Effect of rural residence on surveillance for hepatocellular carcinoma in VA primary care patients with cirrhosis

Villalvazo Y, Vaughan-Sarrazin MS, Rajesh H, Katz DA. Effect of rural residence on surveillance for hepatocellular carcinoma in VA primary care patients with cirrhosis. Poster session presented at: Digestive Disease Week Annual Conference; 2015 May 16; Washington, DC.

BACKGROUND: Hepatocellular Carcinoma (HCC), a known complication of cirrhosis of the liver and non-cirrhotic Hepatitis B, is the 3rd leading cause of cancer-related mortality worldwide. In the US, the rate of increase of HCC detection lags behind that of Hepatitis C (HCV), alcoholic hepatitis, and nonalcoholic fatty liver disease, the leading causes of cirrhosis. Despite published guidelines, HCC surveillance is highly variable in patients with cirrhosis (18-64 /o). In one study of US Veterans, only 45 /o of those with cirrhosis secondary to Hepatitis C received HCC surveillance within the first year after diagnosis and only 12 /o received ongoing surveillance. Previous studies have attributed lapses in HCC survemance to provider factors such as under recognition of cirrhosis and lack of knowledge of HCC guidelines, and patient factors such as lack of healthcare engagement, nonadherence, and racial and socioeconomic disparities. Little is known about the association between geographic accessibility and HCC surveillance in US veterans. OBJECTIVE: The purpose of this study is to evaluate hepatocellular carcinoma cancer (HCC) surveillance patterns among veterans as a function of geographic access to their assigned primary care provider (PCP) and VA medical center. METHODS: We conducted a retrospective cohort study using administrative data to identify veteran patients with an assigned primary care provider (PCP) who were initially diagnosed with cirrhosis (ICD-9 codes 571.2, 571.5, and 571.6) between October 1, 2005-June 30, 2012. Initial HCC surveillance was defined as having received alpha-fetoprotein testing plus an abdominal ultrasound, CT scan, or MRI (CPT codes 76700, 76705, 74170, 74181- 74183) within 6 months of the initial diagnosis of cirrhosis (index date). Geocoded address/zip code data were used to estimate travel distance, and patients' residences were categorized as urban versus rural. RESULTS: Of the 61,053 veterans who were diagnosed with cirrhosis, 34 and 10 /o received surveillance for HCC within 6 months and between 6 and 12 months following the index date, respectively. Among those who were screened within 6 months, the median time from cirrhosis diagnosis to a screening test was 42 days (IQR: 14-98 days). 64 /o had an ultrasound, 25 /o had a CT scan, and 10 /o had a MRI. Furthermore, 80 /o had an alphafetoprotein test performed; the median time from the index data to alphafetoprotein testing was 53 days (IQR: 0-164 days). Compared to those who were not screened, patients who were screened were more likely to have seen their PCP before the diagnosis of cirrhosis (85 /o vs. 75 /o; P < 0.001) and were more likely to reside in an urban area (77 /o vs. 72 /o; P < 0.001). CONCLUSIONS: HCC surveillance is low among veteran patients. Patients who were actively seeing their PCP prior to their diagnosis of cirrhosis were more likely to be screened for HCC and reside in an urban geographical area. Further efforts should focus on identifying appropriate intervention targets to increase HCC surveillance such as including recognition of cirrhosis and selection of cirrhotic patients at high risk for HCC, reducing geographic barriers to screening through coordination of primary and specialty care, and teleradiology.