strategies in comparison to the FIB-4-only strategy realized substantial cost savings ranging from 7.56% to 61.17%.