title: Adherence to diagnostic guidelines of hepatocellular carcinoma: 12-year experience in a veterans affairs medical center.
abstract: BACKGROUND
  Noninvasive diagnostic criteria for cirrhotic hepatocellular carcinoma (HCC) were first established in 2001 by the European Association for the Study of the Liver.
  
  
  OBJECTIVE
  The aim of this study was to evaluate adherence to the HCC diagnostic algorithm over time and identify factors associated with nonadherence.
  
  
  METHODS
  Between 2001 and 2013, 224 consecutive cirrhotic HCC cases were retrospectively reviewed. Nonadherent biopsy (NAB) was defined as cases diagnosed either by biopsy despite meeting noninvasive criteria for HCC or by biopsy in place of an optional second imaging modality. Nonadherent nonbiopsy (NANB) was defined as cases diagnosed without performing biopsy when noninvasive criteria were not met. Factors associated with nonadherence were identified using multivariate analysis.
  
  
  RESULTS
  Nonadherence rate decreased from 52 to 30% over the study period (P = 0.003). Among all patients, there were 34% NAB and 13% NANB cases. Compared with the adherence group, both NAB and NANB groups were likely to undergo only computed tomography scanning [odds ratio (OR) 3.08, 95% confidence interval (CI) 1.71-5.66 and OR 3.18, 95% CI 1.28-8.27, respectively] and were less likely to undergo MRI (OR 0.29, 95% CI 0.16-0.53 and OR 0.26, 95% CI 0.10-0.66, respectively). In addition, the NAB group was less likely to be presented in a multidisciplinary tumor conference (OR 0.12, 95% CI 0.02-0.61).
  
  
  CONCLUSIONS
  This is the first study to report adherence to HCC diagnostic guidelines over time in a veteran hospital. Despite overall improvement, nonadherence at the present time is still high (∼ 30%). Underutilization of MRI and the multidisciplinary tumor conference is associated with nonadherence, representing a potential area for improvement.
authors.affiliation: aDepartment of Internal Medicine, University of Minnesota Departments of bRadiology cGastroenterology, Minneapolis Veterans Affairs Health Care System, Minneapolis dDivision of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
authors.forename: Thoetchai
authors.initials: T
authors.lastname: Peeraphatdit
authors.forename: Niyada
authors.initials: N
authors.lastname: Naksuk
authors.forename: Parkpoom
authors.initials: P
authors.lastname: Phatharacharukul
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Bell
authors.forename: Paola
authors.initials: P
authors.lastname: Ricci
mesh_terms: D000368:Aged; D000465:Algorithms; D001706:Biopsy / Q000706:statistics & numerical data; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006787:Hospitals, Veterans; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016522:Oncology Service, Hospital; D018579:Patient Selection; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014463:Ultrasonography / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000706:statistics & numerical data