Strategies to Improve Hepatocellular Carcinoma Surveillance in Veterans With Hepatitis B Infection

Providers may not have obtained a screening ultrasound if another type of abdominal imaging (eg, computed tomography [CT] or magnetic resonance imaging [MRI]) had been performed for a separate indication and could be reviewed to evaluate for possible HCC. Therefore, the annual number of all abdominal imaging tests, including ultrasound, CT, and MRI, also was determined. Adherence, in this case defined as having ≥ 1 abdominal imaging test per year, was evaluated as a secondary endpoint.

To evaluate whether providers were recommending HCC screening, CPRS records were reviewed using the following search terms: “HCC,” “ultrasound,”
“u/s,” “hepatitis B,” and “HBV.” Patients whose CPRS records did not document their HBV infection status or mention HCC screening were identified.

HCC Diagnoses

Incident HCC diagnoses were identified during the study period, and the diagnostic evaluation was further characterized. An HCC diagnosis was considered definite if the study participant had an ICD-9 code recorded for HCC (ICD-9 155.0) or histologic diagnosis of HCC by liver biopsy. The use of an ICD-9 code for HCC diagnosis had been validated previously in a retrospective chart review of VA data.²² An HCC diagnosis was considered possible if the participant did not meet the aforementioned definition but had radiographic and clinical findings suggestive of HCC.

Statistical Analyses

Differences in the demographic and clinical characteristics of patients with HBV infection seen by primary care, GI, and ID providers were assessed using chi-square or Fisher exact tests for categoric data and analysis of variance or Kruskal-Wallis tests, as appropriate, for continuous data. The
proportion and 95% confidence interval (CI) of patients with adherence to HCC screening guidelines were determined by provider type. Differences in outcomes by provider group were evaluated using chi-square tests. The proportions of patients whose CPRS records did not mention their HBV infection status or address HCC screening were determined. Last, HCC incidence (diagnoses/person-years) was determined by dividing the number of definite or possible HCC cases by the total follow-up time in person-years among those with and without cirrhosis (defined earlier) as well as in those who met criteria for HCC surveillance.

For the qualitative work, all focus group discussions were recorded, and transcripts were reviewed by 3 members of the study team to categorize responses into themes, using an iterative process. Discrepancies in coding of themes were resolved by mutual agreement among the reviewers. Analysis focused on highlighting the similarities and differences among the different specialties and identifying strategies to improve provider adherence to HCC screening guidelines.

Results

Among 215 patients with a positive HBsAg test between September 1, 2003 and August 31, 2008, 14 patients were excluded because they had either a negative HBsAg test on follow-up without antiviral treatment or were not retained in care. The final study population included 201 patients with a median follow-up of 7.5 years. Forty (20%) had their HBV infection managed by primary care, while 114 (57%) had GI, and 47 (23%) had ID providers. There were 15 patients who had no documentation in the CPRS of being chronically infected with HBV despite having a positive HBsAg test during the study period.

Patients with HBV infection seen by the different provider groups were fairly similar with respect to sex, race, and some medical comorbidities (Table 1). All but 1 of the patients co-infected with HIV/HBV was seen by ID providers and were younger and more likely to receive anti-HBV therapy than were patients who were HBV mono-infected. Patients with cirrhosis or other risk factors that placed them at increased risk for HCC were more likely to be followed by GI providers.

According to AASLD recommendations, 99/201 (49.3%) of the cohort qualified for HCC screening (Figure 1). Overall adherence to HCC screening was low, with only 15/99 (15%) having ≥ 1 annual abdomen ultrasound. Twenty-seven patients (27%) had ≥ 1 type of abdominal imaging test (including ultrasound, CT, and MRI scans) performed annually. Although primary care HCPs had lower adherence rates compared with that of the other provider groups, these differences were not statistically significant (P > .1 for all comparisons).

During the study period, 5 definite and 3 possible HCC cases were identified (Table 2). Routine screening for HCC led to 5 diagnoses, and the remaining 3 cases were identified during a workup for abnormal examination findings or another suspected malignancy. Among the 8 patients with a definite or a possible diagnosis, 5 were managed by GI providers and 6 had cirrhosis by the time of HCC diagnosis. All but 2 of these patients died during the study period from HCC or related complications. Incidence of HCC was 2.8 and 0.45 cases per 100 person-years in those with and without cirrhosis, respectively. Among those meeting criteria for HCC surveillance, the incidence of HCC was 0.88 cases per 100 person-years overall.

Barriers to Guideline Adherence

Nineteen providers participated in the focus group discussions (9 primary care, 5 GI, and 5 ID). Physicians and nurse practitioners (n = 18; 95%) comprised the majority of participants. Health care providers had varying years of clinical experience at the CMCVAMC, ranging from < 1 year to > 20 years.