Abstract
Simple SummaryLiver cancer is a growing problem that largely impacts people with cirrhosis. This article describes the Veterans Health Administration’s national cirrhosis quality improvement program and its focus on early detection of liver cancer.After implementing a successful hepatitis C elimination program, the Veterans Health Administration’s (VHA) Hepatic Innovation Team (HIT) Collaborative pivoted to focus on improving cirrhosis care. This national program developed teams of providers across the country and engaged them in using systems redesign methods and population health approaches to improve care. The HIT Collaborative developed an Advanced Liver Disease (ALD) Dashboard to identify Veterans with cirrhosis who were due for surveillance for hepatocellular carcinoma (HCC) and other liver care, promoted the use of an HCC Clinical Reminder in the electronic health record, and provided training and networking opportunities. This evaluation aimed to describe the VHA’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates, using a quasi-experimental design. Across all VHA facilities, as the HIT focused on cirrhosis between 2018–2019, HCC surveillance rates increased from 46% (IQR 37–53%) to 51% (IQR 42–60%, p < 0.001). The median HCC surveillance rate was 57% in facilities with high ALD Dashboard utilization compared with 45% in facilities with lower utilization (p < 0.001) and 58% in facilities using the HCC Clinical Reminder compared with 47% in facilities not using this tool (p < 0.001) in FY19. Increased use of the ALD Dashboard and adoption of the HCC Clinical Reminder were independently, significantly associated with HCC surveillance rates in multivariate models, controlling for other facility characteristics. In conclusion, the VHA’s HIT Collaborative is a national healthcare initiative associated with significant improvement in HCC surveillance rates.
Highlights
The incidence of hepatocellular carcinoma (HCC) continues to rise globally [1,2,3], paralleling the rising incidence of cirrhosis [4]
This evaluation of the Hepatic Innovation Team (HIT) Collaborative’s impact on HCC surveillance rates aimed to describe the Veterans Health Administration (VHA)’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates
The HIT Collaborative Leadership Team was available to provide technical assistance and coaching between calls. They provided education about the Advanced Liver Disease (ALD) Dashboard and HCC Clinical Reminder, trained clinicians in systems redesign methods, and developed a tool to estimate the cost of facility-level cirrhosis care
Summary
The incidence of hepatocellular carcinoma (HCC) continues to rise globally [1,2,3], paralleling the rising incidence of cirrhosis [4]. While guidelines recommend that persons with cirrhosis undergo biannual HCC surveillance with imaging [5,6,7,8], adherence to these guidelines remains low across all sectors of healthcare [9,10] Such gaps between evidence or guidelines and clinical practice have been identified across healthcare systems and clinical areas. The HIT Collaborative remains a VHA-wide program of interdisciplinary healthcare providers organized into regional teams (defined by Veterans Integrated Service Networks or VISNs) and led by a national leadership team. This network of over 400 VHA clinicians and staff includes hepatologists, pharmacists, infectious disease providers, systems redesign experts, implementation scientists, and health services researchers. This transition leveraged the existing HIT infrastructure and leadership support to focus on cirrhosis care including HCC surveillance and surveillance for and treatment of varices [17,18,19]
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