ABSTRACT
INTRODUCTION: Hepatocellular carcinoma (HCC) commonly occurs in patients with known risk factors. Guidelines recommend HCC surveillance with ultrasound with/without serum alpha fetoprotein every 6 months, but less than 20% undergo recommended surveillance. The objective of this study was to identify provider-and system-level barriers to surveillance from the provider perspective and to examine the role of provider knowledge and attitudes. Providers' suggestions for potential interventions to improve HCC surveillance were also elicited. METHODS: Qualitative research methods were employed. Providers from the Departments of Internal Medicine and Family and Community Medicine who provide primary care, and from the Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition were invited to participate. A semi-structured interview guide was used. Transcribed interviews were analyzed to reveal emergent themes. RESULTS: 22 providers were interviewed including primary care providers, general gastroenterologists and hepatologists. Provider-level barriers to HCC surveillance identified by participants included variable provider comfort managing chronic liver disease;relationships between primary care, gastroenterology, infectious disease and hepatology;if/how providers discuss HCC surveillance;provider knowledge of guidelines and specific provider-level barriers including time and competing issues in clinic, deferral of responsibility, provider-patient relationships, and time spent on patient education. System-level barriers to HCC surveillance included the absence of relevant technology tools, insurance denial of imaging, difficulty scheduling surveillance studies, and the COVID-19 pandemic. Provider suggestions for interventions included patient navigation, use of technology, education for patients and primary care providers, partnering with primary care practices, and media campaigns. CONCLUSIONS: Important barriers to HCC surveillance and opportunities for intervention were identified. Future research should focus on the design, testing and implementation of interventions to target provider-and system-level barriers.