Provider- and system-level barriers to surveillance for hepatocellular carcinoma among patients with chronic liver disease.

Abstract

404 Background: Most cases of hepatocellular carcinoma (HCC) occur in patients with known risk factors. Expert society guidelines recommend HCC surveillance with ultrasound with or without serum alpha fetoprotein every 6 months for these patients, but less than 20% undergo recommended surveillance. The objective of this study was to identify provider- and system-level barriers to surveillance from the provider perspective and to examine the role of provider knowledge and attitudes. Providers’ suggestions for potential interventions to improve HCC surveillance were also elicited. Methods: Qualitative research methods were employed. Purposive sampling was used to invite providers from the Departments of Internal Medicine and Family and Community Medicine who provide primary care, and from the Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition to participate. A semi-structured interview guide was used. Transcribed interviews were analyzed to reveal emergent themes. Results: 22 providers were interviewed including primary care providers, general gastroenterologists and hepatologists. These providers spend a median of 70% (range 20% - 100%) of their time in clinical practice, versus research and administrative responsibilities, and have been in practice a median of 7 years (range 1.8 – 25 years). Provider-level barriers to HCC surveillance identified by participants included variable provider comfort managing chronic liver disease; relationships between primary care, gastroenterology, infectious disease and hepatology; if/how providers discuss HCC surveillance with high-risk patients; provider knowledge of guidelines and outcomes from HCC surveillance; and specific provider-level barriers including time in clinic, competing issues in clinic, deferral of responsibility to another provider, the provider-patient relationship, and time spent on patient education. System-level barriers to HCC surveillance included the absence of relevant technology tools, insurance denial of surveillance imaging, difficulty scheduling surveillance studies and the COVID-19 pandemic. Provider suggestions for interventions included patient navigation, use of technology, education for patients and primary care providers, partnering with primary care practices, and media campaigns. Conclusions: Important barriers to HCC surveillance and opportunities for intervention to improve HCC surveillance rates in high-risk patients were identified. Future research should focus on the design, testing and implementation of interventions to target provider- and system-level barriers.