AbstractBackground and AimsAs screening for the liver disease and risk‐stratification pathways are not established in patients with type‐2 diabetes mellitus (T2DM), we evaluated the diagnostic performance and the cost‐utility of different screening strategies for MASLD in the community.MethodsConsecutive patients with T2DM from primary care underwent screening for liver diseases, ultrasound, ELF score and transient elastography (TE). Five strategies were compared to the standard of care: ultrasound plus abnormal liver function tests (LFTs), Fibrosis score‐4 (FIB‐4), NAFLD fibrosis score, Enhanced liver fibrosis test (ELF) and TE. Standard of care was defined as abnormal LFTs prompting referral to hospital. A Markov model was built based on the fibrosis stage, defined by TE. We generated the cost per quality‐adjusted life year (QALY) gained and calculated the incremental cost‐effectiveness ratio (ICER) over a lifetime horizon.ResultsOf 300 patients, 287 were included: 64% (186) had MASLD and 10% (28) had other causes of liver disease. Patients with significant fibrosis, advanced fibrosis, and cirrhosis due to MASLD were 17% (50/287), 11% (31/287) and 3% (8/287), respectively. Among those with significant fibrosis classified by LSM≥8.1 kPa, false negatives were 54% from ELF and 38% from FIB‐4. On multivariate analysis, waist circumference, BMI, AST levels and education rank were independent predictors of significant and advanced fibrosis. All the screening strategies were associated with QALY gains, with TE (148.73 years) having the most substantial gains, followed by FIB‐4 (134.07 years), ELF (131.68 years) and NAFLD fibrosis score (121.25 years). In the cost‐utility analysis, ICER was £2480/QALY for TE, £2541.24/QALY for ELF and £2059.98/QALY for FIB‐4.ConclusionScreening for MASLD in the diabetic population in primary care is cost‐effective and should become part of a holistic assessment. However, traditional screening strategies, including FIB‐4 and ELF, underestimate the presence of significant liver disease in this setting.