Hepatocellular Carcinoma Surveillance Rates Research Articles

Interventions to Improve Surveillance for Hepatocellular Carcinoma in High-Risk Patients: A Scoping Review.

Hepatocellular carcinoma (HCC) is most often a sequela of chronic liver disease or chronic hepatitis B infection. Among high-risk patients, surveillance for HCC every 6months is recommended by international guidelines. However, rates of HCC surveillance are suboptimal (11-64%). Barriers at the patient, provider, and healthcare delivery system levels have been identified. We performed a systemic scoping review to identify and characterize interventions to improve HCC surveillance that has previously been evaluated. Searches using key terms in PubMed and Embase were performed to identify studies examining interventions designed to improve the surveillance rate for HCC in patients with cirrhosis or chronic liver disease that were published in English between January 1990 and September 2021. Included studies (14) had the following study designs: (1) randomized clinical trials (3, 21.4%), (2) quasi-experimental (2, 14.3%), (3) prospective cohort (6, 42.8%), and (4) retrospective cohort (3, 21.4%). Interventions included mailed outreach invitations, nursing outreach, patient education with or without printed materials, provider education, patient navigation, chronic disease management programs, nursing-led protocols for image ordering, automated reminders to physicians and nurses, web-based clinical management tools, HCC surveillance databases, provider compliance reports, radiology-led surveillance programs, subsidized HCC surveillance, and the use of oral medications. It was found that HCC surveillance rates increased after intervention implementation in all studies. Despite improvements in HCC surveillance rates with intervention, compliance remained suboptimal. Further analysis of which interventions yield the greatest increases in HCC surveillance, design of multi-pronged strategies, and improved implementation are needed.

Hepatocellular carcinoma surveillance in the telehealth era: A single-centre review.

Real-world hepatocellular carcinoma (HCC) surveillance uptake remains suboptimal, despite evidence that surveillance is associated with lower cancer-related mortality in patients with cirrhosis and chronic hepatitis B. We aimed to examine the impact of telehealth consultations on HCC surveillance rates within a specialist liver clinic. We conducted a retrospective observational study within an Australian outreach liver clinic within a culturally diverse community, comparing standard consultations before the COVID-19 pandemic to telehealth consultations during the pandemic. The primary outcome was surveillance uptake defined as the percentage of time up-to-date with surveillance (PTUDS) with the 6-month interval following each scan considered up-to-date. Over 18 months of follow-up for each cohort, the median PTUDS was 86.5% in the standard consultation cohort and 85.5% in the telehealth consultation cohort (p = 0.12). HCC diagnoses did not differ between groups and hospitalisation and mortality rates were low. Using multivariate regression, increasing age, the need for an interpreter and being born in South-East Asia independently predicted PTUDS in the standard consultation cohort, whereas being born in Australia or New Zealand was predictive of a lower PTUDS. Current alcohol use and distance from the clinic predicted a lower PTUDS in the telehealth consultation cohort. In both groups, missed clinic attendances were strongly predictive of a lower PTUDS. Telehealth hepatology consultations effectively coordinate HCC surveillance and are associated with similar outcomes to standard consultations. Its implementation should be widely considered given its advantages with regards to accessibility for patients.

Barriers to surveillance for hepatocellular cancer among patients with chronic liver disease -providers' perspectives

Aims: Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. While patients who are known to be at high risk for HCC should be under surveillance, only 20% of eligible patients in the United States are surveilled. The aim of this study was to identify providers’ perspectives about patient-, provider- and system-level barriers to surveillance for HCC among high-risk patients and to examine provider knowledge and attitudes related to HCC surveillance. We also explored interventions providers suggested as ways to improve HCC surveillance. Methods: Purposive sampling was used to recruit physicians and nurse practitioners in hepatology, gastroenterology, and primary care (internal and family medicine) from one academic medical center to participate in semi-structured interviews. Interviews were transcribed verbatim, and analyzed deductively and inductively to reveal emergent themes. Results: 22 informants were interviewed. During these interviews, several important themes emerged, including: (1) Provider comfort with managing chronic liver disease and the relationships between hepatology, gastroenterology, infectious disease, and primary care providers; (2) Provider knowledge of guidelines for HCC surveillance in high-risk patients and their knowledge about the impact that HCC surveillance can have; (3) How providers discuss HCC surveillance with their high-risk patients; (4) Provider-Level barriers to surveillance; (5) System-level barriers to surveillance; (6) COVID-19; (7) Patient-level barriers to surveillance, and (8) Suggested interventions to improve HCC surveillance rates. Conclusions: In designing interventions to improve HCC surveillance rates of high-risk patients in the United States, there are important targets at the patient, provider and system levels.

Factors associated with nonadherence to surveillance for hepatocellular carcinoma among patients with hepatic C virus cirrhosis, 2000-2015.

Hepatocellular carcinoma (HCC) surveillance can detect the early stage of tumors and lead to improved survival. Adherence to guideline-concordant HCC surveillance is crucial in at-risk populations, including patients with hepatic C virus (HCV) cirrhosis. This study was conducted to identify patient and provider factors associated with nonadherence to HCC surveillance in patients with HCV cirrhosis. Data were primarily obtained from the Taiwan National Health Insurance Research Database for the 2000 to 2015 period. Adult patients newly diagnosed as having HCV cirrhosis between 2003 and 2012 were enrolled. Each patient was followed up for 3 years and until the end of 2015. Annual HCC surveillance was defined as the uptake of an abdominal ultrasound and alpha-fetoprotein (AFP) test annually during the 3-years follow-up. Nonannual surveillance was defined as the lack of an annual abdominal ultrasound and AFP test during the same 3-years period. Multinomial logistic regression models were applied to determine factors influencing adherence or nonadherence to annual HCC surveillance. We included a total of 4641 patients with HCV cirrhosis for analysis. Of these patients, only 14% adhered to annual HCC surveillance. HCC surveillance improved in later years, compared with the earlier phases of the study period. Patients with HCV cirrhosis comorbid with coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) or those with a relatively high number of comorbidities had a significantly higher likelihood of nonadherence. Patients who primarily received care from internists were significantly less likely to exhibit nonadherence to annual HCC surveillance compared with patients receiving care from physicians of other specialties. Patients who primarily received care from physicians practicing in larger hospitals were significantly less likely to exhibit nonadherence. HCC surveillance rates remain unacceptably low among high-risk patients, and our findings may be helpful in the development of effective interventions to increase HCC surveillance. The effective incorporation of HCC surveillance into routine visits for other chronic comorbidities, particularly for CAD or COPD, may be crucial for increasing HCC surveillance.

S1285 Association Between Distance to a Radiology Center and HCC Surveillance Among Patients With Cirrhosis in Florida

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in patients with cirrhosis, and HCC survival is directly correlated with stage at diagnosis. Current guidelines recommend HCC surveillance with an abdominal ultrasound every 6 months, but unfortunately many patients do not meet this threshold.1 Our aim was to determine whether distance to a radiology center, measured in travel time, was associated with HCC surveillance rates. Methods: We included data on adult patients with cirrhosis within the OneFlorida Clinical Research Consortium from October 1, 2015- December 31, 2019. The primary outcome was a continuous measure of the percentage of time up to date with HCC surveillance (PTUDS) based on abdominal ultrasound (US), triple phase CT, and/or MRI with contrast. Travel time was calculated using ArcGIS geomodelling software as the estimated minimum travel time between the geographic centroid of patient’s zip code and the nearest American College of Radiology-accredited center for US, CT, and/or MRI. Linear regression models were fit with PTUDS as the outcome; all covariates with a p< 0.05 were included in the final multivariable model. (Figure) Results: Among 25,299 patients with cirrhosis (median follow-up=4.1 years), the median PTUDS was 10.0% (interquartile range 0-29.9%). Variables found to have a statistically significant association with PTUDS are displayed in Table. Travel time, hepatic encephalopathy at baseline, and ascites at baseline were associated with increased PTUDS. Patients with alcohol-related liver disease, nonalcoholic steatohepatitis, and cryptogenic cirrhosis had lower PTUDS compared with patients with HCV. Conclusion: Travel time to the nearest radiology center is not associated with lower HCC surveillance rates while race, etiology of liver disease, and disease severity do appear to variably influence surveillance. By establishing factors associated with currently suboptimal surveillance rates, we can create targeted interventions to improve surveillance and, ultimately, patient outcomes.Figure 1.: Median PTUDS by County Table 1. - Multivariable Linear Regression Model of Factors Associated with HCC Surveillance Variable Beta Coefficient, 95% CI P-Value Travel Time 0.0016 (0.0012-0.0020) <0.001 Liver Disease Etiology Hepatitis C Virus Reference - Hepatitis B Virus 0.0246 (0.0019-0.0473) 0.034 Wilson's Disease 0.0137 (-0.571-0.0845) 0.704 Hemochromatosis 0.0067 (-0.0220-0.0354) 0.647 a1-Antitrypsin Deficiency 0.0673 (0.0200-0.1145) 0.005 Alcohol-Related Liver Disease -0.0720 (-0.0801- -0.0639) <0.001 Primary Biliary Cholangitis -0.0037 (-0.0261- 0.0186) 0.745 Autoimmune Hepatitis -0.0193 (-0.0406- 0.0019) 0.075 Primary Sclerosing Cholangitis 0.0123 (-0.0462- 0.0708) 0.680 Nonalcoholic Steatohepatitis -0.0835 (-0.0917- -0.0752) <0.001 Unknown/Cryptogenic -0.01566 (-0.1664- -0.1467) <0.001 Race White/Caucasian Reference - American Indian/Alaskan -0.0207 (-0.0871- 0.0457) 0.541 Asian 0.0531 (0.0258- 0.0805) <0.001 Black 0.0171 (0.0082- 0.0260) <0.001 Native Hawaiian/Pacific Islander -0.0075 (-0.1109- 0.0959) 0.887 Multiple Race -0.0474 (-0.0781- -0.0168) 0.002 Refuse to answer 0.0904 (0.0212- 0.1596) 0.010 No information 0.0575 (0.0283- 0.0866) <0.001 Other 0.0050 (-0.0048- 0.0148) 0.318 Unknown -0.0591 (-0.0837- -0.0346) <0.001 Disease Severity Hepatic Encephalopathy at Baseline 0.0431 (0.0328- 0.0534) <0.001 Ascites at Baseline 0.0638 (0.0551- 0.0724) <0.001

Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic.

We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion. Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables. The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9-10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9-3.6) and telemedicine (β 2.1, 95% CI 1.9-2.4) were associated with a higher PTUDS. Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.

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

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.

The Hepatic Innovation Team Collaborative: A Successful Population-Based Approach to Hepatocellular Carcinoma Surveillance.

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.

Disparities in Hepatocellular Carcinoma Surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.

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

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.

Inadequate Hepatocellular Carcinoma Screening in Patients With Nonalcoholic Steatohepatitis Cirrhosis.

Nonalcoholic steatohepatitis (NASH) is a common cause of liver disease which can progress to cirrhosis and hepatocellular carcinoma (HCC). American Association for the Study of Liver Diseases (AASLD) guidelines recommend abdominal ultrasound, with or without serum alpha-fetoprotein, every 6 months for HCC surveillance in cirrhotic patients. Describe HCC surveillance rates in NASH cirrhosis compared with hepatitis C (HCV) cirrhosis and the impact of surveillance on tumor size, treatment, and mortality. Adults with NASH and HCV cirrhosis diagnosed with HCC from 2009 to 2016 were retrospectively evaluated. Patients were categorized into 3 mutually exclusive disease screening groups based on abdominal imaging with or without serum alpha-fetoprotein testing before HCC diagnosis. In total, 99 patients with NASH cirrhosis and 162 patients with HCV cirrhosis were evaluated. In total, 51.5% of NASH cirrhosis patients and 25.9% of HCV cirrhosis patients had no screening before HCC diagnosis. Patients with HCV cirrhosis were significantly more likely to undergo surveillance compared with patients with NASH cirrhosis (P=0.002). NASH cirrhosis patients who underwent complete screening had smaller tumors compared with those with incomplete screening and no screening (P=0.006). There were no differences in number of tumors at diagnosis or mortality between screening groups in patients with NASH cirrhosis (P=0.281 and 0.468, respectively). There is suboptimal HCC surveillance in NASH and HCV cirrhotic patients, with a greater proportion of patients with NASH cirrhosis not undergoing surveillance. Patients with NASH cirrhosis who had complete surveillance had smaller tumors at diagnosis, but there were no differences in treatment outcomes or mortality.

Low Rates of Retention Into Hepatocellular Carcinoma (HCC) Surveillance Program After Initial HCC Screening.

To evaluate rates and predictors of retention into hepatocellular carcinoma (HCC) surveillance beyond initial screening among underserved cirrhosis patients. Although initial HCC screening among cirrhosis patients remains low, few studies have evaluated retention to HCC surveillance beyond initial screening. We retrospectively evaluated all consecutive adults with cirrhosis from 2014 to 2017 at a single underserved safety net hospital system to determine rates of HCC surveillance at 6 months and at 1 year beyond initial screening. Rates of HCC surveillance was stratified by sex, race/ethnicity, and etiology of liver disease. Multivariate Cox proportional hazards models evaluated predictors of retention into HCC surveillance. Among 235 cirrhosis patients [hepatitis C virus: 35.7%, hepatitis B virus (HBV): 15.7%, alcoholic cirrhosis: 36.2%, nonalcoholic steatohepatitis (NASH): 8.1%], mean age of cirrhosis diagnosis was 54.2±8.9 years. Overall, 74.8% received initial screening within 1 year of cirrhosis diagnosis. Among those who completed initial screening, 47.6% [95% confidence interval (CI), 41.4-54.2) received second surveillance within 1 year. On multivariate analyses, patients with NASH and HBV were significantly more likely to receive second HCC surveillance compared with hepatitis C virus, HBV (hazard ratio, 2.32; 95% CI, 1.18-4.56; P=0.014) and NASH (hazard ratio, 2.49; 95% CI, 1.22-5.11; P=0.012). No sex or race-specific/ethnicity-specific differences in HCC surveillance retention were observed. Although overall rates of initial HCC screening among cirrhosis patients is nearly 75%, retention into continued HCC surveillance is poor, with less than half of patients undergoing subsequent HCC surveillance. Cirrhosis patients with HBV and NASH were more likely to be retained into HCC surveillance.

1045 - Mailed Outreach Invitations and Patient Navigation Significantly Improve Hepatocellular Carcinoma Surveillance Rates in Patients with Cirrhosis: A Randomized Controlled Trial

1045 - Mailed Outreach Invitations and Patient Navigation Significantly Improve Hepatocellular Carcinoma Surveillance Rates in Patients with Cirrhosis: A Randomized Controlled Trial

Hepatocellular Carcinoma Surveillance-Experience from Croatian Referral Centre for Chronic Liver Diseases.

For patients at high-risk of developing hepatocellular carcinoma (HCC), biannual ultrasound surveillance has long been recommended, in order to detect the tumor in the early, potentially curative stages. However, globally reported HCC surveillance rates vary greatly, ranging from as low as 1.7 to as high as 80%. Our aim was to assess the utilization of surveillance with biannual ultrasound in high-risk Croatian patients and to identify the factors that impact the implementation of the recommended protocol. This retrospective study included 145 newly diagnosed HCC patients in the period from January 2010 to September 2015. We identified low-risk and high-risk patients. The latter were further subdivided into the regular biannual ultrasound surveillance group and the non-surveillance group. The groups were compared according to demographic characteristics and BCLC stage at the time of HCC diagnosis. Among 145 patients, 80 patients were classified as high-risk according to EASL criteria. During the relevant period, 28.7% underwent regular surveillance, while 71.25% did not. Younger patients were more likely to undergo surveillance (OR 0.935 CI 0.874-0.999; p=0.05). The patients who underwent regular surveillance had a higher chance of being diagnosed at a curative stage (BCLC 0 or A) (OR 3.701 CI 1.279-10.710; p<0.05).Gender was not a predictor of participation in the regular surveillance protocol. Among the high-risk patients who did not undergo regular surveillance, 56.1% were not aware of the chronic liver disease prior to the HCC diagnosis. HCC surveillance is still underutilized in high-risk Croatian patients despite its obvious benefits possibly due to the untimely diagnosis of the chronic liver disease.

Cirrhosis Patients with Nonalcoholic Steatohepatitis Are Significantly Less Likely to Receive Surveillance for Hepatocellular Carcinoma.

Disparities in receipt of hepatocellular carcinoma (HCC) surveillance contribute to disparities in overall survival outcomes. We aim to evaluate disparities in receipt of routine HCC surveillance among patients with cirrhosis in a large urban safety-net hospital. Consecutive adults (age≥18) with cirrhosis from July 1, 2014, to December 31, 2015, were retrospectively evaluated to determine rates of receiving appropriate HCC surveillance within 6months and 1year after diagnosis of cirrhosis. Rates of HCC surveillance were stratified by sex, race/ethnicity, and liver disease etiology. Multivariate Cox proportional hazards models were utilized to evaluate for predictors of receiving appropriate HCC surveillance. Among 157 cirrhosis patients enrolled [hepatitis C virus (HCV): 29.9%, hepatitis B virus: 13.4%, alcoholic cirrhosis: 44.6%, nonalcoholic steatohepatitis (NASH): 8.9%], mean age of cirrhosis diagnosis was 53.8±9.0years. Among these patients, 49% received (n=77) HCC surveillance within 6months and 78% (n=123) were surveyed within 1year of cirrhosis diagnosis. On multivariate analyses, patients with NASH cirrhosis were significantly less likely to receive HCC surveillance compared with chronic HCV cirrhosis patients (HR 0.44, 95% CI 0.19-0.99, p<0.05). No significant sex-specific or race/ethnicity-specific disparities in receipt of HCC surveillance were observed. Among a diverse safety-net hospital population, sub-optimal HCC surveillance rates were observed: Only 49% of cirrhosis patients received HCC surveillance within 6months, and 78% of cirrhosis patients received HCC surveillance within 1year. Differences in rates of HCC screening by liver disease etiology were observed.

Integrative review: patient and provider factors related to hepatocellular carcinoma surveillance in patients with liver cirrhosis

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and the fifth most prevalent cancer worldwide, with cirrhosis being the main risk factor for the development of HCC. The American Association for Study of Liver Disease (AASLD) recommends surveillance of patients with cirrhosis for HCC using ultrasound (US) of the abdomen every 6 months as a cost-effective intervention to reduce mortality and improve survival. However, it is widely known that surveillance is not consistently completed, and the rates of HCC surveillance are very low. The purpose of this integrative review was to evaluate and summarize the available data related to provider and patient factors that are associated with surveillance and missed surveillance for HCC in patients with cirrhosis of the liver, and to recommend interventions to improve these rates of surveillance and subsequently improving survival in patients with cirrhosis.

Hepatocellular Carcinoma Surveillance Among Patients With Cirrhosis in a Population-based Integrated Health Care Delivery System.

Fewer than 1 in 5 patients with cirrhosis receive hepatocellular carcinoma (HCC) surveillance; however, most studies were performed in select patient populations, which may not be informative of practice patterns in population-based community practices. Further, few reported guideline-concordant consistent surveillance rates. Characterize guideline-concordant HCC surveillance rates and patient-level factors associated with surveillance among a population-based cohort of patients with cirrhosis. We retrospectively characterized HCC surveillance among cirrhosis patients followed between January 2010 and December 2012 at an integrated health care delivery system in Washington state. Consistent surveillance was defined as an ultrasound every 6 months, and inconsistent surveillance was defined as ≥1 ultrasound during the 2-year follow-up period. Univariate and multivariate analyses were conducted to identify correlates of HCC surveillance receipt. Of 1137 patients with cirrhosis, 22 (2%) underwent consistent surveillance, 371 (33%) had inconsistent surveillance, and 744 (65%) received no surveillance during follow-up. Correlates of HCC surveillance receipt in multivariate analysis included Gastroenterology/Hepatology subspecialty care [odds ratio (OR), 1.88; 95% confidence interval (CI), 1.44-2.46], Child Pugh B/C cirrhosis (OR, 1.61; 95% CI, 1.07-2.43), elevated aspartate aminotransferase (OR, 1.63; 95% CI, 1.13-2.35), and etiology of liver disease. Compared with hepatitis C-infected patients, patients with hepatitis B infection were more likely to undergo surveillance (OR, 2.72; 95% CI, 1.28-5.81), whereas patients with alcohol-related cirrhosis (OR, 0.63; 95% CI, 0.42-0.93) and nonalcoholic steatohepatitis (OR, 0.39; 95% CI, 0.28-0.56) were less likely to undergo surveillance. Although one third of patients undergo inconsistent HCC surveillance, <2% of patients receive guideline-concordant biannual HCC surveillance.

Hepatocellular Carcinoma Surveillance Among Cirrhotic Patients With Commercial Health Insurance.

To evaluate hepatocellular carcinoma (HCC) surveillance rates among commercially insured patients, and evaluate factors associated with compliance with surveillance recommendations. Most HCC occurs in patients with cirrhosis. American Association for the Study of Liver Diseases and European Association for the Study of the Liver guidelines each recommend biannual HCC surveillance for cirrhotic patients to diagnose HCC at an early, curable stage. However, compliance with these guidelines in commercially insured patients is unknown. We used the Truven Health Analytics databases from 2006 to 2010, using January 1, 2006 as the anchor date for evaluating outcomes. The primary outcome was continuous surveillance measure, defined as the proportion of time "up-to-date" with surveillance (PTUDS), with the 6-month interval immediately following each ultrasound categorized as "up-to-date." During a median follow-up of 22.9 (interquartile range, 16.3 to 33.9) months among 8916 cirrhotic patients, the mean PTUDS was 0.34 (SD, 0.29), and the median was 0.31 (interquartile range, 0.03 to 0.52). These values increased only modestly with inclusion of serum alpha-fetoprotein testing, contrast-enhanced abdominal computed tomographic scans or magnetic resonance imagings, and/or extension of up-to-date time to 12 months. Being diagnosed by a nongastroenterology provider and increasing age were significantly associated with decreased HCC surveillance (P<0.05), whereas a history of a hepatic decompensation event, presence of any component of the metabolic syndrome, and diagnosis of hepatitis B or hepatitis C were significantly associated with increased surveillance (P<0.05). However, even among patients with the most favorable characteristics, surveillance rates remained low. HCC surveillance rates in commercially insured at-risk patients remain poor despite formalized guidelines, highlighting the need to develop interventions to improve surveillance rates.

Hepatocellular carcinoma surveillance rates in commercially insured patients with noncirrhotic chronic hepatitis B.

American association for the study of liver diseases (AASLD) and European Association for the Study of the Liver (EASL) guidelines recommend biannual hepatocellular carcinoma (HCC) screening for noncirrhotic patients with chronic hepatitis B infection (HBV), yet there are no data estimating surveillance rates or factors associated with surveillance. We performed a retrospective cohort study of US patients using the Truven Health Analytics databases from 2006 to 2010 and identified patients with noncirrhotic chronic HBV. Surveillance patterns were characterized using categorical and continuous outcomes, with the continuous measure of the proportion of time 'up to date' with surveillance (PUTDS), with the 6-month interval following each ultrasound categorized as 'up to date'. During a median follow-up of 26.0 (IQR: 16.2-40.0) months among 4576 noncirrhotic patients with chronic HBV (median age: 44 years, IQR: 36-52), only 306 (6.7%) had complete surveillance (one ultrasound every 6-month interval), 2727 (59.6%) incomplete (≥1 ultrasound) and 1543 (33.7%) none. The mean PUTDS was 0.34 ± 0.29, and the median was 0.32 (IQR: 0.03-0.52). In multinomial logistic regression models, patients diagnosed by a nongastroenterologist were significantly less likely to have complete surveillance (P < 0.001), as were those coinfected with HBV/HIV (P < 0.001). In linear regression models, nongastroenterologist provider, health insurance subtype, HBV/HIV coinfection, rural status and metabolic syndrome were independently associated with decreased surveillance. Patients with HIV had an absolute decrease in the PUTDS of 0.24, while patients in less populated rural areas had an absolute decrease of 0.10. HCC surveillance rates in noncirrhotic patients with chronic HBV in the United States are poor and lower than reported rates of HCC surveillance in cirrhotic patients.

Racial, Social, and Clinical Determinants of Hepatocellular Carcinoma Surveillance

ObjectivesLess than 1 in 5 patients receive hepatocellular carcinoma surveillance; however, most studies were performed in racially and socioeconomically homogenous populations, and few used guideline-based definitions for surveillance. The study objective was to characterize guideline-consistent hepatocellular carcinoma surveillance rates and identify determinants of hepatocellular carcinoma surveillance among a racially and socioeconomically diverse cohort of cirrhotic patients. MethodsWe retrospectively characterized hepatocellular carcinoma surveillance among cirrhotic patients followed between July 2008 and July 2011 at an urban safety-net hospital. Inconsistent surveillance was defined as at least 1 screening ultrasound during the 3-year period, annual surveillance was defined as screening ultrasounds every 12 months, and biannual surveillance was defined as screening ultrasounds every 6 months. Univariate and multivariate analyses were conducted to identify predictors of surveillance. ResultsOf 904 cirrhotic patients, 603 (67%) underwent inconsistent surveillance. Failure to recognize cirrhosis was a significant barrier to surveillance use (P < .001). Inconsistent surveillance was associated with insurance status (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.03-1.98), multiple primary care visits per year (OR, 2.63; 95% CI, 1.86-3.71), multiple hepatology visits per year (OR, 3.75; 95% CI, 2.64-5.33), African American race (OR, 0.61; 95% CI, 0.42-0.99), nonalcoholic steatohepatitis cause (OR, 0.60; 95% CI, 0.37-0.98), and extrahepatic cancer (OR, 0.43; 95% CI, 0.24-0.77). Only 98 (13.4%) of 730 patients underwent annual surveillance, and only 13 (1.7%) of 786 had biannual surveillance. ConclusionsOnly 13% of patients with cirrhosis receive annual surveillance, and less than 2% of patients receive biannual surveillance. There are racial and socioeconomic disparities, with lower rates of hepatocellular carcinoma surveillance among African Americans and underinsured patients.