Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis at US Safety-Net Health Systems

INTRODUCTION: Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is associated with improved patient outcomes. We aim to evaluate real-world utilization of HCC surveillance among safety-net populations with cirrhosis. METHODS: We performed a retrospective cohort study of adults with cirrhosis across 4 safety-net health systems from March 1, 2017, to February 28, 2022. Receipt of abdominal imaging with ultrasound, computed tomography, or magnetic resonance imaging and the corresponding ICD-9-CM / ICD-10-CM diagnosis codes at 6 months and 12 months were used to assess HCC surveillance. RESULTS: Among 14,556 patients with cirrhosis (61.8% male, 73.0% non-White ethnic minorities, 54.4% with Medicaid or indigent care/uninsured), 70.9% and 78.1% received abdominal imaging agnostic to indication within 6 months and 12 months, respectively. When evaluating the receipt of abdominal imaging with a specific indication for HCC surveillance, 29.1% and 34.0% of patients received surveillance within 6 months and 12 months, respectively. On adjusted multivariable regression, greater odds of HCC surveillance were observed in older patients, ethnic minorities, and those with commercial insurance. Lower odds of HCC surveillance were observed in patients with indigent care (vs Medicare: odds ratio OR 0.85, 95% confidence interval CI 0.72-1.00), drug use (OR 0.63, 95% CI 0.55-0.71), and concurrent mental health/psychiatric diagnoses (OR 0.88, 95% CI 0.80-0.97). DISCUSSION: Among a multicenter safety-net cohort of patients with cirrhosis, fewer than 30% received HCC surveillance within 6 months. While greater proportions received abdominal imaging agnostic to indication, the clinical benefit of these examinations for HCC surveillance may be limited because of concerns with abbreviated protocols, quality, and interpretation.