HFI Connect - Hepatitis
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HCC surveillance found to be low among insured patients with HBV without cirrhosis

Surveillance for hepatocellular carcinoma was poor among patients with insurance and hepatitis B virus infection without cirrhosis vs. patients with cirrhosis, according to published data in the Journal of Viral Hepatitis.

“Given that patients with noncirrhotic HBV diagnosed with early stage HCC are potentially eligible for curative treatment, including resection, without the need for liver transplantation, timely and routine surveillance is critical,” the researchers wrote. “Identification of surveillance rates and factors associated with surveillance are needed in order to develop targeted interventions to improve surveillance, and in turn, HCC-related survival among patients with noncirrhotic HBV.”

Researchers, including David S. Goldberg, MD, MSCE, assistant professor of medicine and medical director of living donor liver transplantation at the Perelman School of Medicine, University of Pennsylvania, analyzed data of 4,576 patients with chronic HBV without cirrhosis from the Truven Health Analytics databases.

“Surveillance patterns were characterized using categorical and continuous outcomes, with the continuous measure of the proportion of time ‘up to date’ with surveillance, with the 6-month interval following each ultrasound categorized as ‘up to date,’” the researchers wrote.

The mean age of the patients was 44.2 years and over 90% had insurance through a preferred provider organization or point-of-service plan (n = 3,039) or a health maintenance organization (n = 1,174). Only 52% of all patients were diagnosed with HBV by a gastroenterologist (n = 2,375).

Over a median follow-up of 26 months, 6.7% of patients (n = 306) had complete surveillance, whereas 59.6% (n = 2,727) had incomplete surveillance and 33.7% had no surveillance at all (n = 1,543).

In analyses restricting follow-up to the first 12 months after the index date, only 13.2% of patients had complete surveillance (n = 604). When the cohort consisted of only patients without cirrhosis at least 50 years of age at the index date (n = 1,511), the proportion of complete, incomplete and no surveillance rates remained the same. However, when including the 27 patients who developed HCC within the first 12 months, who were excluded from the primary analysis, and classifying them as having complete surveillance, the proportion of HBV patients without cirrhosis with complete HBV surveillance overall was 7.2% and 13.8% in the first year. The proportion with complete surveillance ranged from 12.6% in 2006 to 14.9% in 2009, according to the research.

“There was no appreciable difference in the proportion of noncirrhotic HBV patients receiving complete follow-up when patients were stratified by year of index date and follow-up restricted to the first 12 months after the index date in order to ensure uniform follow-up for all patients,” the researchers wrote.

Multinomial logistic regression models showed that patients diagnosed by a non-gastroenterologist and patients coinfected with HBV/HIV were less likely to have complete surveillance (P < .001 for both).

In linear regression models, non-gastroenterologist provider, health insurance subtype, HBV/HIV coinfection, rural status and metabolic syndrome were “independently associated with decreased surveillance,” according to the researchers.

The researchers concluded: “HCC surveillance rates for commercially insured noncirrhotic patients with chronic HBV in the United States remain inadequate despite formalized screening guidelines and are much lower than national screening rates for other cancers in the general population. Targeted interventions are needed to reduce morbidity and mortality from this curable disease in well-identified at-risk populations.”