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Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality.

ABSTRACT: Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival.We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival.In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60-2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15-2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98-1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16-0.31), liver resection (HR, 0.38; 95% CI, 0.28-0.52), ablative therapy (HR, 0.63; 95% CI, 0.52-0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74-0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63-0.78), medical oncologists (HR, 0.82; 95% CI, 0.74-0.91), or surgeons (HR, 0.79; 95% CI, 0.71-0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77-0.90), were associated with reduced mortality.In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.

SUBMITTER: Serper M

PROVIDER: S-EPMC5664153 | biostudies-literature | 2017 Jun

REPOSITORIES: biostudies-literature

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Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality.

Serper Marina M Taddei Tamar H TH Mehta Rajni R D'Addeo Kathryn K Dai Feng F Aytaman Ayse A Baytarian Michelle M Fox Rena R Hunt Kristel K Goldberg David S DS Valderrama Adriana A Kaplan David E DE

Gastroenterology 20170307 8

<h4>Background & aims</h4>Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival.<h4>Methods</h4>We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through Decembe ...[more]

PMID: 28283421

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Project description:BACKGROUND & AIMS:Low rates of hepatocellular carcinoma (HCC) surveillance are primarily due to provider-related process failures. However, few studies have evaluated primary care provider (PCP) practice patterns, attitudes, and barriers to HCC surveillance at academic tertiary care referral centers. METHODS:We conducted a web-based survey of PCPs at 2 tertiary care referral centers (133 providers) from June 2017 through December 2017. The survey was adapted from pretested surveys and included questions about practice patterns, attitudes, and barriers to HCC surveillance. We used the Fisher exact and Mann-Whitney rank-sum tests to identify factors associated with adherence to HCC surveillance recommendations, for categoric and continuous variables, respectively. RESULTS:We obtained a provider-level response rate of 75% and clinic-level response rate of 100% (133 providers). Whereas most PCPs performed HCC surveillance themselves, one-third deferred surveillance to subspecialists and referred patients to a hepatology clinic. Providers believed the combination of ultrasound and ?-fetoprotein analysis to be highly effective for early stage tumor detection and reported using the combination for assessment of most patients. However, PCPs were more likely to use computed tomography- or magnetic resonance imaging-based surveillance for patients with nonalcoholic steatohepatitis or decompensated cirrhosis. Most providers believed HCC surveillance to be efficacious for early tumor detection and increasing survival. However, they desired increased high-quality evidence to characterize screening benefits and harms. Providers expressed notable misconceptions about HCC surveillance, including the role for measurement of liver enzyme levels in HCC surveillance and cost effectiveness of surveillance in patients without cirrhosis. They also reported barriers, including not being up to date on HCC surveillance recommendations, limited time in the clinic, and competing clinical concerns. CONCLUSIONS:In a web-based survey, PCPs reported misconceptions and barriers to HCC surveillance. This indicates the need for interventions, including provider education, to improve HCC surveillance effectiveness in clinical practice.

Project description:BACKGROUND:More information is needed about the long-term effects of low-dose aspirin (?160 mg) on incident hepatocellular carcinoma, liver-related mortality, and gastrointestinal bleeding in persons with chronic hepatitis B or hepatitis C virus infection. METHODS:Using nationwide Swedish registries, we identified all adults who received a diagnosis of chronic hepatitis B or hepatitis C from 2005 through 2015 and who did not have a history of aspirin use (50,275 patients). Patients who were starting to take low-dose aspirin (14,205 patients) were identified by their first filled prescriptions for 90 or more consecutive doses of aspirin. We constructed a propensity score and applied inverse probability of treatment weighting to balance baseline characteristics between groups. Using Cox proportional-hazards regression modeling, we estimated the risk of hepatocellular carcinoma and liver-related mortality, accounting for competing events. RESULTS:With a median of 7.9 years of follow-up, the estimated cumulative incidence of hepatocellular carcinoma was 4.0% among aspirin users and 8.3% among nonusers of aspirin (difference, -4.3 percentage points; 95% confidence interval [CI], -5.0 to -3.6; adjusted hazard ratio, 0.69; 95% CI, 0.62 to 0.76). This inverse association appeared to be duration-dependent; as compared with short-term use (3 months to <1 year), the adjusted hazard ratios were 0.90 (95% CI, 0.76 to 1.06) for 1 to less than 3 years of use, 0.66 (95% CI, 0.56 to 0.78) for 3 to less than 5 years of use, and 0.57 (95% CI, 0.42 to 0.70) for 5 or more years of use. Ten-year liver-related mortality was 11.0% among aspirin users and 17.9% among nonusers (difference, -6.9 percentage points [95% CI, -8.1 to -5.7]; adjusted hazard ratio, 0.73 [95% CI, 0.67 to 0.81]). However, the 10-year risk of gastrointestinal bleeding did not differ significantly between users and nonusers of aspirin (7.8% and 6.9%, respectively; difference, 0.9 percentage points; 95% CI, -0.6 to 2.4). CONCLUSIONS:In a nationwide study of patients with chronic viral hepatitis in Sweden, use of low-dose aspirin was associated with a significantly lower risk of hepatocellular carcinoma and lower liver-related mortality than no use of aspirin, without a significantly higher risk of gastrointestinal bleeding. (Funded by the National Institutes of Health and others.).

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Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality.

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Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality.

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