Implementation of Quality Improvement Measures Improve Hepatocellular Carcinoma Surveillance Among Individuals With Cirrhosis

Abstract

Introduction: Hepatocellular carcinoma (HCC) surveillance detects early stage cancer, increases curative options and improves survival. Practice guidelines recommend HCC screening every 6 months in this population. Our previous study of adherence to HCC surveillance was not optimal. Our goal was to assess the improvement in adherence to HCC surveillance guidelines among patients with cirrhosis after implementation of QI measures. Methods: Previous study of adherence to HCC surveillance guidelines at Northwell Health Hepatology practice in 2016 (January 1st to December 31st) showed that routine surveillance every 6 months was 36%, and inconsistent surveillance was 60% (mean 10 ± 3 months). We retrospectively reviewed HCC surveillance among patients with cirrhosis after implementation of dedicated patient education and monthly reminder to health care providers. Patients with cirrhosis having visits between January 1st 2017 and March 1st 2018 were included in this follow-up study. Records were reviewed for demographics, liver disease, surveillance modality, interval and results. Prior HCC was excluded. Results: A total of 933 patients were included. Demographics and surveillance modalities are listed in table 1 and 2 respectively. Eighty six percent had routine surveillance every 6 months; 14% had inconsistent surveillance (range 8 to 12 months, mean 10 ± 2 months). Mean surveillance interval was 6 ± 2 months. Thirty six de novo HCC (3.9%) were detected, the majority had alcohol associated liver disease (56%). Eighty nine percent were single tumors (n=32), 11% multifocal (n=4), none were metastatic. All met Milan criteria for liver transplantation (OLT). Twenty (56%) were referred to OLT, 12 (33%) underwent resection and 4 (11%) radiofrequency ablation. Conclusion: Our study illustrates that implementation of QI measures improve HCC surveillance. In our population, 3.9% of patients with cirrhosis were detected with de novo HCC by routine surveillance. The majority were single tumors, early cancers and eligible for curative therapy, including resection and OLT. There was a marked improvement in adherence to standard HCC surveillance from previous study in 2016 of 36% to 86% following implementation of our QI measures. Our study shows that QI measures by patient education and physician reminders increase adherence to practice guidelines significantly and improve quality of patient care.922_A Figure 1. Patient Demographics and Characteristics.922_B Figure 2. Hepatocellular Carcinoma (HCC) Surveillance Modality.