title: Referral patterns and treatment choices for patients with hepatocellular carcinoma: a United States population-based study.
abstract: BACKGROUND
  Patterns of care of physician specialists may differ for patients with hepatocellular carcinoma (HCC). Reasons underlying variations are poorly understood. One source of variation may be disparate referral rates to specialists, leading to differences in cancer-directed treatments.
  
  
  METHODS
  Surveillance, Epidemiology, and End Results (SEER)-linked Medicare database was queried for patients with HCC, diagnosed between 1998 and 2007, who consulted 1 or more physicians after diagnosis. Visit and procedure records were abstracted from Medicare billing records. Factors associated with specialist consult and subsequent treatment were examined.
  
  
  RESULTS
  There were 6,752 patients with HCC identified; 1,379 (20%) patients had early-stage disease. Median age was 73 years; the majority were male (66%), white (60%), and from the West region (56%). After diagnosis, referral to a specialist varied considerably (hepatology/gastroenterology, 60%; medical oncology, 62%; surgery, 56%; interventional radiology [IR], 33%; radiation oncology, 9%). Twenty-two percent of patients saw 1 specialist; 39% saw 3 or more specialists. Time between diagnosis and visitation with a specialist varied (surgery, 37 days vs IR, 55 days; p = 0.04). Factors associated with referral to a specialist included younger age (odds ratio [OR] 2.16), Asian race (OR 1.49), geographic region (Northeast OR 2.10), and presence of early-stage disease (OR 2.21) (all p < 0.05). Among patients with early-stage disease, 77% saw a surgeon, while 50% had a consultation with medical oncologist. Receipt of therapy among patients with early-stage disease varied (no therapy, 30%; surgery, 39%; IR, 9%; chemotherapy, 23%). Factors associated with receipt of therapy included younger age (OR 2.48) and early-stage disease (OR 2.20).
  
  
  CONCLUSIONS
  After HCC diagnosis, referral to a specialist varied considerably. Both clinical and nonclinical factors were associated with consultation. Disparities in referral to a specialist and subsequent therapy need to be better understood to ensure all HCC patients receive appropriate care.
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Omar
authors.initials: O
authors.lastname: Hyder
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Dodson
authors.forename: Hari
authors.initials: H
authors.lastname: Nathan
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.forename: David
authors.initials: D
authors.lastname: Cosgrove
authors.forename: Ihab
authors.initials: I
authors.lastname: Kamel
authors.forename: Jean-Francois H
authors.initials: JF
authors.lastname: Geschwind
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000628:therapy*; D002755:Choice Behavior; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D008113:Liver Neoplasms / Q000628:therapy*; D008297:Male; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data*; D014481:United States
keywords: HCC; HR; IR; OR; SES; TACE; TAE; bland embolization; hazard ratio; hepatocellular carcinoma; interventional radiology; odds ratio; socioeconomic status; transarterial chemoembolization
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