title: Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality.
abstract: Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival.
  
  
  
  We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival.
  
  
  
  In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60-2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15-2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98-1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16-0.31), liver resection (HR, 0.38; 95% CI, 0.28-0.52), ablative therapy (HR, 0.63; 95% CI, 0.52-0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74-0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63-0.78), medical oncologists (HR, 0.82; 95% CI, 0.74-0.91), or surgeons (HR, 0.79; 95% CI, 0.71-0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77-0.90), were associated with reduced mortality.
  
  
  
  In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.
authors.affiliation: Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Marina
authors.initials: M
authors.lastname: Serper
authors.affiliation: VA Connecticut-Healthcare System, West Haven, Connecticut.
authors.forename: Tamar H
authors.initials: TH
authors.lastname: Taddei
authors.affiliation: VA Connecticut-Healthcare System, West Haven, Connecticut.
authors.forename: Rajni
authors.initials: R
authors.lastname: Mehta
authors.affiliation: VA Connecticut-Healthcare System, West Haven, Connecticut.
authors.forename: Kathryn
authors.initials: K
authors.lastname: D'Addeo
authors.affiliation: VA Connecticut-Healthcare System, West Haven, Connecticut.
authors.forename: Feng
authors.initials: F
authors.lastname: Dai
authors.affiliation: VA New York Harbor Health Care System, Brooklyn, New York.
authors.forename: Ayse
authors.initials: A
authors.lastname: Aytaman
authors.affiliation: Boston VA Healthcare System, Boston, Massachusetts.
authors.forename: Michelle
authors.initials: M
authors.lastname: Baytarian
authors.affiliation: San Francisco VA Medical Center, San Francisco, California.
authors.forename: Rena
authors.initials: R
authors.lastname: Fox
authors.affiliation: James J. Peters VA Medical Center, Bronx, New York.
authors.forename: Kristel
authors.initials: K
authors.lastname: Hunt
authors.affiliation: Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: David S
authors.initials: DS
authors.lastname: Goldberg
authors.affiliation: Bayer HealthCare Pharmaceuticals, Whippany, New Jersey.
authors.forename: Adriana
authors.initials: A
authors.lastname: Valderrama
authors.affiliation: Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: dakaplan@mail.med.upenn.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Kaplan
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D019033:Delivery of Health Care, Integrated / Q000639:trends*; D005260:Female; D000072102:Gastroenterologists / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D000072103:Oncologists / Q000639:trends; D010348:Patient Care Team / Q000639:trends*; D010818:Practice Patterns, Physicians' / Q000639:trends*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013038:Specialization / Q000639:trends*; D066231:Surgeons / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
keywords: Liver Cancer; Population; Quality; Risk Factor