February 2018

In this Issue: Improving Cancer Care
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Multilevel Intervention to Improve Care for Veterans with Hepatocellular Cancer

Feature Article

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and occurs most often in people with chronic liver diseases (i.e., hepatitis B or hepatitis C infection); the latter is especially prevalent among  Veterans in the VA healthcare system. Appropriate treatment evaluation for patients with HCC requires multidisciplinary input from a team of specialists that is best provided through the tumor board platform. Although tumor boards are common in the VA healthcare system, there is no universal standardized tool to ensure appropriate multidisciplinary evaluation of cancer cases during the tumor board encounter. Moreover, there is no standardized process for implementing the tumor board’s recommendations or conveying information to patients. Therefore, the overall goal of this ongoing HSR&D study (2015-2019) is to develop a multi-level intervention to improve HCC care in three ways:

• Implement standardized tumor board processes to promote appropriate multidisciplinary evaluation;
• Expedite specialist referrals to facilitate timely initiation of treatment; and
• Increase patient engagement in the treatment plan.

As part of this study, investigators are conducting a comprehensive review of VA electronic medical records to identify tumor board process factors associated with appropriate multidisciplinary evaluation. Using these data, they also are examining the impact of tumor board involvement on timely referral and treatment initiation in a national sample of Veterans. In addition, investigators are interviewing focus groups of patients and providers at three VA medical centers (Houston, West Haven, and Philadelphia) to identify barriers and facilitators to timely referral and treatment initiation following tumor board evaluation for Veterans with HCC – and to explore the informational needs of Veterans regarding treatment recommendations. They also will develop and pilot test a tumor board-based multi-level intervention to improve multidisciplinary evaluation, expedite specialist referrals for treatment, and increase patient engagement with the treatment plan.

Findings: Thus far, investigators have reviewed the electronic medical records of 506 Veterans with HCC, whose records had been evaluated by a tumor board. Previous preliminary data indicate that the average number of tumor board meetings per patient is 2.4, and the average number of days from diagnosis to first tumor board meeting is 46.

A focus group of 6 physicians and interviews with 10 patients were conducted at the Houston VAMC, along with a focus group of 7 clinicians at the West Haven, CT VAMC and 3 clinician interviews at the Philadelphia VAMC. Important points for patients included the need to have available treatment options and discussion about their imaging. Suggestions for improving tumor boards included:

• Standardization of images ordered,
• Inclusion of a summative/narrative statement in the tumor board note,
• Content headings for organization, and
• A copy of the patient’s most recent lab results.

Overall findings are expected to lay the groundwork for a large, randomized controlled trial of the proposed intervention in the VA healthcare system.

Impact: This patient-centered intervention is expected to facilitate activation of care, convey transparent tumor board recommendations to patients, increase patient engagement in the treatment plan through the use of My HealtheVet, and improve patient satisfaction.

Principal Investigator: Jessica Davila, PhD, is Chief, Methodology & Statistics Core at HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX.

Publications:

Chhatwal J, Samur S, Kues B, et al. Optimal timing of hepatitis C treatment for patients on the liver transplant waiting list. Hepatology. March 2017; 65(3):777-788. 

Multilevel Intervention to Improve Care for Veterans with Hepatocellular Cancer project abstract