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Surveillance of patients with cirrhosis remains suboptimal in the United States

  • Yee Hui Yeo
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States

    Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States
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  • Jungyun Hwang
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States
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  • Donghak Jeong
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States
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  • Nolan Dang
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States
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  • Leslie Y. Kam
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States
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  • Linda Henry
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States
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  • Haesuk Park
    Affiliations
    Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States
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  • Ramsey Cheung
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States

    Department of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
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  • Mindie H. Nguyen
    Correspondence
    Corresponding author. Address: Stanford University Medical Center, 780 Welch Road, Rm CJ250K, Palo Alto, CA 94304, United States; Tel.: (650) 498-6080, fax: (650) 721-8710.
    Affiliations
    Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States

    Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, United States

    Stanford Cancer Institute, Stanford University Medical Center, Palo Alto, California, United States
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      Highlights

      • Adherence to monitoring/surveillance for liver complications was assessed in patients with cirrhosis.
      • Adherence rates for HCC surveillance (8.78%), laboratory testing (29.72%) and EV surveillance (10.6%) were disappointing.
      • Adherence rates did improve in more recent years.
      • Age, insurance plan, being followed up by specialist, severity of cirrhosis, and comorbidities were linked to adherence.

      Background & Aims

      Regular monitoring/surveillance for liver complications is crucial to reduce morbidity and mortality in patients with cirrhosis. Recommendations from professional societies are available but adherence is not well studied, especially outside of academic centers. We aimed to determine the frequencies and factors associated with laboratory monitoring, and hepatocellular carcinoma (HCC) and esophageal varices (EV) surveillance in patients with cirrhosis.

      Methods

      We identified 82,427 patients with cirrhosis (43,280 compensated and 39,147 decompensated) from the Truven Health MarketScan Research Database®, 2007–2016. We calculated the proportion of patients with cirrhosis with various frequencies of procedures/testing: laboratory (complete blood count, comprehensive metabolic panel, and prothrombin time), HCC and EV surveillance. We also used multivariable logistic regression to determine factors associated with having procedures.

      Results

      The proportions of patients undergoing HCC surveillance (8.78%), laboratory testing (29.72%) at least every 6–12 months, or EV surveillance (10.6%) at least every 1–2 years were suboptimal. The majority did not have HCC (45.4%) or EV (80.3%) surveillance during the entire study period. On multivariable regression, age 41–55 (vs. <41) years, preferred provider organization (vs. health maintenance organization) insurance plan, specialist care (vs. primary care and other specialties), diagnosis between 2013–2016 (vs. 2007–2009), decompensated (vs. compensated) cirrhosis, non-alcoholic fatty liver disease (vs. viral hepatitis), and higher Charlson comorbidity index were associated with significantly higher odds of undergoing procedures/testing every 6–12 months and EV surveillance every 1–2 years.

      Conclusions

      Despite modest improvements in more recent years, routine monitoring and surveillance for patients with cirrhosis is suboptimal. Further efforts including provider awareness, patient education, and system/incentive-based quality improvement measures are urgently needed.

      Lay summary

      Patients with cirrhosis should undergo health monitoring for liver complications to achieve early detection and treatment. In a large nationwide cohort of 82,427 patients with cirrhosis in the United States, we found a low rate of adherence (well less than half) to routine blood test monitoring and surveillance for liver cancer and esophageal varices (swollen blood vessels in the abdomen that could lead to fatal bleeding). Adherence has increased in the recent years, but much more improvement is needed.

      Graphical abstract

      Keywords

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