The recent cost models say yes, provided the screening uses blood tests and scans rather than a liver biopsy. A model across the US and five European countries found multi-step non-invasive screening of adults with type 2 diabetes cost-effective in all six, at up to £18,572 per quality-adjusted life year [1]. Pathways that relied on biopsy came out worse than not screening at all, in every one of those countries.
The reason to look is how common serious liver disease is in this group. In a prospective study of 501 adults aged 50 or over with type 2 diabetes, 65% had fatty liver disease, 14% had advanced fibrosis and 6% had cirrhosis [5]. The disease is also expensive to carry, as the annual cost of fatty liver in diabetes shows. Whether the drugs then help the liver is a separate question, taken up in what the liver trials found.
How the screening works
The pathways these models test run in steps. They start with a blood-based score such as FIB-4 or the Enhanced Liver Fibrosis (ELF) test, and move to imaging such as vibration-controlled transient elastography, which measures liver stiffness. Biopsy, the older reference test, takes a sample of the liver itself.
In economic terms, one strategy dominates another when it is both cheaper and better. The non-invasive pathways ran from dominating no screening up to £18,572 per QALY. The biopsy pathways were dominated by no screening in all six markets [1], which means they spent more money and produced worse outcomes than doing nothing. In Germany, France, Italy and the US, at least one non-invasive strategy dominated no screening outright, and the probability of cost-effectiveness ran from 90% to 100% depending on the country.
What the other models found
A twelve-country analysis covering every World Health Organization region modeled people with type 2 diabetes from screening through treatment [2]. Screening with ELF or elastography followed by intensive lifestyle changes was cost-effective in all twelve countries. Adding semaglutide after screening was cost-effective in eleven, and the value of that drug step is examined in whether semaglutide is cost-effective for MASH.
A London study screened 287 people with type 2 diabetes in primary care rather than modeling a hypothetical cohort [3]. It found fatty liver disease in 64%, significant fibrosis in 17% and advanced fibrosis in 11%, and screening came out cost-effective, with elastography at £2,480 per QALY, ELF at £2,541.24 and FIB-4 at £2,059.98.
The model that said no, and why
A 2016 analysis reached the opposite answer [4]. Its screening pathway was an ultrasound, then a biopsy for anyone with fatty liver, then medical treatment. Screening cut cirrhosis by 12.9% and liver-related deaths by 11.9%, yet it produced 0.02 fewer QALYs, because the treatment assumed at the time made people feel worse. Without that quality-of-life penalty, screening became cost-effective at $42,134 per QALY.
The authors predicted that screening would become cost-effective once better-tolerated treatments arrived. The 2026 model makes the matching forward claim. Its authors expect the value of screening to grow as drugs able to reverse fibrosis, naming resmetirom and semaglutide, reach the market [1]. Both statements are the authors’ expectations rather than findings, and a model that assumes an effective treatment downstream will always make finding patients look more worthwhile.
Who decides whether you are tested
Whether a person with diabetes is screened is decided by the clinician who orders the test and, in practice, by whether the payer covers it. The 2026 model’s authors note that guidelines already recommend non-invasive tests for high-risk patients, while access, adoption and payer coverage remain limited in many markets [1]. How coverage decisions reach a patient more generally is covered in what insurance decides about these drugs.
Screening also sits upstream of treatment. Semaglutide’s liver indication is written around a fibrosis stage, so a test has to establish that stage before a prescription for that indication exists. The trial behind the indication is described in what the liver trial ran. None of these studies is a reason by itself to request a test; they are the analyses that shape whether a test is offered and paid for.