Racial, social, and clinical determinants of hepatocellular carcinoma surveillance.

OBJECTIVES: Less than 1 in 5 patients receive hepatocellular carcinoma surveillance; however, most studies were performed in racially and socioeconomically homogenous populations, and few used guideline-based definitions for surveillance. The study objective was to characterize guideline-consistent hepatocellular carcinoma surveillance rates and identify determinants of hepatocellular carcinoma surveillance among a racially and socioeconomically diverse cohort of cirrhotic patients. METHODS: We retrospectively characterized hepatocellular carcinoma surveillance among cirrhotic patients followed between July 2008 and July 2011 at an urban safety-net hospital. Inconsistent surveillance was defined as at least 1 screening ultrasound during the 3-year period, annual surveillance was defined as screening ultrasounds every 12 months, and biannual surveillance was defined as screening ultrasounds every 6 months. Univariate and multivariate analyses were conducted to identify predictors of surveillance. RESULTS: Of 904 cirrhotic patients, 603 (67%) underwent inconsistent surveillance. Failure to recognize cirrhosis was a significant barrier to surveillance use (P < .001). Inconsistent surveillance was associated with insurance status (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.03-1.98), multiple primary care visits per year (OR, 2.63; 95% CI, 1.86-3.71), multiple hepatology visits per year (OR, 3.75; 95% CI, 2.64-5.33), African American race (OR, 0.61; 95% CI, 0.42-0.99), nonalcoholic steatohepatitis cause (OR, 0.60; 95% CI, 0.37-0.98), and extrahepatic cancer (OR, 0.43; 95% CI, 0.24-0.77). Only 98 (13.4%) of 730 patients underwent annual surveillance, and only 13 (1.7%) of 786 had biannual surveillance. CONCLUSIONS: Only 13% of patients with cirrhosis receive annual surveillance, and less than 2% of patients receive biannual surveillance. There are racial and socioeconomic disparities, with lower rates of hepatocellular carcinoma surveillance among African Americans and underinsured patients.

Use of administrative claims data for identifying patients with cirrhosis.

BACKGROUND: Administrative data are used in clinical research, but the validity of ICD-9 codes to identify cirrhotic patients has not been well established. GOALS: To determine the diagnostic accuracy of ICD-9 codes for cirrhosis in clinical practice. STUDY: We conducted a retrospective cohort study of patients from a safety-net hospital between 2008 and 2011. Patients were initially identified using ICD-9 codes for cirrhosis or a resultant complication. The gold-standard for diagnosis of cirrhosis was histology and/or imaging based on medical record review. Sensitivity, specificity, positive predictive values, and negative predictive values for each ICD-9 code were calculated. Diagnostic accuracy was assessed by the c-statistic using receiver operator characteristic curve analysis. RESULTS: We identified 2893 patients with an ICD-9 code for cirrhosis, of whom 50.2% had 1 ICD-9 code, 20.3% had 2 different codes, and 29.5% had 3 or more codes. Cirrhosis was confirmed in 44.0% of patients with 1 ICD-9 code, 82.6% with 2 codes, and 95.7% of those with at least 3 codes. Ascites had a significantly lower positive predictive values for cirrhosis than other ICD-9 codes (P<0.001). The optimal combination of ICD-9 codes to identify cirrhotic patients included all codes except that of ascites, with a c-statistic of 0.71 in our derivation cohort. The sensitivity of this combination was confirmed to be 98% in a validation cohort of 285 patients with known cirrhosis. CONCLUSIONS: Administrative data can identify patients with cirrhosis with high accuracy, although ascites has a significantly lower positive predictive value than other ICD-9 codes.