title: Racial, social, and clinical determinants of hepatocellular carcinoma surveillance.
abstract: OBJECTIVE
  Less than 1 in 5 patients receive hepatocellular carcinoma surveillance; however, most studies were performed in racially and socioeconomically homogenous populations, and few used guideline-based definitions for surveillance. The study objective was to characterize guideline-consistent hepatocellular carcinoma surveillance rates and identify determinants of hepatocellular carcinoma surveillance among a racially and socioeconomically diverse cohort of cirrhotic patients.
  
  
  METHODS
  We retrospectively characterized hepatocellular carcinoma surveillance among cirrhotic patients followed between July 2008 and July 2011 at an urban safety-net hospital. Inconsistent surveillance was defined as at least 1 screening ultrasound during the 3-year period, annual surveillance was defined as screening ultrasounds every 12 months, and biannual surveillance was defined as screening ultrasounds every 6 months. Univariate and multivariate analyses were conducted to identify predictors of surveillance.
  
  
  RESULTS
  Of 904 cirrhotic patients, 603 (67%) underwent inconsistent surveillance. Failure to recognize cirrhosis was a significant barrier to surveillance use (P < .001). Inconsistent surveillance was associated with insurance status (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.03-1.98), multiple primary care visits per year (OR, 2.63; 95% CI, 1.86-3.71), multiple hepatology visits per year (OR, 3.75; 95% CI, 2.64-5.33), African American race (OR, 0.61; 95% CI, 0.42-0.99), nonalcoholic steatohepatitis cause (OR, 0.60; 95% CI, 0.37-0.98), and extrahepatic cancer (OR, 0.43; 95% CI, 0.24-0.77). Only 98 (13.4%) of 730 patients underwent annual surveillance, and only 13 (1.7%) of 786 had biannual surveillance.
  
  
  CONCLUSIONS
  Only 13% of patients with cirrhosis receive annual surveillance, and less than 2% of patients receive biannual surveillance. There are racial and socioeconomic disparities, with lower rates of hepatocellular carcinoma surveillance among African Americans and underinsured patients.
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Tex; Department of Clinical Sciences, University of Texas Southwestern, Dallas, Tex; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Tex. Electronic address: amit.singal@utsouthwestern.edu.
authors.forename: Amit G
authors.initials: AG
authors.lastname: Singal
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern, Dallas, Tex.
authors.forename: Xilong
authors.initials: X
authors.lastname: Li
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern, Dallas, Tex; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Tex.
authors.forename: Jasmin
authors.initials: J
authors.lastname: Tiro
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Tex.
authors.forename: Pragathi
authors.initials: P
authors.lastname: Kandunoori
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern, Dallas, Tex.
authors.forename: Beverley
authors.initials: B
authors.lastname: Adams-Huet
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Tex.
authors.forename: Mahendra S
authors.initials: MS
authors.lastname: Nehra
authors.affiliation: Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Tex; Department of Surgery, University of Texas Southwestern, Dallas, Tex.
authors.forename: Adam
authors.initials: A
authors.lastname: Yopp
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012189:Retrospective Studies; D012959:Socioeconomic Factors
keywords: Cirrhosis; Disparities; Liver cancer; Surveillance; Underuse