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Mo1036 Cascade of Care for Hepatitis C Virus (HCV) Infection Within the U.S. Department of Veterans Affairs (VA)
Diagnosed with HCV-known detectable HCV viral load or genotype. (3) Linked to HCV careentered into the HCV Clinical Case Registry which requires manual review of cases and HCV entered on the problem list. (4) Antiviral treatment-receipt of any HCV antiviral medication including boceprevir, consensus interferon, interferon, peginterferon, ribavirin or telaprevir from VA at any time up to and including 31 December 2013. (5) Achieved SVR-undetectable HCV RNA on at least one test 12 weeks or more after the end of antiviral treatment. The SVR rate among those evaluable for SVR was then applied to those still on treatment or recently completing treatment to determine the number of patients expected to have an SVR. Results Overall, 5,596,178 Veterans had a VA outpatient visit in 2013 and 3,135,396 (56.0%) had VA HCV screening. Of the 218,111 Veterans with positive antibody screens, 208,893 (95.8%) had RNA testing for HCV infection. Of those with positive antibody screens who received RNA-based testing, 161,044 (77.1%) had HCV infection. An additional 20,124 Veterans had HCV infection based on RNA testing without preceding antibody testing. Altogether 181,168 individuals were diagnosed with HCV infection. An estimated 45,623 additional cases of HCV infection would be found with screening of the entire unscreened population in VA care in 2013. An estimated additional 7,107 individuals with HCV infection would be identified by applying the observed prevalence (77.1%) in those with RNA testing to the 9,218 with positive HCV antibody tests who lacked RNA testing. Results for each step of the Cascade appear in the Table. Conclusion VA has diagnosed the majority of patients with HCV and linked them to HCV care. The largest gap in the Cascade of HCV Care is in the initiation of antiviral treatment. VA Cascade of HCV Care
Mo1035 Characteristics and Outcomes of Acute Biliary Pancreatitis Among Patients With Cirrhosis John N. Gaetano, Ajaypal Singh, Christopher G. Chapman
Mo1037 Web-Based EMR-Linked Cancer Tracking Application Facilitates Earlier Detection of Hepatocellular Carcinoma Lin Shen, Tamar Taddei
Background: The most frequent cause of pancreatitis in the United States is gallstone pancreatitis, and not an uncommon reason for admission to the hospital. Despite cholelithiasis being more common among cirrhotic patients than non-cirrhotics, there is a relative paucity of literature on incidence, treatment and outcomes of cirrhotics with acute biliary pancreatitis. Aim: We sought to evaluate the incidence, methods of treatment, and outcomes of acute biliary pancreatitis in cirrhotic patients compared to non-cirrhotics. Methods: The Health Care Utilization Project's Nationwide Inpatient Sample (NIS) is the largest all-payer, nonfederal, acute care inpatient database in the United States. All patients aged > 17 years, nonelectively admitted with acute biliary pancreatitis (based on ICD-9-CM diagnosis codes), and not transferred to or from another acute care facility from 2008-2012 were included. Independent variables included patient and hospital demographic data, ERCP, surgery, timing of procedures, the presence of cholangitis, as well as various comorbidities. The primary outcome was inpatient mortality. Results: 1,790 patients with cirrhosis and 44,986 non-cirrhotics with acute biliary pancreatitis met our inclusion criteria. The overall inhospital mortality was 3.3% for cirrhotics with acute biliary pancreatitis, compared to 1.5% without cirrhosis, (adjusted OR 1.95, 95% CI 1.47-2.59). Cirrhotics had concurrent cholangitis in 3.0% of cases (n=53), compared to a rate of 3.9% in non-cirrhotics, n=1,748 (p=0.046). Overall, the presence of cholangitis was associated with an increased mortality (adjusted OR 1.83, 95% CI 1.33-2.53). In the setting of cholangitis, non-cirrhotics were more likely to undergo ERCP (73.4%), than patients with cirrhosis (56.6%) (adjusted OR (2.19, 95% CI 1.16-4.11). Cirrhotics with cholangitis were more likely to undergo percutaneous biliary drainage than non-cirrhotics with cholangitis (7.5% vs. 2.9%, respectively). Cholecystectomy was performed during the hospitalization in 9.8% of patients with cirrhosis, compared to 22.3% undergoing cholecystectomy in non-cirrhotics. Additional factors associated with mortality include the presence of acute kidney injury (aOR 5.30, 95% CI 2.969.50), alteration in mental status (aOR 3.12, 95% CI 1.65-5.90), and acidosis (aOR, 3.77, 95% CI 1.99-7.14). The absence of all 3 clinical signs was associated with mortality rate of 0.5%, while those with all 3 factors had a mortality of 20.4%. Limitations: This study is limited by its retrospective design and administrative nature of the database. Conclusion: Adult patients with acute biliary pancreatitis in the setting of cirrhosis have a two-fold increase in mortality compared to non-cirrhotics. Independent risk factors for mortality include being cirrhotic, acute kidney injury, acidosis, and altered mental status or encephalopathy.
BACKGROUND: A web-based EMR-linked cancer care tracking system (CCTS) for the detection of lung and liver cancers was developed from 2007 to 2010 at our institution. CCTS was formally implemented in 2010, as part of the infrastructure of a dedicated liver cancer program. Designated radiology codes and a natural language processor (NLP) are used to conduct daily automated reviews of all relevant radiology reports from which flags are generated for findings suspicious for hepatocellular carcinoma (HCC). We aimed to evaluate whether the implementation of this system has had any impact upon BCLC stage at the time of HCC diagnosis. METHODS: This study was a retrospective cohort design with research data collected by chart review from years 2003-2013. Two primary groups were compared: patients diagnosed with HCC prior to CCTS implementation, and those diagnosed after. The primary outcome was BCLC stage at diagnosis, which was analyzed by Chi-squared Test (χ2 test) to assess for difference in proportional distributions. RESULTS: 78/78 patients diagnosed with HCC from 2003-2009 and 96/104 patients from 2010-2013 had sufficient data on chart review for BCLC staging. In the pre-CCTS group, stages at diagnosis were BCLC-0 1.3%, BCLC-A 33%, BCLC-B 7.7%, BCLC-C 32%, and BCLC-D 25.6%. In the post-CCTS group, stages at diagnosis were BCLC-0 9.4% BCLC-A 42.7%, BCLC-B 18.8%, BCLC-C 16.7%, and BCLC-D 12.5%. The proportional distribution was significantly different between the two groups (p<0.001) with a shift observed toward earlier stage disease. CONCLUSION: We observed a statically significant difference in the distribution of BCLC-staged HCC at diagnosis pre- and post- implementation of a webbased EMR-linked cancer tracking application. The observed shift towards earlier stage disease suggests that such a system facilitates earlier diagnosis of HCC. Mo1038 Racial Disparities in In-Hospital Outcomes for Hepatocellular Carcinoma in the United States Ruma Rajbhandari, Raymond T. Chung, Ashwin N. Ananthakrishnan Background and Aims: The incidence of hepatocellular carcinoma (HCC) is increasing. Racial disparities have been documented in treatment and outcomes of HCC but have been attributed to differences in access to care. In-hospital outcomes reduce the influence of access to care and are an important cohort to assess for racial disparities. Variations in inhospital care and outcomes of treatment for HCC have not been examined previously. Methods: Using the 2011 US Nationwide Inpatient Sample, we identified hospitalized patients with HCC-related hospitalizations using ICD-9-CM codes for diagnoses or procedures related to the management of HCC [liver transplantation, hepatic resection, ablation or transarterial chemoembolization (TACE)]. Multivariable regression was performed to identify the independent effect of race on receiving a therapeutic procedure as well as inhospital mortality. Results: We identified a total of 23,004 HCC-related discharges in 2011, among which 10,286 were associated with one of the four therapeutic procedures listed above. Overall, hospitalization related to HCC among blacks was associated with a significantly lower proportion of therapeutic procedures compared to whites (35% vs. 46%, multivariate OR 0.66, 95% CI 0.51 - 0.85). Among specific procedures, blacks had reduced odds of undergoing liver transplantation (OR 0.46, 95% CI 0.28-0.74), hepatic resection (OR 0.54, 95% CI 0.31-0.93) and ablation (0.52, 95% CI 0.34-0.81) compared to whites but were similarly likely to undergo TACE (OR 0.94, 95% CI 0.71-1.24). On multivariable analysis
Mo1036 Cascade of Care for Hepatitis C Virus (HCV) Infection Within the U.S. Department of Veterans Affairs (VA) Marissa Maier, David Ross, Maggie Chartier, Pamela S. Belperio, Lisa I. Backus Background With new efficacious HCV treatments available, a population health approach is useful to assess a healthcare system's ability to identify infected individuals, link them to care, provide antiviral treatment, and achieve sustained virologic response (SVR). Methods The Cascade of HCV Care for all Veterans in VA care in 2013 (as defined by at least one outpatient visit) has five steps: (1) Number with HCV infection-We used VA's Corporate Data Warehouse to determine HCV screening, RNA confirmatory testing, infection prevalence and per year incident diagnosis rates. The estimated total number with HCV infection reflects the sum of 1) those already identified with a detectable HCV viral load or genotype, 2) estimated additional cases if RNA testing were performed on those with positive HCV antibody results without RNA testing and 3) estimated additional cases if all unscreened Veterans were screened based on the incident diagnosis rate in each sex, birth cohort and race/ethnicity stratum in care in 2013 multiplied by the ratio of the 2013 to 2012 rate. (2)
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AASLD Abstracts
AASLD Abstracts
with cirrhosis (18-64%). Previous studies have attributed lapses in HCC surveillance to provider under recognition of cirrhosis, lack of knowledge of HCC guidelines, lack of healthcare engagement and nonadherence by patients. The aim was to evaluate HCC surveillance patterns among veterans as a function of geographic access to their assigned primary care provider and Veterans Affairs Medical Center. METHODS: A retrospective cohort study was conducted to identify veteran patients with an assigned primary care provider who were initially diagnosed with cirrhosis between October 1, 2005-June 30, 2012. Initial HCC surveillance was defined as having received an abdominal ultrasound, CT scan, or MRI with or without alpha-fetoprotein within 12 months of the initial diagnosis of cirrhosis (index date). The independent variables of interest were distance and patient rurality. Geocoded address' using zip code data were used to estimate travel distance. Rurality categories (isolated, small rural, large rural and urban) from the Department of Veterans Affairs Planning Systems Support Group (PSSG) were used. Associations were examined using Cox proportional hazards regression adjusting for demographic, non-liver co-morbidities (Gagne score) and liver disease severity (MELD score). RESULTS: Of the 59,296 veterans with cirrhosis (93% male), 34.2% received surveillance for HCC within 12 months of the index date. 50.4% of the patients living < 10 miles away from their medical center were screened compared with 41.7% of the patient's living ≥ 60 miles (P < 0.001). For each surveillance method, as distance from the medical center decreased the proportion of patients receiving surveillance increased. On average, 15.4% of patients received alpha fetoprotein alone while the proportion of patients receiving any image plus alpha fetoprotein ranged from 30.2% to 36.4% (< 10 mile vs ≥ 60 mile group), P < 0.001. Patients who lived ≥ 30 miles from a medical center were less likely to receive HCC surveillance in the first 12 months after the cirrhosis index date compared with patients who lived < 10 miles, [Hazard Ratio(≥30 miles to < 60 miles): 0.95, Confidence Intervals (CI): 0.92-0.99; HR (≥ 60 miles), CI: 0.89-0.96)]. There was no association between surveillance for HCC and location of primary care provider. CONCLUSIONS: Geographic access is associated with HCC surveillance in patients who live more than 30 miles away from a VA medical center. Further efforts should focus on identifying systematic strategies to increase HCC surveillance using co-management roles between primary care physicians and subspecialist.
Mo1035 Characteristics and Outcomes of Acute Biliary Pancreatitis Among Patients With Cirrhosis John N. Gaetano, Ajaypal Singh, Christopher G. Chapman
Mo1037 Web-Based EMR-Linked Cancer Tracking Application Facilitates Earlier Detection of Hepatocellular Carcinoma Lin Shen, Tamar Taddei
Background: The most frequent cause of pancreatitis in the United States is gallstone pancreatitis, and not an uncommon reason for admission to the hospital. Despite cholelithiasis being more common among cirrhotic patients than non-cirrhotics, there is a relative paucity of literature on incidence, treatment and outcomes of cirrhotics with acute biliary pancreatitis. Aim: We sought to evaluate the incidence, methods of treatment, and outcomes of acute biliary pancreatitis in cirrhotic patients compared to non-cirrhotics. Methods: The Health Care Utilization Project's Nationwide Inpatient Sample (NIS) is the largest all-payer, nonfederal, acute care inpatient database in the United States. All patients aged > 17 years, nonelectively admitted with acute biliary pancreatitis (based on ICD-9-CM diagnosis codes), and not transferred to or from another acute care facility from 2008-2012 were included. Independent variables included patient and hospital demographic data, ERCP, surgery, timing of procedures, the presence of cholangitis, as well as various comorbidities. The primary outcome was inpatient mortality. Results: 1,790 patients with cirrhosis and 44,986 non-cirrhotics with acute biliary pancreatitis met our inclusion criteria. The overall inhospital mortality was 3.3% for cirrhotics with acute biliary pancreatitis, compared to 1.5% without cirrhosis, (adjusted OR 1.95, 95% CI 1.47-2.59). Cirrhotics had concurrent cholangitis in 3.0% of cases (n=53), compared to a rate of 3.9% in non-cirrhotics, n=1,748 (p=0.046). Overall, the presence of cholangitis was associated with an increased mortality (adjusted OR 1.83, 95% CI 1.33-2.53). In the setting of cholangitis, non-cirrhotics were more likely to undergo ERCP (73.4%), than patients with cirrhosis (56.6%) (adjusted OR (2.19, 95% CI 1.16-4.11). Cirrhotics with cholangitis were more likely to undergo percutaneous biliary drainage than non-cirrhotics with cholangitis (7.5% vs. 2.9%, respectively). Cholecystectomy was performed during the hospitalization in 9.8% of patients with cirrhosis, compared to 22.3% undergoing cholecystectomy in non-cirrhotics. Additional factors associated with mortality include the presence of acute kidney injury (aOR 5.30, 95% CI 2.969.50), alteration in mental status (aOR 3.12, 95% CI 1.65-5.90), and acidosis (aOR, 3.77, 95% CI 1.99-7.14). The absence of all 3 clinical signs was associated with mortality rate of 0.5%, while those with all 3 factors had a mortality of 20.4%. Limitations: This study is limited by its retrospective design and administrative nature of the database. Conclusion: Adult patients with acute biliary pancreatitis in the setting of cirrhosis have a two-fold increase in mortality compared to non-cirrhotics. Independent risk factors for mortality include being cirrhotic, acute kidney injury, acidosis, and altered mental status or encephalopathy.
BACKGROUND: A web-based EMR-linked cancer care tracking system (CCTS) for the detection of lung and liver cancers was developed from 2007 to 2010 at our institution. CCTS was formally implemented in 2010, as part of the infrastructure of a dedicated liver cancer program. Designated radiology codes and a natural language processor (NLP) are used to conduct daily automated reviews of all relevant radiology reports from which flags are generated for findings suspicious for hepatocellular carcinoma (HCC). We aimed to evaluate whether the implementation of this system has had any impact upon BCLC stage at the time of HCC diagnosis. METHODS: This study was a retrospective cohort design with research data collected by chart review from years 2003-2013. Two primary groups were compared: patients diagnosed with HCC prior to CCTS implementation, and those diagnosed after. The primary outcome was BCLC stage at diagnosis, which was analyzed by Chi-squared Test (χ2 test) to assess for difference in proportional distributions. RESULTS: 78/78 patients diagnosed with HCC from 2003-2009 and 96/104 patients from 2010-2013 had sufficient data on chart review for BCLC staging. In the pre-CCTS group, stages at diagnosis were BCLC-0 1.3%, BCLC-A 33%, BCLC-B 7.7%, BCLC-C 32%, and BCLC-D 25.6%. In the post-CCTS group, stages at diagnosis were BCLC-0 9.4% BCLC-A 42.7%, BCLC-B 18.8%, BCLC-C 16.7%, and BCLC-D 12.5%. The proportional distribution was significantly different between the two groups (p<0.001) with a shift observed toward earlier stage disease. CONCLUSION: We observed a statically significant difference in the distribution of BCLC-staged HCC at diagnosis pre- and post- implementation of a webbased EMR-linked cancer tracking application. The observed shift towards earlier stage disease suggests that such a system facilitates earlier diagnosis of HCC. Mo1038 Racial Disparities in In-Hospital Outcomes for Hepatocellular Carcinoma in the United States Ruma Rajbhandari, Raymond T. Chung, Ashwin N. Ananthakrishnan Background and Aims: The incidence of hepatocellular carcinoma (HCC) is increasing. Racial disparities have been documented in treatment and outcomes of HCC but have been attributed to differences in access to care. In-hospital outcomes reduce the influence of access to care and are an important cohort to assess for racial disparities. Variations in inhospital care and outcomes of treatment for HCC have not been examined previously. Methods: Using the 2011 US Nationwide Inpatient Sample, we identified hospitalized patients with HCC-related hospitalizations using ICD-9-CM codes for diagnoses or procedures related to the management of HCC [liver transplantation, hepatic resection, ablation or transarterial chemoembolization (TACE)]. Multivariable regression was performed to identify the independent effect of race on receiving a therapeutic procedure as well as inhospital mortality. Results: We identified a total of 23,004 HCC-related discharges in 2011, among which 10,286 were associated with one of the four therapeutic procedures listed above. Overall, hospitalization related to HCC among blacks was associated with a significantly lower proportion of therapeutic procedures compared to whites (35% vs. 46%, multivariate OR 0.66, 95% CI 0.51 - 0.85). Among specific procedures, blacks had reduced odds of undergoing liver transplantation (OR 0.46, 95% CI 0.28-0.74), hepatic resection (OR 0.54, 95% CI 0.31-0.93) and ablation (0.52, 95% CI 0.34-0.81) compared to whites but were similarly likely to undergo TACE (OR 0.94, 95% CI 0.71-1.24). On multivariable analysis
Mo1036 Cascade of Care for Hepatitis C Virus (HCV) Infection Within the U.S. Department of Veterans Affairs (VA) Marissa Maier, David Ross, Maggie Chartier, Pamela S. Belperio, Lisa I. Backus Background With new efficacious HCV treatments available, a population health approach is useful to assess a healthcare system's ability to identify infected individuals, link them to care, provide antiviral treatment, and achieve sustained virologic response (SVR). Methods The Cascade of HCV Care for all Veterans in VA care in 2013 (as defined by at least one outpatient visit) has five steps: (1) Number with HCV infection-We used VA's Corporate Data Warehouse to determine HCV screening, RNA confirmatory testing, infection prevalence and per year incident diagnosis rates. The estimated total number with HCV infection reflects the sum of 1) those already identified with a detectable HCV viral load or genotype, 2) estimated additional cases if RNA testing were performed on those with positive HCV antibody results without RNA testing and 3) estimated additional cases if all unscreened Veterans were screened based on the incident diagnosis rate in each sex, birth cohort and race/ethnicity stratum in care in 2013 multiplied by the ratio of the 2013 to 2012 rate. (2)
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AASLD Abstracts
AASLD Abstracts
with cirrhosis (18-64%). Previous studies have attributed lapses in HCC surveillance to provider under recognition of cirrhosis, lack of knowledge of HCC guidelines, lack of healthcare engagement and nonadherence by patients. The aim was to evaluate HCC surveillance patterns among veterans as a function of geographic access to their assigned primary care provider and Veterans Affairs Medical Center. METHODS: A retrospective cohort study was conducted to identify veteran patients with an assigned primary care provider who were initially diagnosed with cirrhosis between October 1, 2005-June 30, 2012. Initial HCC surveillance was defined as having received an abdominal ultrasound, CT scan, or MRI with or without alpha-fetoprotein within 12 months of the initial diagnosis of cirrhosis (index date). The independent variables of interest were distance and patient rurality. Geocoded address' using zip code data were used to estimate travel distance. Rurality categories (isolated, small rural, large rural and urban) from the Department of Veterans Affairs Planning Systems Support Group (PSSG) were used. Associations were examined using Cox proportional hazards regression adjusting for demographic, non-liver co-morbidities (Gagne score) and liver disease severity (MELD score). RESULTS: Of the 59,296 veterans with cirrhosis (93% male), 34.2% received surveillance for HCC within 12 months of the index date. 50.4% of the patients living < 10 miles away from their medical center were screened compared with 41.7% of the patient's living ≥ 60 miles (P < 0.001). For each surveillance method, as distance from the medical center decreased the proportion of patients receiving surveillance increased. On average, 15.4% of patients received alpha fetoprotein alone while the proportion of patients receiving any image plus alpha fetoprotein ranged from 30.2% to 36.4% (< 10 mile vs ≥ 60 mile group), P < 0.001. Patients who lived ≥ 30 miles from a medical center were less likely to receive HCC surveillance in the first 12 months after the cirrhosis index date compared with patients who lived < 10 miles, [Hazard Ratio(≥30 miles to < 60 miles): 0.95, Confidence Intervals (CI): 0.92-0.99; HR (≥ 60 miles), CI: 0.89-0.96)]. There was no association between surveillance for HCC and location of primary care provider. CONCLUSIONS: Geographic access is associated with HCC surveillance in patients who live more than 30 miles away from a VA medical center. Further efforts should focus on identifying systematic strategies to increase HCC surveillance using co-management roles between primary care physicians and subspecialist.