Surveillance for Hepatocellular Carcinoma in a Medicaid Cirrhotic Population

Abstract

Goals To estimate hepatocellular carcinoma surveillance in the Medicaid cirrhotic population. Background Most studies predate 2005 AASLD surveillance recommendations and do not examine the primary target population, cirrhotics. Study For 2006-2007 we identified adults with at least one cirrhosis International Classification of Disease code and 15 months of continuous enrollment in North Carolina Medicaid, recording claims for abdominal ultrasound, computed tomography, magnetic resonance imaging, and alpha-fetoprotein testing. We used multi-variable logistic regression to identify factors independently associated with imaging. Results Five-thousand sixty one subjects (5,061) were identified: mean age 54 years, 54% male, 35% African-American, 56% White. Cirrhosis risk factors were alcohol (59%), hepatitis C (30%), hepatitis B (4%), other (18%), and unknown (24%). Only 26% had at least one imaging test. Just 12% of those not hospitalized or seen in an emergency department had any imaging. Care in an academic facility, younger age, female gender, viral hepatitis, and Medicare co-insurance were positively associated with imaging. Twenty-one percent saw a gastroenterologist which increased the odds of undergoing imaging [Odds Ratio (O.R.) 2.81, 95% Confidence Interval (C.I.) 2.32, 3.41] while primary care visits did not (O.R. 0.94, 95% C.I. 0.76, 1.16). Conclusions Only a quarter of North Carolina Medicaid cirrhotics had abdominal imaging over a 15 month period, and many tests may have occurred without surveillance intent. Gastroenterology visits nearly tripled the odds of imaging, but primary care visits had no effect. Efforts to improve surveillance rates in cirrhotic patients should target primary care and increased access to sub-specialty care.

Suboptimal Surveillance for and Knowledge of Hepatocellular Carcinoma Among Primary Care Providers

“…As expected, hepatologists and gastroenterologists tend to believe in surveillance and are more likely to routinely order it for their cirrhotic patients (5, 7) but only 20-50% of such patients are seen by such subspecialists. (7, 8) Primary care providers (PCPs) see most of the remainder.…”

“…(4-7) Such low rates may be because 20-50% of cirrhosis patients are not seen by gastroenterologists who tend to recommend surveillance more than PCPs. (7, 8) Even after being seen by a gastroenterologist, patients may see their PCP more frequently, especially in remote regions where the distance to a subspecialist is greater. If surveillance is to ever have a sustainable rate over 50%, enlistment of PCP help will probably be necessary.…”

“…(1-3) Nevertheless, surveillance rates remain well below 50% and in some populations as low as 12%. (4-7) Among the many steps needed for surveillance to be accomplished, physician education and incorporation of surveillance into their practice are critical. As expected, hepatologists and gastroenterologists tend to believe in surveillance and are more likely to routinely order it for their cirrhotic patients (5, 7) but only 20-50% of such patients are seen by such subspecialists.…”

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

“…While there have been several studies evaluating HCC surveillance rates in cirrhotic patients in the United States, only a small fraction of these patients had HBV . Furthermore, despite published recommendations for HCC surveillance in patients with chronic noncirrhotic HBV in both the United States and Europe, there has only been a single study of HCC surveillance rates in this population from either the United States or Europe.…”

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

“…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 …”