Hepatocellular carcinoma surveillance among Hepatitis C virus-infected patients with cirrhosis in Veterans Affairs

Dr Jessica Davila and Missouri, USA examined the prevalence and determinants of hepatocellular carcinoma surveillance among Hepatitis C virus-infected patients with cirrhosis in Veterans Affairs (VA) health care facilities in the United States.

The research team performed a retrospective cohort study of 128 HCV-infected patients using data obtained from the national VA Hepatitis C Clinical Case Registry.

Hepatitis C virus-infected patients with cirrhosis diagnosed between fiscal years 1998 and 2005.
Abdominal ultrasonography and measurement of α-fetoprotein for hepatocellular carcinoma surveillance were identified from administrative data by using a previously validated algorithm.
Patients were categorized as having routine (tests done during at least 2 consecutive years in the 4 years after cirrhosis diagnosis), inconsistent (at least 1 test, but not routine), or no surveillance in the 4 years after cirrhosis diagnosis.

Predictors of surveillance were identified by using hierarchical random-effects regression.
The research team identified 126,670 patients with Hepatitis C, of which 10% had cirrhosis.
Approximately 42% of patients with cirrhosis received 1 or more hepatocellular carcinoma surveillance tests within the first year after the cirrhosis index date.

However, a decline in receipt of surveillance was observed in the following 2 to 4 years.
The researchers observed that among patients with cirrhosis and at least 2 years of follow-up, routine surveillance occurred in 12%, inconsistent surveillance in 59%, and no surveillance in 30%.

Lower medical and psychological comorbid conditions, presence of varices, and the absence of decompensated liver disease were associated with a higher likelihood of receiving routine surveillance.

Dr Davila's team concludes, "Few Hepatitis C virus-infected veterans with cirrhosis received routine hepatocellular carcinoma surveillance."
"New strategies are needed to improve the implementation of hepatocellular carcinoma surveillance in clinical practice."

http://www.gastrohep.com/news/news.asp?id=107800


Utilization of Surveillance for Hepatocellular Carcinoma Among Hepatitis C Virus–Infected Veterans in the United States

Ann Int Med 2011: 154(2): 85-93

Jessica A. Davila, PhD; Louise Henderson, PhD; Jennifer R. Kramer, PhD; Fasiha Kanwal, MD, MSHS; Peter A. Richardson, PhD; Zhigang Duan, MD, MS; and Hashem B. El-Serag, MD, MPH
+ Author Affiliations

From the Houston Center for Quality of Care and Utilization Studies, The Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas; University of North Carolina, Chapel Hill, North Carolina; and St. Louis University School of Medicine, St. Louis, Missouri.

Abstract
Background: Surveillance for hepatocellular carcinoma (HCC) is recommended for patients with hepatitis C virus (HCV) infection and cirrhosis. However, whether surveillance is being done as recommended is unknown.

Objective: To examine the prevalence and determinants of HCC surveillance among HCV-infected patients with cirrhosis in Veterans Affairs (VA) health care facilities in the United States.

Design: Retrospective cohort study of HCV-infected patients using data obtained from the national VA Hepatitis C Clinical Case Registry.

Setting: 128 VA medical centers.

Patients: HCV-infected patients with cirrhosis diagnosed between fiscal years 1998 and 2005.

Measurements: Abdominal ultrasonography and measurement of α-fetoprotein for HCC surveillance were identified from administrative data by using a previously validated algorithm. Patients were categorized as having routine (tests done during at least 2 consecutive years in the 4 years after cirrhosis diagnosis), inconsistent (at least 1 test, but not routine), or no surveillance in the 4 years after cirrhosis diagnosis. Predictors of surveillance were identified by using hierarchical random-effects regression.

Results: 126 670 patients with HCV were identified; 13 002 (10.1%) had cirrhosis. Approximately 42.0% of patients with cirrhosis received 1 or more HCC surveillance tests within the first year after the cirrhosis index date; however, a decline in receipt of surveillance was observed in the following 2 to 4 years. Among patients with cirrhosis and at least 2 years of follow-up, routine surveillance occurred in 12.0%, inconsistent surveillance in 58.5%, and no surveillance in 29.5%. Lower medical and psychological comorbid conditions, presence of varices, and the absence of decompensated liver disease were associated with a higher likelihood of receiving routine surveillance.

Limitations: Hepatocellular carcinoma surveillance tests were indirectly identified from registry data. Physician recommendations could not be captured.

Conclusion: Few HCV-infected veterans with cirrhosis received routine HCC surveillance. New strategies are needed to improve the implementation of HCC surveillance in clinical practice.

Primary Funding Source: Houston Veterans Affairs Health Services Research and Development Center of Excellence and the National Cancer Institute.
http://www.annals.org/content/154/2/85.abstract?sid=63da8830-db6f-4f15-8c30-c8e5140d3265