Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States.

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.