Hepatocellular carcinoma (HCC) surveillance is underused in clinical practice, which may be owing to patient and clinician barriers.
To characterize HCC surveillance barriers and associations with ...clinical outcomes in a multicenter cohort of patients with cirrhosis.
This retrospective, multicenter cohort study included 5 medical centers in the United States. Patients with cirrhosis and newly diagnosed HCC treated from 2014 to 2018 were included. Data were analyzed from June 2021 to February 2022.
Surveillance completion in the 36-month period prior to HCC diagnosis.
Surveillance receipt was classified as semiannual, annual, or no surveillance. Multivariable logistic regression analysis was used to identify factors associated with semiannual surveillance. We conducted multivariable logistic and Cox regression analyses to characterize associations between surveillance completion with curative treatment and overall survival.
A total 629 eligible patients (median IQR age, 63.6 56.2-71.0 years; 491 78.1% men) were assessed, including 7 American Indian or Alaska Native patients (1.1%), 14 Asian patients (2.2), 176 Black patients (28.0%), 86 Hispanic patients (13.1%), and 340 White patients (54.1%). Nearly two-thirds of the cohort had no surveillance prior to HCC diagnosis (mean range by site 63.7% 37.9%-80.4%), with a mean (range by site) of 14.0% (5.3%-33.3%) of patients having received semiannual surveillance and 22.3% (14.3%-28.8%) of patients having received annual surveillance. The most common reasons for no surveillance were lack of surveillance orders or nonadherence (mean range by site, 82.4% 66.7%-92.4%, although a mean (range by site) of 17.6% (10.2%-22.1%) of patients had unrecognized cirrhosis at HCC presentation. Semiannual surveillance was associated with hepatitis B infection (odds ratio OR, 3.06 95% CI, 1.24-7.23) and inversely associated with Black race (OR, 0.41 95% CI, 0.20-0.80) and lack of cirrhosis recognition (OR, 0.14 95% CI, 0.02-0.46). Semiannual HCC surveillance was significantly associated with curative treatment receipt (OR, 2.73 95% CI, 1.60-4.70) but not overall survival (HR, 0.81 95% CI, 0.55-1.18).
In this cohort study of patients with cirrhosis, HCC surveillance was underused in more than 80% of patients and associated with failures across the screening process. Dedicated programs to improve cirrhosis detection and HCC surveillance attainment are needed.
Cost of Care for Patients with Cirrhosis Kanwal, Fasiha; Nelson, Richard; Liu, Yan ...
The American journal of gastroenterology,
03/2024, Letnik:
119, Številka:
3
Journal Article
Recenzirano
There are limited longitudinal data on the cost of treating patients with cirrhosis which hampers value-based improvement initatives.
We conducted a retrospective cohort study of patients with ...cirrhosis seen in the Veterans Affairs healthcare system from 2011 to 2015. Patients were followed up through 2019. We identified a sex- and age-matched control cohort without cirrhosis. We estimated incremental annual health care costs attributable to cirrhosis for 4 years overall and in subgroups based on severity (compensated, decompensated), cirrhosis complications (ascites, encephalopathy, varices, hepatocellular cancer, acute kidney injury), and comorbidity (Deyo index).
We compared 39,361 patients with cirrhosis and 138,964 controls. The incremental adjusted costs for caring of patients with cirrhosis were $35,029 (95% CI, $32,473-$37,585) during the first year and ranged from $14,216 to $17,629 in the subsequent 3 years. Cirrhosis complications accounted for most of these costs. Cost of managing patients with hepatic encephalopathy (year 1 cost, $50,080) or ascites ($50,364) were higher than the cost of managing patients with varices ($20,488) or hepatocellular cancer ($37,639) in the first year. Subgroups with acute kidney injury or those who had multimorbidity were the most costly at $64,413 and $66,653 in the first year, respectively.
Patients with cirrhosis had substantially higher healthcare costs than matched controls and multimorbid patients had even higher costs. Cirrhosis complications accounted for most of the excess cost, so preventing complications has the largest potential for cost saving and could serve as targets for improvement.
Background/Aims
We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with ...end-stage liver disease (PC-ESLD).
Methods
We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool.
Results
Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%,
p
= 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%.
Conclusion
Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.
Patients with indeterminate liver nodules, classified as LR‐3 and LR‐4 observations per the Liver Imaging Reporting and Data System, are at risk of developing hepatocellular carcinoma (HCC), but risk ...estimates remain imprecise. We conducted a systematic review of Ovid MEDLINE, EMBASE, and Cochrane databases from inception to December 2021 to identify cohort studies examining HCC incidence among patients with LR‐3 or LR‐4 observations on computed tomography (CT) or magnetic resonance imaging (MRI). Predictors of HCC were ed from each study, when available. Of 13 total studies, nine conducted LR‐3 observation‐level analyses, with the proportions of incident HCC ranging from 1.2% to 12.5% at 12 months and 4.2% to 44.4% during longer study follow‐up. Among three studies with patient‐level analyses, 8%–22.2% of patients with LR‐3 lesions developed LR‐4 observations and 11.1%–24.5% developed HCC. Among nine studies conducting LR‐4 observation‐level analyses, incident HCC ranged from 30.8% to 44.0% at 12 months and 30.9% to 71.0% during study follow‐up; conversely, 6%–42% of observations were downgraded to LR‐3 or lower. Patient‐level factors associated with HCC included older age, male sex, higher alpha‐fetoprotein levels, viral etiology, and prior history of HCC; observation‐level factors included maximum diameter, threshold growth, T2 hyperintensity, and visibility on ultrasound. Studies were limited by small sample sizes, inclusion of patients with prior HCC, short follow‐up duration, and failure to account for clustering of observations in patients or competing risks of transplantation and death. LR‐3 and LR‐4 observations have elevated but variable risks of HCC. Higher quality studies are necessary to identify high‐risk patients who warrant close CT or MRI‐based follow‐up.
Introduction
Patients hospitalized for cirrhosis are at high risk for readmission and death for the first 30 days following discharge. However, there is no information on how these risks dynamically ...change over a full year after discharge. Our aim was to determine the absolute risks of first readmission and death and characterize these changes in the first year following hospital discharge.
Methods
We conducted a retrospective cohort study of patients who were hospitalized with cirrhosis at all Veterans Affairs hospitals and discharged home between 01/01/2010 and 12/31/2013. We used separate survival models to determine risk of first readmission and death after hospital discharge. We also examined the absolute daily risks for first readmission and death by day and identified the time required for risks of readmission and death to decline 50% and 75% from maximum values.
Results
Of the 38,955 patients who survived index hospitalization for cirrhosis, 23,318 patients (59.9%) had at least one readmission and 11,567 patients (29.7%) died within the first year. Daily risk of readmission was the highest on day 1 (1.23%) and declined 50% by day 71 and 75% by day 260. After 1 year, daily risk of readmission did not plateau. Daily risk of death was the highest on day 1 (0.78%) and declined 50% by day 31 and 75% by day 64.
Conclusion
The risk of readmission and death after cirrhosis-related hospitalization remains elevated for prolonged periods. Patients and providers should remain vigilant for clinical health deterioration beyond the first 30 days following hospitalization.
Healthcare reimbursement is shifting from fee‐for‐service to fee‐for‐value. Cirrhosis, which costs the U.S. healthcare system as much as heart failure, is a prime target for value‐based care. This ...article describes models in which physician groups or health systems are paid for improving quality and lowering costs for a given population of patients with cirrhosis. If done correctly, we believe that such frameworks, once adopted, could help reduce burnout by freeing physicians of the burden of checking boxes in the electronic medical record so that they can devote their energies to managing populations. Conclusion: Value‐based payment models for cirrhosis have the potential to benefit patients, physicians, and healthcare insurers.
Background: Hepatitis C virus (HCV) infections in the United States have increased in recent years, with the most rapid rise among people who inject drugs (PWIDs). Historically, there have been ...concerns regarding treatment adherence among PWIDs with HCV infection, leading to undertreatment of this population and increased HCV transmission. Elbasvir (EBR)/grazoprevir (GZR) has demonstrated high rates of virologic cure (sustained virologic response SVR) in clinical trials enrolling PWIDs with HCV infection.
Objective:
To evaluate the real-world effectiveness of EBR/GZR in HCV genotype (GT) 1-infected patients with a diagnosis of opioid use disorder.
Methods:
A retrospective analysis of electronic medical records from the US Department of Veterans Affairs Corporate Data Warehouse. Adults with chronic HCV GT1 infection, ≥1 prescription for EBR/GZR, and ≥1 clinic visit were included. All patients had ≥1 ICD-9/10 code of opioid use disorder. SVR was the primary outcome.
Results: 419 patients were included; 97.1% had a history of any illicit drug use and 40.8% were receiving medication for opioid use disorder (MOUD). SVR was achieved by 96.9% (406/419) of all patients, 97.0% (350/361) of those receiving EBR/GZR for 12 weeks, and 95.3% (163/171) of those receiving MOUD. SVR in patients receiving psychiatric medications ranged from 96.1% (221/230) in those taking antidepressant medications to 98.5% (128/130) in those taking mood stabilizers.
Conclusion:
In this real-world setting, high rates of virologic cure were achieved in patients with HCV GT1 infection on MOUD receiving EBR/GZR for 12 weeks, including patients with multiple comorbidities and high rate of psychiatric medication use.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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