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

Goldberg, David S.; Taddei, Tamar H.; Serper, Marina; Mehta, Rajni; Dieperink, Eric; Aytaman, Ayse; Baytarian, Michelle; Fox, Rena K.; Hunt, Kristel; Pedrosa, Marcos; Pocha, Christine; Valderrama, Adriana; Kaplan, David E.

doi:10.1002/hep.28765

Cited by 107 publications

(127 citation statements)

References 30 publications

(93 reference statements)

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“…One year after baseline only half of patients had had AFP or US performed taking competing events into account. Ideally, the cumulative incidence should be approaching 100% after 6‐12 months; however, in many clinical, real life settings acceptable surveillance adherence has proven difficult to achieve …”

Section: Discussionsupporting

confidence: 92%

Hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis in Denmark: A nationwide cohort study

Hallager

Ladelund

Kjær

et al. 2017

Journal of Viral Hepatitis

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SummaryCirrhosis in patients with chronic hepatitis C increases the risk of hepatocellular carcinoma (HCC), and surveillance with ultrasound (US) and alpha-fetoprotein (AFP) is recommended. This study aimed to estimate changes in the HCC incidence rate (IR) over time, HCC stage and prognosis, and AFP and US performed in patients with hepatitis C and cirrhosis. Eligible patients were identified in the Danish Database for Hepatitis B and C, and data from national health registries and patient charts were obtained.

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Section: Discussionsupporting

confidence: 92%

Hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis in Denmark: A nationwide cohort study

Hallager

Ladelund

Kjær

et al. 2017

Journal of Viral Hepatitis

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“…QM2: Patients with cirrhosis should receive surveillance for HCC every 6 months with ultrasound (or other liver imaging), with or without alpha‐fetoprotein (AFP). Imaging data were obtained from the radiology database in the CDW and supplemented from the “fee‐basis” database, which contains additional data on studies performed outside of VA facilities that are paid for by VA funds; 95% of fee‐basis claims are processed within 200 days . Imaging adherence was measured over the first 2 years of follow‐up after the cirrhosis diagnosis and assessed as the percentage of time under direct surveillance (PTUDS), as reported .…”

Section: Methodsmentioning

confidence: 99%

“…QM3: Patients with cirrhosis and platelet count <150,000/mm 3 should receive upper GI endoscopy to assess for esophageal varices within 12 months of the initial diagnosis of cirrhosis (excluding patients on nonselective beta blockers). Data for upper endoscopy were obtained from outpatient data and supplemented with fee‐basis data to capture studies performed outside of the VA (using current procedural terminology [CPT] codes 43191‐43232, 43235‐43259) . Procedures for upper endoscopy with stent placement, foreign body extraction, balloon dilation, and guidewire insertion were specifically excluded .…”

Section: Methodsmentioning

confidence: 99%

“…For QM2 (HCC surveillance with abdominal imaging), we used a Cox model with the exposure being PTUDS categorized as a dichotomous variable (≥50% of time under surveillance versus <50%) as the primary exposure. The PTUDS threshold was chosen for ease of measurement and interpretation . For QM4 (postdischarge specialty/primary care access) and QM6 (30‐day and 90‐day rehospitalizations), Cox models were fit with hospital discharge as the unit of analysis.…”

Section: Methodsmentioning

confidence: 99%

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Quality Measures, All‐Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

et al. 2019

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Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis‐related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all‐cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow‐up time was 2.7 years (interquartile range, 1.1‐5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78‐0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90‐0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89‐0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54‐0.60) were associated with lower all‐cause mortality. Readmissions after 30 days (HR, 1.53; 1.46‐1.60) and 90 days (HR, 1.88; 95% CI, 1.54‐1.70) were associated with higher all‐cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

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“…Among patients with known risk factors in the US, less than one-third are up to date with recommended screening guidelines 19–21. Providers, patients, and the American health care system all contribute to failed surveillance programs 22. Among health care providers, patients followed in gastroenterology specialty clinics are more likely to be screened according to guidelines 23.…”

Section: Surveillance Noncompliance Among At-risk Populationsmentioning

confidence: 99%

Hepatocellular carcinoma: early-stage management challenges

Erstad

Tanabe

2017

JHC

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Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.

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

Cited by 107 publications

References 30 publications

Hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis in Denmark: A nationwide cohort study

Hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis in Denmark: A nationwide cohort study

Quality Measures, All‐Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

Hepatocellular carcinoma: early-stage management challenges

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