title: Improved surveillance for hepatocellular carcinoma with a primary care-oriented clinical reminder.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  In a VA population, a clinical reminder system increased HCC surveillance in patients with cirrhosis.
authors.affiliation: 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. Electronic address: lauren.beste@va.gov.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Beste
authors.affiliation: Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington, Seattle, WA.
authors.forename: George N
authors.initials: GN
authors.lastname: Ioannou
authors.affiliation: Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Yin
authors.initials: Y
authors.lastname: Yang
authors.affiliation: Gastroenterology and Hepatology Department, Portland Veterans Affairs Medical Center, Portland, Oregon; Gastroenterology and Hepatology Division, Oregon Health and Sciences University, Portland, Oregon.
authors.forename: Michael F
authors.initials: MF
authors.lastname: Chang
authors.affiliation: Department of Veterans Affairs, Office of Clinical Public Health, HIV, Hepatitis C, and Public Health Pathogens Program, Washington, D.C; Division of Infectious Diseases, George Washington University, Washington, D.C.
authors.forename: David
authors.initials: D
authors.lastname: Ross
authors.affiliation: Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington, Seattle, WA.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Dominitz
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D065228:Non-Randomized Controlled Trials as Topic; D011320:Primary Health Care / Q000379:methods*; D017010:Reminder Systems; D014463:Ultrasonography
keywords: Cirrhosis; Liver Cancer; Screening; Veterans