Transient Elastography

Health Technology Assessment Committee Recommendations¹

  1. The Health Technology Assessment Committee recommends that Transient Elastography (TE) be publicly provided, but restricted to the assessment of liver fibrosis in patients with hepatitis B and/or C.
  2. It is recommended that use of TE beyond the assessment of liver fibrosis in patients with hepatitis B and/or C should not be permitted at this time, as other indications were beyond the scope of this review. Alternative indications should be assessed through the Health Technology Review process, if there is health authority interest in expanding the scope beyond hepatitis B and C patients.
  3. A review of acoustic radiation force impulse imaging (ARFI) will be undertaken by HTAC, as it is an alternate, latent technology currently widespread across the health system. A preliminary review of the evidence suggests that ARFI may have similar performance capabilities and cost less than TE. ARFI can also be enabled in existing ultrasound machines making the diffusion of the technology potentially easier than TE.
  4. There are also other types of elastography that may be effective and cost effective. Alternative types of elastography should be assessed through the Health Technology Review process, where there is health authority interest.

Health Technology Assessment Committee Findings

  1. The body of evidence reviewed suggests that TE has comparable diagnostic accuracy to liver biopsy, but clinical utility is uncertain.
  2. TE is likely to provide good value for money. The evidence review by CADTH reported that non-invasive tests (such as TE) have lower diagnostic accuracy than liver biopsy; however, they are potentially more cost-effective than liver biopsy.
  3. Coverage of a non-invasive alternative to biopsy with comparable accuracy is consistent with the province’s core focus of enabling and delivering patient centred services and care.
  4. Other non-invasive technologies for assessing liver fibrosis should also be investigated. For example, a recent review of acoustic radiation force impulse imaging (ARFI) by NICE concluded that it is equally effective and less costly than TE in assessing liver fibrosis. ARFI can also be enabled in existing ultrasound machines making the diffusion of the technology potentially easier and less costly than TE (see appendix C).
  5. There is potential for TE to be used for clinical indications beyond the assessment of fibrosis in patients with hepatitis B and/or C, where there is limited evidence to support its use.
  6. Currently, only Manitoba and Quebec publicly fund TE. A recommendation to publicly fund was also made in Ontario in November 2015.
  7. TE is expected to have minimal impact on physician workload and TE results would simply replace the liver biopsy results which a physician would currently consider in making treatment decisions. Given this, the impact of a new fee code is not included in the budget impact analysis.
  8. There is uncertainty regarding the size of the patient population that would use TE. Due to its non-invasive nature and the recent introduction of curative drug therapies for HCV, it is anticipated that the number of patients assessed for liver fibrosis with TE will be higher than those historically assessed by liver biopsy.
  9. The business case presented a budget impact associated with the public provision of TE in BC for HBV and HCV patients ranging from $212,000 to $233,000 per year. Feedback from HTAC suggested that an additional scenario be developed to reflect the actual number of live biopsies performed in BC, rather than the estimated number of newly infected patients. The new scenario suggests an estimated budget impact of $164,000 per year.

The Health Technology Assessment Committee recommendations on Transient Elastography were accepted by a committee of senior health authority and ministry executives in May 2016. Please note health authorities determine how health technologies are implemented within their programs and services. Other relevant scientific findings may have been reported since the completion of the reference documents used to form the basis of committee's recommendations. 

¹ The findings and recommendations of the Health Technology Assessment Committee do not necessarily reflect the views or policy of the Ministry of Health.