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

Abstract

AASLD and EASL guidelines recommend biannual hepatocellular carcinoma (HCC) screening for non-cirrhotic 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 U.S. patients using the Truven Health Analytics databases from 2006-2010, and identified patients with non-cirrhotic 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 six-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 4,576 non-cirrhotic patients with chronic HBV (median age: 44 years, IQR: 36-52), only 306 (6.7%) had complete surveillance (one ultrasound every 6-month interval), 2,727 (59.6%) incomplete (≥1 ultrasound), and 1,543 (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 non-gastroenterologist were significantly less likely to have complete surveillance (p<0.001), as were those co-infected with HBV/HIV (p<0.001). In linear regression models, non-gastroenterologist provider, health insurance subtype, HBV/HIV co-infection, 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 non-cirrhotic patients with chronic HBV in the United States are poor, and lower than reported rates of HCC surveillance in cirrhotic patients.

Identifying barriers to hepatocellular carcinoma surveillance in a national sample of patients with cirrhosis

“…The primary outcome was the percentage of time up‐to‐date with surveillance (PTUDS), a previously applied methodology to assess the number and frequency of HCC surveillance tests in patients with cirrhosis . This endpoint was chosen because it accounts for both the number of surveillance tests performed and the timing of such tests during the study period.…”

“…Markov modeling suggests that to achieve outcome improvements in HCC, at least 34% of individuals within a cirrhosis population must undergo surveillance to yield an early‐stage diagnosis rate of at least 42% . However, reported HCC surveillance rates in most observational studies in the United States and Europe do not reach this threshold …”

“…Uniquely, discrete information regarding radiology test orders, scheduling, and test completion can be examined. Using these data, we first applied a recently developed, continuous measurement of surveillance adherence to quantify HCC surveillance; second, we evaluated factors leading to insufficient test ordering and completion; and third, we used geocoding to assess the association of geography and adherence with HCC surveillance guidelines …”

Care delivery and outcomes among US veterans with hepatitis B: A national cohort study

“…(5,24) In these two subgroups, we calculated the proportion of total follow-up time during which patients were adherent to annual or biannual screening intervals with appropriate liver imaging (ultrasound, contrast-enhanced computed tomography, or magnetic resonance imaging) using a similar method to Goldberg et al in which adherence is measured as a continuous variable. (25) A grace period of 30 days was accounted for in adherence calculations. Outpatient pharmacy data were used to determine whether patients were prescribed antiviral therapy with oral nucleoside analogues such as lamivudine, adefovir, telbivudine, entecavir, or tenofovir.…”

Quality of care metrics in chronic hepatitis B

“…Over the past 10 years, screening and treatment of HCV in the VA health care system have received a great deal of attention, while little, if any, focus has been directed to the diagnosis and management of chronic HBV despite the high hepatitis B surface antigen seroprevalence among veterans. Other studies have evaluated care delivery and outcomes for civilian segments of the US population with chronic HBV using large administrative claims data sets or manual review of individual patient records (Table ) . Regardless of the research methodology employed, these retrospective studies have consistently found that rates of antiviral therapy and HCC surveillance are suboptimal and that specialty care is associated with a greater likelihood of receiving recommended care.…”