Creation of a VISN Wide Multi-Disciplinary, Multi-Facility Team and Tumor Board: Its Impact on Timeliness and Quality of Hepatocellular Carcinoma Care

Abstract

Introduction: Hepatocellular Carcinoma (HCC) is the most rapidly increasing cause of cancer death in the US. If lesions are detected early,curative treatments such as liver transplantation,surgical resection and tumor ablation can improve 5-year survival from a dismal 14% to 40%-70%. VA data shows that only 11% of veterans with HCC receive these potentially curative treatments.We aimed to create the nation's first Veterans Integrated Service Network (VISN)-wide, multi-disciplinary, sevenfacility team with five separate university affiliations to improve access, timeliness and quality of care. A shared network space was created for tumor board schedules, submission templates, educational materials and procedure protocols.A VISN-wide web of telehealth and in-person clinics as well as e-consults was established.Standardization of HCC screening, diagnosis,surveillance,imaging protocols,staging and treatment was implemented.The VISN-wide HCC tumor board met for the first time in July 2012. Methods: We performed a cross sectional chart review of veterans diagnosed with HCC between 2010-2015.Those diagnosed before July 2012 were the control group and those after were the intervention group.Demographic and clinical data were collected.Outcome measures were number of days between diagnosis and initial therapy,advanced directives discussion within 90 days and cancer staging before therapy.Descriptive statistics were applied using SPSS v23®. Data is presented as the mean±standard error of mean (SEM). Results: Of 146 patients' charts reviewed,mean age (years) was 64.4±0.65, range 51-89. 50 patients were in the control group and 96 in the intervention group.The age,race and mean Child-Pugh between the groups was not statistically significant.After intervention,we found a significant decrease in number of days from diagnosis to initial treatment from 47.0±6.26 to 29.5±3.27, p< 0.01.There was an increase in cancer staging prior to treatment with 67.3% before intervention and 83.3% after,p=0.03.Of the control group, 42.6% had advanced directives discussed within 90 days of diagnosis compared to 70.2% after intervention, p < 0.01. Conclusion: The creation of a VISN wide, multi-facility, multi-disciplinary HCC team shows significant improvement in timeliness and quality of care in veterans with HCC.We are eager to continue to examine other quality measures and outcomes data to evaluate the impact of this system redesign on our vulnerable veteran population.