Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic

Abstract

Introduction: We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion.

Methods: Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables.

Results: The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9-10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9-3.6) and telemedicine (β 2.1, 95% CI 1.9-2.4) were associated with a higher PTUDS.

Discussion: Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.

Figure 1.

Cohort clinical outcomes, healthcare utilization and HCC Surveillance during the COVID-19 pandemic Panel A shows crude monthly mortality rates from 1/1/20 to 12/31/21 Panel B shows the percent visit type, in-person versus telemedicine, superimposed on the monthly visit volume Panel C shows total monthly hospitalization rates among patients with cirrhosis, percent attributable to COVID-19 infection, and U.S. COVID-19 cases during the study period Panel D shows the monthly percent of the cohort that was up to date with HCC surveillance during the study period

Figure 2 –

Association between Incremental Visits and Changes in Percent Time Up to Date (UTD), Stratified by U.S. Region

Figure 3 –

Adjusted Association between Center-Level Advanced Liver Disease Dashboard Usage and Percent of Time Up to Date with HCC Surveillance in (A) Model 2 and (B) Interaction Model with Academic Center Status* * In both models, estimates were computed for a hypothetical Black patient with hepatitis C virus-related cirrhosis, diabetes, MELD-Na 20, Child-Pugh class B. All other model variables are held at mean values.