OBJECTIVES: The cost of new HCV treatments leads payers and insurance providers to question if delaying treatment for low risk patients can be accomplished without adversely impacting their clinical outcome.  Retrospective cohort data from the Veterans Administration [VA] were used to estimate the impact on patient risk of initiating treatment before versus after the patient’s FIB4 levels became elevated. METHODS: Essentially all VA HCV patients with one or more reported FIB-4 values during the study period were included in the analysis.   Primary outcome measures were: time to death, and time to the first occurrence of a composite of liver-related clinical events.  The impact of treatment initiation relative to three different definitions of an elevated FIB4 level was estimated using a time-dependent Cox proportional hazards models.    RESULTS: