1117 Same Day, Walk-In Ultrasound Appointments Improve Hepatocellular Carcinoma Screening Rates in Patients With Cirrhosis at a Veterans Affairs Center

Abstract

INTRODUCTION: The incidence of hepatocellular carcinoma (HCC) is rapidly increasing in the United States and 80% have pre-existing cirrhosis. It is imperative to implement effective screening programs to detect clinically silent or early stage HCC in patients with cirrhosis to improve cancer-related mortality. The 2018 American Association for the Study of Liver Diseases (AASLD) Guidelines recommends surveillance using ultrasound (US), with or without alpha fetal protein (AFP), every 6 months. Prior studies have shown low HCC surveillance rates of approximately 20% among eligible patients in clinical practice. Our aim is to improve the HCC surveillance rate at our local Veterans Affairs Medical Center (VAMC). METHODS: We developed a process map and an apparent cause analysis (fishbone) to identify the barriers to HCC screening. We implemented a quality improvement initiative and collected the HCC screening compliance rates on a monthly basis on all eligible patients with cirrhosis seen at a local VAMC between January 2018 and February 2019. RESULTS: Based on our process map (Figure 1) and apparent cause analysis (Figure 2), the barriers to HCC screening at our local VAMC included the lack of a set protocol in our radiology department for limited ultrasound scans which limited patient access and compliance, such as the schedulers’ inability to reach patients for ultrasound appointments and patients’ no-show on ultrasound appointments. Our primary intervention was to institute same day walk-in ultrasounds, such that patients could go directly from their liver clinic appointment to the radiology department for a dedicated HCC screening ultrasound, without the need for patients to fast or return on a different date. At the start of the study period in January 2018, the HCC screening compliance rate was 39.6%, with 195/324 patients overdue. The same day walk-in ultrasound was implemented on 31 July 2018, at a time when the compliance rate was 42.1%. Six months after the intervention, the compliance rate in February 2019 was 66% with just 90/215 patients overdue for their ultrasounds. (Figure 2) CONCLUSION: It is standard of care to provide biannual screening ultrasounds for HCC surveillance in patients with cirrhosis. At our local VAMC, providing patients with same day walk-in ultrasounds to coincide with their liver clinic appointment days eliminated a number of barriers to HCC screening and lead to an increase in compliance.