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• W3106917117 abstract "We read with interest work by Kim et al.1Kim N.J. et al.Clin Gastroenterol Hepatol. 2020; ([E-pub ahead of print])Google Scholar In a Web-based anonymous 29-question survey, Kim et al canvassed 654 gastroenterology and hepatology providers from 26 U.S. medical centers in 17 states. About half of the providers (n = 305, 47%) responded, with 40% faculty physicians, 21% advanced practice providers, and 39% trainees. Notably, 82.6% worked in an academic setting, and 87.2% were affiliated to liver transplant centers. Further, 52.8% of practitioners saw >100 unique cirrhotic patients in clinic in a year. From the responses, Kim et al found that 98.4% felt hepatocellular carcinoma (HCC) surveillance should be every 6 months for patients with cirrhosis, with the most preferred test being ultrasound ± α-fetoprotein (AFP) (84.2%). In one case scenario, posing 2 patients with cirrhosis who had 0.1% and 0.5% risk of developing HCC per year, respectively, 61% felt that both patients should undergo regular HCC surveillance. Further, comparing 2 patients with cirrhosis who had 1% and 3% risk of developing HCC per year, respectively, 86% felt that both patients should undergo regular HCC surveillance whereas 13% felt surveillance was only needed for the patient with 3% annual HCC risk. When the scenario was changed so that the HCC risk for 2 patients were 3% and 5% risk per year, 99.7% of providers recommended HCC surveillance for both patients. In resource-unlimited settings, providers would on average recommend surveillance for patients with annual HCC risk >0.5%, though the distribution of responses varied. Finally, as annual risk of HCC increased, providers were more likely to pursue computed tomography or magnetic resonance imaging ± AFP over ultrasound ± AFP.1Kim N.J. et al.Clin Gastroenterol Hepatol. 2020; ([E-pub ahead of print])Google Scholar Overall, we appreciate the findings and are impressed by the level of detail included in the questions. One of the great detractors unfortunately is that this is not a representative sample of gastroenterologists and hepatologists across the United States. According to the Medscape Gastroenterologist Compensation Report in 2019, only 10% classified themselves as “Academic (nonhospital), research, military, [or] government.”2Kane L. Available at: https://www.medscape.com/slideshow/2019-compensation-gastroenterologist-6011330#19. Accessed October 16, 2020.Google Scholar In a recent meta-analysis, the pooled HCC surveillance rate was 24.0% (95% confidence interval: 18.4%–30.1%).3Wolf E. et al.Hepatology. 2020 May 8; ([E-pub ahead of print])Google Scholar Different approaches have been used to improve HCC surveillance, including mailed-outreach programs,4Singal A.G. et al.Hepatology. 2019; 69: 121-130PubMed Google Scholar,5Aby E.S. et al.Hepatol Commun. 2020; 4: 825-833Crossref PubMed Scopus (4) Google Scholar electronic medical record reminders, and nurse- or pharmacist-based protocols.3Wolf E. et al.Hepatology. 2020 May 8; ([E-pub ahead of print])Google Scholar In a study by Singal et al,4Singal A.G. et al.Hepatology. 2019; 69: 121-130PubMed Google Scholar HCC surveillance was only 7.3% among usual care patients with cirrhosis but improved to 23.3% for patients who received outreach or navigation. However, given the poor overall surveillance rate, while having a more refined algorithm may provide a small incremental improvement in quality of care for select patients, decreased surveillance due to increased complexity of the algorithm may potentially lead to worsened outcomes. In conclusion, this work by Kim et al sheds light on several important perspectives on cirrhosis surveillance. More work is needed to better assess perspectives from providers in nonacademic settings as well as ways to improve overall surveillance to better care for our patients with cirrhosis. Provider Attitudes Toward Risk-Based Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis in the United StatesClinical Gastroenterology and HepatologyVol. 20Issue 1PreviewHepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers’ opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient’s HCC risk on the choice of surveillance modality. Full-Text PDF ReplyClinical Gastroenterology and HepatologyVol. 19Issue 9PreviewWe thank our colleagues Wei et al for their interest in our study1 on provider attitudes toward risk-based hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis. We agree that the perspectives of community-based gastroenterology and hepatology providers are important. Most of the surveyed providers in our study reported practicing in academic settings, which was a limitation we described in our paper. However, our findings remain relevant because HCC surveillance rates have been suboptimal even in academic-based subspecialty settings. Full-Text PDF" @default.
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• W3106917117 title "Provider Perspectives on HCC Surveillance in Patients With Cirrhosis: Community Provider Perspectives Matter" @default.
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• W3106917117 doi "https://doi.org/10.1016/j.cgh.2020.10.050" @default.
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