Cirrhosis patients who received outreach interventions were much more likely to meet the primary care endpoint than those who received usual care.
Dr. Amit G. Singal, hepatologist and associate professor of medicine at the University of Texas Southwestern Medical Center, and colleagues compared the clinical effectiveness of intervention strategies aimed at increasing one-time hepatocellular carcinoma (HCC) screening rates.
Hepatocellular carcinoma is the second leading cause of cancer-related deaths worldwide.
While HCC surveillance using ultrasound every 6 months is associated with early tumor detection and improved survival, its effectiveness is hampered by underuse. In fact, fewer than 20% of patients with cirrhosis undergo HCC surveillance in clinical practice.
Until the present study, there have been no randomized studies assessing interventions aimed at improving HCC surveillance rates.
Patients in outreach arm more likely to meet primary care endpoint
Dr. Singal and his co-workers randomized about 900 patients with documented or suspected cirrhosis to one of three strategies: usual care with opportunistic, visit-based screening by clinic providers, mailed surveillance outreach for ultrasonography, or mailed surveillance outreach plus patient navigation.
Documented cirrhosis was defined using International Classification of Diseases (ICD) codes for cirrhosis or cirrhosis-related complications. Suspected cirrhosis was defined as an AST to platelet ratio index greater than 1.5 in the presence of underlying liver disease.
The study excluded patients with Child C cirrhosis who were not transplant candidates, as well as patients with significant comorbidities given the limited benefit of HCC surveillance in these populations.
Patients who did not respond to outreach invitations within 2 weeks received up to three reminder telephone calls.
The primary outcome measure was the completion of an abdominal ultrasound for surveillance purposes within 6 months of randomization.
Interim results showed that 16.1% of patients in the usual care arm met the primary endpoint, compared with 34.3% of patients in the outreach arm and 37.3% of patients in the outreach plus navigation arm.
Patients with documented cirrhosis were significantly more likely to schedule an ultrasound than those with suspected cirrhosis.
Dr. Singal, who is also the medical director of the Parkland Liver Tumor Clinic in Dallas, TX, says that future research will include a comparison of the effectiveness of HCC surveillance outreach and patient navigation for promoting repeat surveillance ultrasound completion.