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Surveillance for Hepatocellular Carcinoma in a Medicaid Cirrhotic Population

Palmer, Lena B. MD, MSCR*; Kappelman, Michael D. MD, MPH; Sandler, Robert S. MD, MPH; Hayashi, Paul H. MD, MPH

Journal of Clinical Gastroenterology: September 2013 - Volume 47 - Issue 8 - p 713–718
doi: 10.1097/MCG.0b013e318286fd97
LIVER, PANCREAS AND BILIARY TRACT: Original Articles

Goals: To estimate the hepatocellular carcinoma surveillance in the Medicaid cirrhotic population.

Background: Most studies predate 2005 American Association for the Study of Liver Diseases surveillance recommendations and do not examine the primary target population, cirrhotics.

Study: From 2006 to 2007, we identified adults with at least 1 cirrhosis International Classification of Disease code and 15 months of continuous enrollment in North Carolina Medicaid, recording claims for abdominal ultrasound, computed tomography, magnetic resonance imaging, and α-fetoprotein testing. We used multivariable logistic regression to identify factors independently associated with imaging.

Results: A total of 5061 subjects were identified: mean age 54 years, 54% male patients, 35% African American, 56% white. Cirrhosis risk factors were alcohol (59%), hepatitis C (30%), hepatitis B (4%), others (18%), and unknown (24%). Only 26% underwent at least 1 imaging test. Just 12% of those not hospitalized or seen in an emergency department underwent any imaging test. Care in an academic facility, younger age, female sex, viral hepatitis, and Medicare coinsurance were positively associated with imaging. Twenty-one percent saw a gastroenterologist, which increased the odds of undergoing imaging (odds ratio, 2.81; 95% confidence interval, 2.32-3.41), whereas primary care visits did not (odds ratio, 0.94; 95% confidence interval, 0.76-1.16).

Conclusions: Only a quarter of North Carolina Medicaid cirrhotics underwent abdominal imaging over a 15-month period, and many tests may have been conducted without surveillance intent. Gastroenterology visits nearly tripled the odds of imaging, but primary-care visits had no effect. Efforts to improve surveillance rates in cirrhotic patients should target primary care and increased access to subspecialty care.

*Department of Medicine, Division of Gastroenterology, Hepatology, & Nutrition, Loyola University Chicago Stritch School of Medicine, Maywood, IL

Departments of Pediatrics

Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC

The authors declare that they have nothing to disclose.

The authors received an unrestricted grant from Onyx pharmaceuticals (applied to data usage and programming costs. The funding agency had no part in the design and conduct of the study; analysis and interpretation of the data; or preparation, review, or approval of the manuscript). L.B.P. was supported in part by a T32 National Institutes of Health Training Grant 5-T32 DK007634 (supported author’s time to perform all aspects of research). M.D.K. was supported in part by the National Center for Research Resources Grant KL2 RR025746 and the National Institute for Diabetes and Digestive and Kidney Diseases Grant P30 DK034987 (supported author’s time to contribute to the design and conduct of the study, analysis and interpretation of the data, and review and approval of the manuscript).

L.B.P. is the guarantor of the article and takes full responsibility for the conduct of the study.

L.B.P. participated in the conception and design of the study, data preparation, data analysis, and manuscript preparation. She was involved in final document editing and has approved the final draft submitted. M.D.K. participated in the conception and design of the study, data analysis, and manuscript preparation. He was involved in final document editing and has approved the final draft submitted. R.S.S. participated in the conception and design of the study. He was involved in final document editing and has approved the final draft submitted. P.H.H. participated in the conception and design of the study, data analysis, and manuscript preparation. He was involved in final document editing and has approved the final draft submitted.

Reprints: Lena B. Palmer, MD, MSCR, Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Avenue, Building 54, Room 167, Maywood, IL 60153 (e-mail: lpalmer@lumc.edu).

Received March 14, 2012

Accepted January 9, 2013

© 2013 by Lippincott Williams & Wilkins