Mailed Outreach Program Increases Ultrasound Screening of Patients With Cirrhosis for Hepatocellular Carcinoma.
Surveillance of patients with cirrhosis increases early detection of hepatocellular carcinoma (HCC) and prolongs survival. However, its effectiveness is limited by underuse, particularly among racial/ethnic minorities and individuals of low socioeconomic status. We compared the effectiveness of mailed outreach strategies, with and without patient navigation, in increasing the numbers of patients with cirrhosis undergoing surveillance for HCC in a racially diverse and socioeconomically disadvantaged cohort.



We performed a prospective study of patients with documented or suspected cirrhosis at a large safety-net health system from December 2014 through March 2016. Patients were assigned randomly (1:1:1) to groups that received mailed invitations for an ultrasound screening examination (n = 600), mailed invitations for an ultrasound screening examination and patient navigation (barrier assessment and motivational education for patients who declined screening; n = 600), or usual care (visit-based screening; n = 600). Patients who did not respond to outreach invitations within 2 weeks received up to 3 reminder telephone calls. The primary outcome was completion of abdominal imaging within 6 months of randomization.



Baseline characteristics were similar among groups. Cirrhosis was documented, based on International Classification of Diseases, 9th revision, codes, for 79.6% of patients, and suspected, based on noninvasive markers of fibrosis, for 20.4%. In an intent-to-treat analysis, significantly greater proportions of patients who received the mailed invitation and navigation (47.2%) or the mailed invitation alone (44.5%) underwent HCC screening than patients who received usual care (24.3%) (P < .001 for both comparisons). However, screening rates did not differ significantly between outreach the outreach groups (P = .25). The effects of the outreach program were consistent in all subgroups, including Caucasian vs non-Caucasian race, documented vs suspected cirrhosis, Child-Pugh A vs B cirrhosis, and receipt of gastroenterology care.



In a prospective study, we found outreach strategies to double the percentage of patients with cirrhosis who underwent ultrasound screening for HCC. However, adding patient navigation to telephone reminders provided no significant additional benefit. ClinicalTrials.gov no: NCT02312817.
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: amit.singal@utsouthwestern.edu.
Amit G
AG
Singal
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.
Jasmin A
JA
Tiro
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
Jorge A
JA
Marrero
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
Katharine
K
McCallister
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
Caroline
C
Mejias
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
Brian
B
Adamson
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.
Wendy Pechero
WP
Bishop
Parkland Health and Hospital System, Dallas, Texas.
Noel O
NO
Santini
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.
Ethan A
EA
Halm
D000328:Adult; D001741:Black or African American; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging*; D055088:Early Detection of Cancer / Q000379:methods*; D005006:Ethnicity; D005260:Female; D006630:Hispanic or Latino; D006801:Humans; D008103:Liver Cirrhosis / Q000000981:diagnostic imaging*; D008113:Liver Neoplasms / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D008913:Minority Groups; D062405:Motivational Interviewing; D010353:Patient Education as Topic; D062526:Patient Navigation; D010358:Patient Participation; D011177:Postal Service; D011446:Prospective Studies; D017010:Reminder Systems; D012923:Social Class; D013689:Telephone; D013781:Texas; D014463:Ultrasonography; D044465:White People; D055815:Young Adult
Intervention; Liver Cancer; Prevention; Randomized Controlled Trial