IntroductionNoninvasive tests (NITs), e.g., Fibrosis-4 Index (FIB-4) and vibration-controlled elastography (VCTE), have been used to identify patients with metabolic dysfunction-associated steatotic liver disease (MASLD) 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.MethodsA cost-utility analysis using a Markov model compared no use of NITs with 3 NIT strategies: (i) FIB-4 and VCTE (FIB-4/VCTE), (ii) FIB-4 alone, and (iii) VCTE alone to identify advanced liver fibrosis and initiate HCC surveillance with biannual ultrasonography with alpha-fetoprotein in 4 MASLD populations: (i) general patients with MASLD, (ii) MASLD patients with body mass index (BMI) > 30 kg/m 2 , (iii) MASLD patients with diabetes, and (iv) MASLD patients with 3 metabolic traits (diabetes, hypertension, and BMI >30).ResultsFIB-4/VCTE was the most cost-effective approach across all groups, showing the lowest incremental cost-effectiveness ratio, 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 United States, whereas only FIB-4/VCTE was cost-effective in Thailand. For MASLD patients with BMI >30, all strategies were cost-effective in the United States, whereas 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 United States, whereas FIB-4/VCTE and FIB-4 alone were cost-effective in Thailand.DiscussionUsing FIB-4/VCTE to initiate HCC surveillance is cost-effective for patients with MASLD. If VCTE is unavailable, FIB-4 alone is a cost-effective alternative for MASLD patients with diabetes or 3 metabolic traits.