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Clinical research study
Racial, Social, and Clinical Determinants of Hepatocellular Carcinoma Surveillance

https://doi.org/10.1016/j.amjmed.2014.07.027Get rights and content

Abstract

Objectives

Less 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.

Methods

We 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.

Results

Of 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.

Conclusions

Only 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.

Section snippets

Study Population

We conducted a retrospective cohort study of cirrhotic patients followed at Parkland Health and Hospital System, the safety-net system for Dallas County. Parkland is an integrated system with 11 primary care provider clinics in low-income neighborhoods, a multidisciplinary hepatology outpatient clinic, and a tertiary hospital—all sharing 1 electronic medical record system. Parkland provides inpatient and outpatient care for most cirrhotic patients and approximately 50% of hepatocellular

Patient Characteristics

We identified 904 patients with cirrhosis who met inclusion criteria. The median age of patients was 54.8 years (range, 21.0-84.2), and 592 (65%) were men. Our population was racially diverse; 22% were African Americans, 36% were non-Hispanic Caucasians, and 40% were Hispanic Caucasians. Approximately 43% of patients were uninsured/underinsured, 53% of patients had Medicare or Medicaid, and only 4% of patients had private health insurance. The most common causes of cirrhosis were hepatitis C

Discussion

Although a meta-analysis found that less than 20% of patients in the United States undergo hepatocellular carcinoma surveillance,11 the estimate was limited by heterogeneity of operational definitions for surveillance. Clear consistent definitions and measures are necessary to interpret and quantify hepatocellular carcinoma surveillance rates.21 To the best of our knowledge, our study is the first to report guideline-adherent surveillance rates in a large cohort, with approximately 1000

Conclusions

We believe this is the first study to report guideline-consistent surveillance rates among a large cohort of racially and socioeconomically diverse patients. We found only 13% of patients had annual surveillance and only 1.7% had consistent biannual surveillance. Furthermore, we found racial and socioeconomic disparities in receipt of inconsistent surveillance, with significantly lower rates among African Americans and underinsured patients. Studies are needed to explore the reasons for

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    Funding: Research reported in this publication was conducted with support from the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers KL2TR001103 and UL1TR001105, the ACG Junior Faculty Development Award, and the American Cancer Society and Simmons Cancer Center Grant ACS-IRG-02-196 awarded to AGS. The content is solely the responsibility of the authors and does not necessarily represent the official views of UT Southwestern Medical Center and its affiliated health care centers or the NIH.

    Conflict of Interest: None.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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