title: Quality improvement measures lead to higher surveillance rates for hepatocellular carcinoma in patients with cirrhosis.
abstract: BACKGROUND
  Cirrhosis is a major risk factor associated with the development of hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends surveillance for HCC in cirrhosis patients with ultrasound every six months. However, various studies suggest that surveillance rates in actual practice are quite low.
  
  
  OBJECTIVE
  The aims of this study were to evaluate the effectiveness of implementing quality improvement (QI) measures in increasing the rate of HCC surveillance among patients in a tertiary care facility.
  
  
  METHODS
  Patients with cirrhosis were prospectively enrolled into a chronic disease management program, which integrates nursing-based protocols with automatic reminders when patients are due for surveillance. Patients enrolled in this program between March 2010 and April 2011 were compared to a prior cohort in 2008-2009. The primary endpoint was the receipt of at least one abdominal imaging study performed for the purposes of surveillance during the study period.
  
  
  RESULTS
  Of the 355 patients enrolled, 331 (93 %) had imaging performed for HCC surveillance, compared to 119/160 (74 %) patients in the previous cohort (p < 0.001). Chart review revealed the most common reasons for failure to undergo surveillance were patients' lack of insurance and lack of follow-up on studies ordered at outside institutions. Six patients were diagnosed with HCC during the study period, of which three were at early stage.
  
  
  CONCLUSIONS
  Implementation of QI measures incorporating automatic reminders of surveillance status for providers can significantly increase the rate of HCC surveillance among cirrhosis patients.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA. faberra@gmail.com
authors.forename: Fasika B
authors.initials: FB
authors.lastname: Aberra
authors.forename: Mary
authors.initials: M
authors.lastname: Essenmacher
authors.forename: Natalie
authors.initials: N
authors.lastname: Fisher
authors.forename: Michael L
authors.initials: ML
authors.lastname: Volk
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000209:etiology; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D011159:Population Surveillance; D058996:Quality Improvement; D055815:Young Adult