title: Optimisation of hepatocellular carcinoma surveillance in patients with viral hepatitis: a quality improvement study.
abstract: BACKGROUND
  Surveillance for hepatocellular carcinoma (HCC) with 6-monthly ultrasound is a standard of care for higher-risk patients with viral hepatitis. Adherence to screening guidelines is an important quality indicator in hepatology, but multiple studies have demonstrated poor HCC surveillance practices in real-world settings.
  
  
  OBJECTIVE
  The aim of this project was to audit and then optimise HCC surveillance of viral hepatitis patients, who fulfilled criteria for screening, associated with a large tertiary hospital.
  
  
  METHODS
  Clinical practice improvement principles were utilised. A baseline audit of 22 consecutive viral hepatitis patients was performed. Major barriers preventing adequate surveillance were identified and three interventions to improve adherence to guidelines were introduced. These included: improved doctor education, system redesign and improved patient education. The effects of interventions were measured by serial random audits of patients. A final audit occurred over 3 years after the initial baseline audit.
  
  
  RESULTS
  At baseline, 46% and 0% of patients had appropriate surveillance performed during the prior 6 months (one surveillance cycle) and 2 years (four surveillance cycles) respectively. Three years after initiation of these strategies, a final audit revealed 92% (vs 46% at baseline) and 64% (vs 0% at baseline) of patients had appropriate HCC surveillance performed during the preceding 6 months and 2 years intervals respectively (P < 0.001 in each case).
  
  
  CONCLUSIONS
  Simple and low-cost interventions can considerably improve the clinical effectiveness of HCC screening programmes in real world settings. Clinical practice improvement principles appear to be a valid methodology for achieving this positive change.
authors.affiliation: Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.
authors.forename: N A
authors.initials: NA
authors.lastname: Kennedy
authors.forename: A
authors.initials: A
authors.lastname: Rodgers
authors.forename: R
authors.initials: R
authors.lastname: Altus
authors.forename: R
authors.initials: R
authors.lastname: McCormick
authors.forename: R
authors.initials: R
authors.lastname: Wundke
authors.forename: A J
authors.initials: AJ
authors.lastname: Wigg
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006525:Hepatitis, Viral, Human / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D008297:Male; D008485:Medical Audit / Q000379:methods / Q000592:standards*; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods; D058996:Quality Improvement / Q000592:standards*
keywords: alphafetoprotein; cirrhosis; hepatitis C; hepatocellular carcinoma; ultrasound