Effect of travel distance and rurality of residence on initial surveillance for hepatocellular carcinoma in VA primary care patient with cirrhosis

Abstract

Objective To determine the relationship between travel distance and surveillance for hepatocellular carcinoma among veterans with cirrhosis. Data Sources Veterans Health Administration (VHA) inpatient and outpatient administrative data were linked to geocoded enrollee files. CMS‐VHA merged data were used to assess receipt of Medicare‐financed non‐VA imaging. Study Design A retrospective cohort of US veterans diagnosed with cirrhosis between 2009 and 2015 was examined. First available abdominal imaging following the diagnosis of cirrhosis was analyzed separately as a function of travel distance to the nearest VA medical center (VAMC) and to the patient's assigned VA primary care provider. Veterans with dual use of Medicare and VA services were also examined for receipt of imaging outside of the VA. Principal Findings Veterans who resided more than 30 miles from the nearest VAMC were less likely to receive any imaging for HCC surveillance. Among dual users, increased travel distance between the patient's residence and nearest VAMC was associated with an increased likelihood of receiving any abdominal imaging at non‐VA facilities. Conclusion Increased travel distance to the nearest VA medical center reduces the likelihood of receiving imaging for HCC surveillance in cirrhotic veterans. Future efforts should focus on reducing geographic barriers to HCC surveillance.

Patients with hepatocellular carcinoma from more rural and lower‐income households have more advanced tumor stage at diagnosis and significantly higher mortality

“…For example, Rongey et al evaluated 156,965 US veterans with chronic HCV to determine the impact of rural residency on quality of liver care and observed that patients in rural regions were significantly less likely to access HCV specialty care 11 . Similar studies using the Veterans Affairs database also observed that rural residency was associated with lower rates of receiving HCC surveillance 32 . Ross et al evaluated data from the Scientific Registry of Transplant Recipients from 2002 through 2014 and observed that patients from low‐income households or from rural geographic regions had significantly greater liver transplantation waitlist mortality, primarily driven by disparities in resources on low‐income and rural regions 33 .…”

Disparities in treatment and survival in early‐stage hepatocellular carcinoma in California

“…This is likely due to the complexity of care involved in HCC, such as diagnosis, surveillance, and other treatments not included in our analysis. For instance, several reports have shown rural residents were found to have lower rates of antiviral treatment for hepatitis, decreased rates of surveillance, and higher stages of disease at diagnosis 19–21 . Therefore, the disparities noted in the current study of patients with early‐stage HCC are likely multifactorial and partially contributed to increased distance from specialty care.…”

“…For instance, several reports have shown rural residents were found to have lower rates of antiviral treatment for hepatitis, decreased rates of surveillance, and higher stages of disease at diagnosis. [19][20][21] Therefore, the disparities noted in the current study of patients with early-stage HCC are likely multifactorial and partially contributed to increased distance from specialty care. Furthermore, additional complexity is added when one considers that while distance from treatment centers is often measured in miles, this often understates travel difficulty.…”

Surveillance for liver cancer in primary care: A systematic review of the evidence

“…Summaries of the included papers are provided in Appendix 2 (outcomes) and Appendix 3 (study design). Most studies originated from the USA [20][21][22][23][24][25][28][29][30][31][32][34][35][36][38][39][40][41][42][43][44][45][46][48][49][50][51][52] (88%; n=28), with two studies from Australia 19,33 and single studies from Italy 37 and Japan. 47 The most common study designs were retrospective cohort (44%; n=14), cross-sectional (28%; n=9) and quasi-experimental (14%; n=4).…”