General Internal Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of General Internal Medicine, University of Washington, Seattle, WA.
Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington, Seattle, WA.
Clin Gastroenterol Hepatol. 2015 Jan;13(1):172-9. doi: 10.1016/j.cgh.2014.04.033. Epub 2014 May 6.
BACKGROUND & AIMS: Surveillance of patients with cirrhosis for hepatocellular carcinoma (HCC) with liver ultrasound every 6 months has been linked to longer survival and greater use of definitive treatment. However, less than 20% of patients typically undergo routine surveillance.
We conducted a quasi-experimental study to assess whether a primary care-oriented, point-of-care clinical reminder improves HCC surveillance. Our study included patients with cirrhosis who made 1 or more primary care visits to 8 Veterans Affairs (VA) facilities over 18 months. Clinicians at 1 facility were sent a reminder to perform liver ultrasound assessments for patients with cirrhosis who had not received surveillance in the preceding 6 months. Outcomes included the proportion of patients receiving adequate HCC surveillance (defined as >2 instances of liver imaging >6 months apart) and HCC diagnosis and stage. Because it was a quality improvement project, this study did not require approval by an institutional review board under Federal law and VA policy.
Baseline rates of adequate HCC surveillance were similar at all facilities (18.2% at the intervention site vs 16.1% elsewhere; P = .23). After the reminder was implemented, adequate surveillance at the intervention site (for 790 patients) increased by 51%, but was unchanged at the other facilities (for 2094 patients) (27.6% vs 17.5%; P < .001). Adequate surveillance occurred more often at the intervention site (adjusted odds ratio, 1.29; 95% confidence interval, 1.03-1.61; P = .02). A higher crude percentage of patients was diagnosed with HCC at the intervention site than elsewhere (3.2% vs 1.9%; P = .03). We detected no difference in tumor stage at diagnosis.
In a VA population, a clinical reminder system increased HCC surveillance in patients with cirrhosis.
对肝硬化患者每 6 个月进行肝脏超声检查以监测肝细胞癌 (HCC) ，与延长生存期和增加确定性治疗的应用有关。然而，通常只有不到 20%的患者接受常规监测。
我们进行了一项准实验研究，以评估以初级保健为导向的即时临床提醒是否能改善 HCC 监测。我们的研究纳入了在 18 个月内到退伍军人事务部 (VA) 8 个设施就诊 1 次或多次的肝硬化患者。在 1 个设施中，向未在前 6 个月内接受监测的肝硬化患者发送进行肝脏超声评估的提醒。结局包括接受充分 HCC 监测的患者比例（定义为＞2 次＞6 个月的肝脏影像学检查）和 HCC 诊断和分期。由于这是一项质量改进项目，根据联邦法律和 VA 政策，本研究无需机构审查委员会批准。
所有设施的基线 HCC 监测充分率相似（干预点为 18.2%，其他地点为 16.1%；P =.23）。在实施提醒后，干预点的充分监测（对 790 例患者）增加了 51%，而其他设施（对 2094 例患者）则无变化（17.5% vs 27.6%；P <.001）。干预点更常进行充分监测（调整后的优势比，1.29；95%置信区间，1.03-1.61；P =.02）。干预点诊断为 HCC 的患者比例高于其他地点（3.2% vs 1.9%；P =.03）。我们未发现诊断时肿瘤分期的差异。
在 VA 人群中，临床提醒系统增加了肝硬化患者的 HCC 监测。
