Quality Improvement Measures Lead to Higher Surveillance Rates for Hepatocellular Carcinoma in Patients with Cirrhosis

Aberra, Fasika; Essenmacher, Mary; Fisher, Natalie C.; Volk, Michael L.

doi:10.1007/s10620-012-2461-4

Cited by 52 publications

(36 citation statements)

References 12 publications

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“…43 Prior studies confirm these reported interventional study results though others have not had as much success highlighting the need for more research into the complex and dynamic concept of adherence. 34,35,[44][45][46] This study has several limitations. There was very large heterogeneity among included studies.…”

Section: Discussionmentioning

confidence: 96%

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta‐analysis of a complex issue

Zhao

Jin

et al. 2017

Liver International

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Section: Discussionmentioning

confidence: 96%

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta‐analysis of a complex issue

Zhao

Jin

et al. 2017

Liver International

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“…Our study builds upon our prior results demonstrating the benefits of a structured surveillance program. (23) Our program using electronic medical record reminders achieved consistent HCC surveillance every 6 months in 46% of enrolled cirrhosis patients over a median of 2.2 years. Furthermore, most patients without consistent surveillance only missed 1 or 2 surveillance examinations.…”

Section: Discussionmentioning

confidence: 99%

Frequency and Outcomes of Abnormal Imaging in Patients With Cirrhosis Enrolled in a Hepatocellular Carcinoma Surveillance Program

et al. 2019

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There are limited data on the downstream effects of hepatocellular carcinoma (HCC) surveillance, including the frequency of false-positive results. We aimed to quantify the incidence of indeterminate nodules (INs) and the follow-up testing needed to resolve these findings among patients enrolled in a structured HCC surveillance program. We retrospectively analyzed adult patients with cirrhosis enrolled in a structured HCC surveillance program in a large tertiary care center. Outcomes included surveillance benefits, defined as early HCC detection, and harm, defined as INs prompting additional diagnostic evaluation. Among 999 patients followed for a median of 2.2 years, HCC surveillance imaging was consistently completed every 6, 9, and 12 months in 46%, 51%, and 68% of patients, respectively. Of 256 (25.6%) patients with abnormal imaging, 69 (27.0%) were diagnosed with HCC and 187 (73.0%) with INs. Most HCC (n = 54, 78.3%) were found within Milan criteria. Among those with an IN, 78.1% returned to ultrasound surveillance after a median of 2 (interquartile range [IQR], 1-3) negative computed tomography (CT)/magnetic resonance imaging (MRI) scans, and 21.9% continued CT/MRI imaging (median, 1; IQR, 1-2). Eleven patients underwent diagnostic liver biopsy. Hypoalbuminemia, thrombocytopenia, and larger nodule size were independently associated with HCC diagnosis. In conclusion, 1 in 4 patients enrolled in an HCC surveillance program had abnormal surveillance imaging, but three-fourths of the lesions were INs, resulting in downstream harm. Improved risk-stratification tools are needed to identify nodules that are benign to reduce follow-up diagnostic evaluation.

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“…Two studies assessing chronic disease management programs, including nursing-based protocols and automated reminders, demonstrated increased one-time HCC screening rates from 74% and 89% at baseline to 93% and 100%, respectively. 27, 28 However, both studies were conducted among patients followed by hepatologists and required patient consent, introducing a selection bias. In a subsequent quasi-experimental study, point-of-care clinical reminders targeting primary care providers increased screening rates from 18.2% to 27.6% (p<0.001); 29 however, intervention benefit was limited to patients with documented cirrhosis and those engaged in clinic.…”

Section: Discussionmentioning

confidence: 99%

Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma

et al. 2017

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Background & Aims Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort. Methods We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were randomly assigned (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n=600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n=600), or usual care (visit-based screening; n=600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization. Results Baseline characteristics were similar among groups. Cirrhosis was documented, based on ICD-9 codes, for 79.6% of patients and suspected, based on non-invasive markers of fibrosis, for 20.4%. In an intent to treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P<0.001 for both comparisons). However, screening rates did not significantly differ between outreach the outreach groups (P=0.25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs. non-Caucasian race, documented vs. suspected cirrhosis, Child Pugh A vs. B cirrhosis, and receipt of gastroenterology care. Conclusions In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817

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Quality Improvement Measures Lead to Higher Surveillance Rates for Hepatocellular Carcinoma in Patients with Cirrhosis

Abstract: Implementation of QI measures incorporating automatic reminders of surveillance status for providers can significantly increase the rate of HCC surveillance among cirrhosis patients.

Cited by 52 publications

References 12 publications

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta‐analysis of a complex issue

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta‐analysis of a complex issue

Frequency and Outcomes of Abnormal Imaging in Patients With Cirrhosis Enrolled in a Hepatocellular Carcinoma Surveillance Program

Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma

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