Comparative and cost effectiveness of treatment modalities for hepatocellular carcinoma in SEER-Medicare

Demographic and survival characteristics of untreated hepatocellular carcinoma patients: insights into the natural history and prognostic determinants

BACKGROUND

Hepatocellular carcinoma (HCC) patients with advanced symptoms or liver failure are often ineligible for transplantation, leading only to symptom control. Additionally, various factors lead to other HCC stage patients remaining in natural history.

OBJECTIVE

To describe the demographic of untreated HCC patients and to analyze survival-influencing factors.

METHODS

single-center retrospective observational study examining HCC patients diagnosed from 2015 to 2021 who received symptom control as their primary treatment. Baseline characteristics and survival data were collected and analyzed.

RESULTS

Of 685 HCC patients, 26% (n=181) remained in natural history, median age 71 years, 82% male patients, 93% with cirrhosis, 53% with previous decompensation. At a mean follow-up of 9.98 months, the mortality rate was 84%. While 49.8% of patients were BCLC-D stage, other reasons for remaining in natural history included frailty (25.4%) comorbidities (16%), and patient's treatment refusal (8%). Independent survival factors were BCLC stage, previous decompensation and diagnosis within the screening program, with 37% of untreated patients detected through surveillance.

CONCLUSIONS

Liver function, BCLC stage and functional status influence survival in natural HCC history. A significant 37% diagnosed through screening indicates inclusion criteria refinement necessity to avoid overdiagnosis and optimize resources.

Financial burden in a US cohort of patients with HCC

BACKGROUND

High financial burden for patients has been reported for multiple types of cancer, but there are limited data in those with HCC. We aimed to describe the financial burden for patients diagnosed with HCC and identify correlates of high financial burden.

METHODS

We used the IQVIA PharMetrics Plus for Academics database to identify commercially insured patients diagnosed with HCC between 2006 and 2021. Patient financial liability was defined as the difference between allowed and paid amounts from adjudicated insurance claims. We reported total and HCC-related financial liabilities (i.e., cost for HCC-related claims), with high total financial liability defined as ≥$3000 annually and high HCC-related financial liability as ≥$1000 annually. We used multivariable logistic regression modeling to identify factors associated with high total and HCC-related financial liability.

RESULTS

Among 11,609 patients with HCC, the median total financial liability during the year after HCC diagnosis was $2955 (Q1-Q3: $972-$6293). Nearly half (45%) of patients experienced high total financial liability, with the greatest liability incurred in the 3-month period immediately following HCC diagnosis. Older age, increased comorbidity, and cirrhosis-related complications were associated with higher total patient liability. Patient liability also varied by type of HCC treatment, with systemic therapy and liver transplantation having the highest financial liability in multivariable analysis. However, only 66.7% of the patients experienced HCC-related liability.

CONCLUSIONS

Patients with HCC experience significant financial liability underscoring a need for price transparency as well as financial counseling in this population.

OHCCPredictor: an online risk stratification model for predicting survival duration of older patients with hepatocellular carcinoma

BACKGROUND

Although the elderly constitute more than a third of hepatocellular carcinoma (HCC) patients, they have not been adequately represented in treatment and prognosis studies. Thus, there is not enough evidence to guide the treatment of such patients. The objective of this study is to identify the prognostic factors of older patients with HCC and to construct a new prognostic model for predicting their overall survival (OS).

METHODS

2,721 HCC patients aged ≥ 65 were extracted from the public database-Surveillance, Epidemiology, and End Results (SEER) and randomly divided into a training set and an internal validation set with a ratio of 7:3. 101 patients diagnosed from 2008 to 2017 in the First Affiliated Hospital of Zhejiang University School of Medicine were identified as the external validation set. Univariate cox regression analyses and multivariate cox regression analyses were adopted to identify these independent prognostic factors. A predictive nomogram-based risk stratification model was proposed and evaluated using area under the receiver operating characteristic curve (AUC), calibration curves, and a decision curve analysis (DCA).

RESULTS

These attributes including age, sex, marital status, T stage, N stage, surgery, chemotherapy, tumor size, alpha-fetoprotein level, fibrosis score, bone metastasis, lung metastasis, and grade were the independent prognostic factors for older patients with HCC while predicting survival duration. We found that the nomogram provided a good assessment of OS at 1, 3, and 5 years in older patients with HCC (1-year OS: (training set: AUC = 0.823 (95%CI 0.803-0.845); internal validation set: AUC = 0.847 (95%CI 0.818-0.876); external validation set: AUC = 0.732 (95%CI 0.521-0.943)); 3-year OS: (training set: AUC = 0.813 (95%CI 0.790-0.837); internal validation set: AUC = 0.844 (95%CI 0.812-0.876); external validation set: AUC = 0.780 (95%CI 0.674-0.887)); 5-year OS: (training set: AUC = 0.839 (95%CI 0.806-0.872); internal validation set: AUC = 0.800 (95%CI 0.751-0.849); external validation set: AUC = 0.821 (95%CI 0.727-0.914)). The calibration curves showed that the nomogram was with strong calibration. The DCA indicated that the nomogram can be used as an effective tool in clinical practice. The risk stratification of all subgroups was statistically significant (p < 0.05). In the stratification analysis of surgery, larger resection (LR) achieved a better survival curve than local destruction (LD), but a worse one than segmental resection (SR) and liver transplantation (LT) (p < 0.0001). With the consideration of the friendship to clinicians, we further developed an online interface (OHCCPredictor) for such a predictive function ( https://juntaotan.shinyapps.io/dynnomapp_hcc/ ). With such an easily obtained online tool, clinicians will be provided helpful assistance in formulating personalized therapy to assess the prognosis of older patients with HCC.

CONCLUSIONS

Age, sex, marital status, T stage, N stage, surgery, chemotherapy, tumor size, AFP level, fibrosis score, bone metastasis, lung metastasis, and grade were independent prognostic factors for elderly patients with HCC. The constructed nomogram model based on the above factors could accurately predict the prognosis of such patients. Besides, the developed online web interface of the predictive model provide easily obtained access for clinicians.

Is surgical treatment of hepatocellular carcinoma at high-volume centers worth the additional cost?

BACKGROUND

Case volume has been associated with improved outcomes for patients undergoing treatment for hepatocellular carcinoma, often with higher hospital expenditures. We sought to define the cost-effectiveness of hepatocellular carcinoma treatment at high-volume centers.

METHODS

Patients diagnosed with hepatocellular carcinoma from 2013 to 2017 were identified from Medicare Standard Analytic Files. High-volume centers were defined as the top decile of facilities performing hepatectomies in a year. A multivariable generalized linear model with gamma distribution and a restricted mean survival time model were used to estimate costs and survival differences relative to high-volume center status. The incremental cost-effectiveness ratio was used to define the additional cost incurred for a 1-year incremental gain in survival.

RESULTS

Among 13,666 patients, 8,467 (62.0%) were treated at high-volume centers. Median expenditure was higher ($19,148, interquartile range $15,280-$29,128) among patients treated at high-volume centers versus low-volume centers ($18,209, interquartile range $14,959-$29,752). Despite similar median length-of-stay (6 days, interquartile range 4-9), a slightly higher proportion of patients were discharged to home from high-volume centers (n = 4,903, 57.9%) versus low-volume centers (n = 2,868, 55.2%) (P = .002). A 0.14-year (95% confidence interval 0.06-0.22) (1 month and 3 weeks) survival benefit was associated with an incremental cost of $1,070 (95% confidence interval $749-$1,392) among patients undergoing surgery at high-volume centers. The incremental cost-effectiveness ratio for treatment at a high-volume center was $7,951 (95% confidence interval $4,236-$21,217) for an additional year of survival, which was below the cost-effective threshold of $21,217.

CONCLUSION

Surgical care at high-volume centers offers the potential to deliver cancer care in a more cost-effective and value-based manner.

Arterial chemotherapy for hepatocellular carcinoma in China: consensus recommendations

Hepatocellular carcinoma (HCC) is one of the most common malignancies and the third leading cause of cancer-related deaths globally. Hepatic arterial infusion chemotherapy (HAIC) treatment is widely accepted as one of the alternative therapeutic modalities for HCC owing to its local control effect and low systemic toxicity. Nevertheless, although accumulating high-quality evidence has displayed the superior survival advantages of HAIC of oxaliplatin, fluorouracil, and leucovorin (HAIC-FOLFOX) compared with standard first-line treatment in different scenarios, the lack of standardization for HAIC procedure and remained controversy limited the proper and safe performance of HAIC treatment in HCC. Therefore, an expert consensus conference was held on March 2023 in Guangzhou, China to review current practices regarding HAIC treatment in patients with HCC and develop widely accepted statements and recommendations. In this article, the latest evidence of HAIC was systematically summarized and the final 22 expert recommendations were proposed, which incorporate the assessment of candidates for HAIC treatment, procedural technique details, therapeutic outcomes, the HAIC-related complications and corresponding treatments, and therapeutic scheme management.

Trends of Hepatocellular Carcinoma (HCC) Inpatients Mortality and Financial Burden From 2011 to 2017: A Nationwide Analysis

INTRODUCTION

Liver cancer, including Hepatocellular carcinoma (HCC) is the seventh most common tumor worldwide. Previously, the financial burden of HCC in the United States between 2002 and 2011 was noted to be continuously increasing. This study aims to evaluate temporal trends of hospitalizations due to HCC.

METHOD

This is a retrospective analysis utilizing the National Inpatient Sample (NIS) database. All subjects admitted between 2011 and 2017 with a diagnosis of HCC were identified. The primary trend characteristics were in-hospital mortality, hospital charges, and length of stay.

RESULTS

An increase in hospitalization from 67,779 (0.18%) admissions in 2011 to 84,580 (0.23%) admissions in 2017( P <0.05) was noted. Most patients were 45 to 64 years old (median 50%), predominantly men (median 68%) ( P <0.05). The primary health care payer was Medicare (Median 49%) and Medicaid (Median 18%) ( P <0.05). The most common geographical location was the south (Median 36%) ( P <0.05). Most patients were admitted to large hospitals (Median 62%) in urban areas ( P <0.05). The median inpatient mortality was estimated to be 9% in 2017 ( P <0.05), which has decreased from 10%( P <0.05) in 2011. The total charges per admission have increased steadily from $58,406 in 2011 to $78,791 in 2017 ( P <0.05). The median length of stay has increased from 5.79 (SD 6.93) in 2011 to 6.07 (SD 8.3) in 2017( P <0.05). The most common mortality risk factor was sepsis, Acute renal failure, and GI hemorrhage.

CONCLUSION

HCC-related admissions continue to be on the rise. HCC mortality has decreased across the years with earlier diagnoses and advances in therapy. However, we observed a significant increase in financial burden on health care with increasing in-hospital costs, a finding that needs to be verified in prospective trials.

Changing treatment landscape associated with improved survival in advanced hepatocellular carcinoma: a nationwide, population-based study

BACKGROUND AND AIMS

The treatment of hepatocellular carcinoma (HCC) is undergoing a historic transformation with the approval of several new systemic therapies in the last few years. This study aimed to examine the impact of this changing landscape on survival and costs in a Western nationwide, real-world cohort.

METHODS

A nationwide representative claims database (InGef) was screened for HCC cases between 2015 and 2020. Survival in an era with only sorafenib (period A, January 2015 to July 2018) and after approval of lenvatinib and other systemic treatments (period B, August 2018 to December 2020) was analysed. Health care costs were assessed.

RESULTS

We identified 2876 individuals with HCC in the study period. The proportion of patients receiving systemic therapy increased significantly over time, from 11.8% in 2015 to 15.1% in 2020 (p < 0.0001). The median overall survival in period B was 6.5 months (95% confidence interval [CI]: 4.9-8.9) and in period A was 5.3 months (95% CI: 4.5-6.3; p = 0.046). In period B, the median overall survival with lenvatinib was 9.7 months (95% CI: 6.3-18.4) versus 4.8 months with sorafenib (95% CI: 4.0-7.1, p = 0.008). Costs for prescription drugs per patient increased from €6150 in 2015 to €9049 in 2020 (p < 0.0001), and costs for outpatient care per patient increased from €1646 to €2149 (p = 0.0240).

CONCLUSION

The approval of new systemic therapies resulted in a survival benefit in patients with HCC. The magnitude of the effect is modest and associated with a moderate increase in health costs.

Cost-effectiveness of selective internal radiation therapy with Y-90 resin microspheres for intermediate- and advanced-stage hepatocellular carcinoma in Brazil

AimsHepatocellular carcinoma (HCC) is a severe condition with poor prognosis that places a significant burden on patients, caregivers, and healthcare systems. Selective internal radiation therapy (SIRT) is a treatment available to patients with HCC which addresses some of the limitations of alternative treatment options. A cost-effectiveness analysis was undertaken into the use of SIRT using Y-90 resin microspheres for the treatment of unresectable, intermediate- and late-stage HCC in Brazil.Materials and methodsA partitioned-survival model was developed, including a tunnel state for patients downstaged to receive treatments with curative intent. Sorafenib was the selected comparator, a common systemic treatment in Brazil and for which comparative evidence exists. Clinical data were extracted from published sources of pivotal trials, and effectiveness was measured in quality-adjusted life-years (QALYs) and life-years (LYs). The analysis was conducted from the Brazilian private payer perspective and a lifetime horizon was implemented. Comprehensive sensitivity analyses were conducted.ResultsLYs and QALYs were higher for SIRT with Y-90 resin microspheres versus sorafenib (0.27 and 0.20 incremental LYs and QALYs, respectively) and costs were slightly higher for SIRT (R$15,864). The base case incremental cost-effectiveness ratio (ICER) was R$77,602 per QALY. The ICER was mostly influenced by parameters defining the sorafenib overall survival curve and SIRT had a 73% probability of being cost-effective at a willingness-to-pay threshold of R$135,761 per QALY (three times the per-capita gross domestic product in Brazil). Overall, sensitivity analyses confirmed the robustness of the results indicating that SIRT with Y-90 resin microspheres is cost-effective compared with sorafenib.LimitationsA rapidly evolving treatment landscape in Brazil and worldwide, and the lack of local data for some variables were the main limitations.ConclusionsSIRT with Y-90 resin microspheres is a cost-effective option compared with sorafenib in Brazil.

Insurance Status Correlates with Access to Procedural Therapy for Patients with Early-Stage Hepatocellular Carcinoma: A Retrospective Cohort Study of the National Cancer Database

PURPOSE

To compare access to specific procedural therapies across insurance types for patients with American Joint Commission on Cancer (AJCC) Stage I or II hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Using the National Cancer Database, patients diagnosed with Stage I or II HCC between 2004 and 2019 were identified. Parametric and nonparametric testing was used to compare the rates of procedural modalities and time to therapy across insurance types. Univariate and multivariate logistic regression analyses were used to identify the likelihood of receiving specific procedural therapy based on insurance status.

RESULTS

In total, 105,703 patients with AJCC Stage I or II HCC were identified. The rates of ablative therapy were similar across insurance types (18.1% total, 17.2% private insurance, 15.3% uninsured, 18.1% Medicaid, and 18.8% Medicare). In the logistic regression analysis, patients with private insurance were more likely to receive a transplant or undergo resection or procedural therapy of any kind. Patients with Medicare insurance were more likely to undergo ablation (odds ratio, 1.11; 95% confidence interval, 1.07-1.15; P < .001) than those with private insurance.

CONCLUSIONS

Patients with private insurance were more likely to receive most forms of procedural therapy for early-stage HCC, with the notable exception of ablative therapy, which patients with Medicare were slightly more likely to receive.

Feasibility Study and Design of Registration System for Upper Gastrointestinal Bleeding Patients in Isfahan Province

Background

Disease registration is an organized system for collecting, storing, retrieving, analyzing a particular disease or exposure to known substances in a specific population. The aim of this study was to assess the feasibility and design of the registration system for upper gastrointestinal bleeding patients based on patients referring to Al-Zahra and Khorshid hospitals, Isfahan, Iran.

Materials and Methods

This study is a research action study in which the members of the registration system team are hospital triage physicians, internal residents in the Emergency department of hospital, subspecialty assistants and gastroenterologists, statisticians (epidemiologists and methodologists), and two trained persons were specified to collect medical information and documents. The data collection tool is a researcher-made checklist. Based on the available tools, the most important criteria related to gastrointestinal bleeding were selected. In the next step, the criteria selected in the council, including team members, were reviewed and a preliminary draft was prepared to record the information of patients.

Results

The results indicated the final version of the checklist in three parts including demographic variables (age, sex, education, et al.), main variables (as the minimum data required by a person to register in the checklist (patient's clinical signs)), extended main variables (its information is designed to be used to diagnose, treat, and follow-up the patient in later stages).

Conclusion

It seems to be predictable by establishing a system for recording gastrointestinal bleeding diseases, disease prevalence, monitoring services and treatment of patients, survival analysis and evaluation of clinical care outcomes, finding patients at higher risk for emergency treatment, reviewing drug interventions, and interventional activities.

Hepatic Arterial Infusion Chemotherapy as a Timing Strategy for Conversion Surgery to Treat Hepatocellular Carcinoma: A Single-Center Real-World Study

Objective

To evaluate whether surgery-related complications are increased after hepatic arterial infusion chemotherapy (HAIC) using oxaliplatin plus fluorouracil/leucovorin for conversion compared with primary hepatocellular carcinoma (HCC) resection and the optimal timing of conversion surgery (CS).

Background

HAIC has been widely used for advanced HCC, especially initially unresectable HCC, to facilitate conversion to curative-intent resection in approximately 23.8% of cases. However, the optimal timing of surgery to reduce surgical complications must be clarified.

Methods

Data from 320 HCC patients, including 107 initially unresectable patients in the HAIC-Surgery group and 213 patients in the Surgery group, were retrospectively collected and analyzed. Survival outcomes and the incidence of surgery-related complications were compared.

Results

There was no significant difference in recurrence-free survival (RFS) between the HAIC-Surgery group and the Surgery group (HR: 1.140, 95% CI: 0.8027-1.618, p=0.444). The HAIC-Surgery group had a higher incidence of surgery-related complications than the Surgery group [biliary leakage (10.3% vs 4.2%, p=0.035), abdominal bleeding (10.3% vs 3.8%, p=0.020), pleural effusion (56.1% vs 23.0%, p<0.0001) and ascites effusion (17.8% vs 5.2%, p<0.0001)]. In the HAIC-Surgery group, postoperative liver function decreased and abdominal bleeding increased with more preoperative HAIC cycles (Spearman=0.229, p=0.042, Spearman=0.198, p=0.041, respectively). The pathological complete remission (pCR) rate after 3-5 HAIC cycles was significantly higher than that after 1-2 cycles (29.4% vs 13.2%, p=0.043).

Conclusion

The prognosis of advanced HCC after conversion surgery is comparable to that after direct surgery. Rather than increasing pCR, more HAIC cycles can exacerbate liver dysfunction and surgery-related complications.

Quality measures in HCC care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

The burden of HCC is substantial. To address gaps in HCC care, the American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) aimed to develop a standard set of process-based measures and patient-reported outcomes (PROs) along the HCC care continuum. We identified candidate process and outcomes measures for HCC care based on structured literature review. A 13-member panel with content expertise across the HCC care continuum evaluated candidate measures on importance and performance gap using a modified Delphi approach (two rounds of rating) to define the final set of measures. Candidate PROs based on a structured scoping review were ranked by 74 patients with HCC across 7 diverse institutions. Out of 135 measures, 29 measures made the final set. These covered surveillance (6 measures), diagnosis (6 measures), staging (2 measures), treatment (10 measures), and outcomes (5 measures). Examples included the use of ultrasound (± alpha-fetoprotein [AFP]) every 6 months, need for surveillance in high-risk populations, diagnostic testing for patients with a new AFP elevation, multidisciplinary liver tumor board (MLTB) review of Liver Imaging-Reporting and Data System 4 lesions, standard evaluation at diagnosis, treatment recommendations based on Barcelona Clinic Liver Cancer staging, MLTB discussion of treatment options, appropriate referral for evaluation of liver transplantation candidacy, and role of palliative therapy. PROs include those related to pain, anxiety, fear of treatment, and uncertainty about the best individual treatment and the future. The AASLD PMC has developed a set of explicit quality measures in HCC care to help bridge the gap between guideline recommendations and measurable processes and outcomes. Measurement and subsequent implementation of these metrics could be a central step in the improvement of patient care and outcomes in this high-risk population.

Conversion to Resectability Using Transarterial Chemoembolization Combined With Hepatic Arterial Infusion Chemotherapy for Initially Unresectable Hepatocellular Carcinoma

Objective

To evaluate whether this conversion rate to resectability could be increased when patients are treated with transarterial chemoembolization and hepatic arterial infusion chemotherapy (TACE-HAIC) using oxaliplatin plus fluorouracil/leucovorin.

Background

Conventional TACE (c-TACE) is a common regimen for initially unresectable hepatocellular carcinoma (HCC), which converts to curative-intent resection in about 10% of those patients. It is urgent need to investigated better regimen for those patients.

Methods

The data of 83 initially unresectable HCC patients were examined, including 41 patients in the TACE-HAIC group and 42 patients in the c-TACE group. Their response rate, conversion rate to resection, survival outcome, and adverse events were compared.

Results

The conversion rate was significantly better in the TACE-HAIC group than in the c-TACE group (48.8% vs 9.5%; P < 0.001). The TACE-HAIC had marginal superiority in overall response rate as compared to c-TACE (14.6% vs 2.4%; P = 0.107 [RECIST]; 65.9% vs 16.7%; P < 0.001 [mRECIST], respectively). The median progression-free survival was not available and 9.2 months for the TACE-HAIC and cTACE groups, respectively (hazard rate [HR]: 0.38; 95% confidence interval [CI], 0.20-0.70; P = 0.003). The median overall survival was not available and 13.5 months for the TACE-HAIC and c-TACE groups, respectively (HR, 0.63; 95% CI, 0.34-1.17; P = 0.132). The 2 groups had similar rates of grade 3/4 adverse events (all P > 0.05).

Conclusions

TACE-HAIC demonstrated a higher conversion rate and progression-free survival benefit than c-TACE and could be considered as a more effective regimen for patients with initially unresectable HCC. Future prospective randomized trials are needed to confirm it.

Survival in untreated hepatocellular carcinoma: A national cohort study

This study aimed to analyze the proportion, characteristics and prognosis of untreated hepatocellular carcinoma (HCC) patients in a large representative nationwide study. A cohort study was conducted using the National Health Insurance Service (NHIS) database in Korea. A total of 63,668 newly-diagnosed HCC patients between January 2008 and December 2013 were analyzed. Patients were categorized into treatment group and no treatment group using claim codes after HCC diagnosis. The proportion of untreated HCC patients was 27.6%, decreasing from 33.4% in 2008 to 24.8% in 2013. Compared to treated patients, untreated patients were more likely to be older (P < 0.001), female (P < 0.01), to have a distant SEER stage (P < 0.001), severe liver disease (P < 0.001), and lower income (P < 0.001). The fully-adjusted hazard ratio for all-cause mortality comparing untreated to treated patients was 3.11 (95% CI, 3.04–3.18). The risk of mortality was higher for untreated patients in all pre-defined subgroups, including those with distant SEER stage and those with severe liver disease. About one fourth of newly diagnosed HCC patients did not receive any HCC-specific treatment. Untreated patients showed higher risk of mortality compared to treated patients in all subgroups. Further studies are needed to identify obstacles for HCC treatment and to improve treatment rates.

Predictors of five-year survival among patients with hepatocellular carcinoma in the United States: an analysis of SEER-Medicare

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) are ≥ 65 years old at diagnosis and ~ 20% present with disease amenable to curative intent surgical therapy. The aim of this study was to examine whether treatment, the demographic variables, and clinical factors could predict 5-year survival among HCC patients.

METHODS

We included patients, 66 years or older, diagnosed with a first primary HCC from 1994 through 2007 in the SEER-Medicare database, and followed up until death or 31 December 2012. Curative intent treatment was defined as liver transplantation, surgery resection, or ablation. We estimated odds ratios (OR) and 95% confidence intervals (CI) for associations with 5-year survival using logistic regression.

RESULTS

We identified 10,826 patients with HCC with mean age 75.3 (standard deviation, 6.4) years. Most were male (62.2%) and non-Hispanic white (59.7%). Overall, only 8.1% of patients were alive 5 years post-HCC diagnosis date. Among all patients that survived ≥ 5 years, 69.8% received potentially curative treatment. Conversely, patients who received potentially curative treatment represented only 15.7% of patients who survived < 5 years. Curative intent treatment was the strongest predictor for surviving ≥ 5 years (vs. none/palliative treatment; adjusted OR 8.12, 95% CI 6.90-9.64). While stage at diagnosis and comorbidities were also independently associated with ≥ 5-year survival in HCC patients, these factors did not improve discrimination between short- and long-term survivors.

CONCLUSIONS

Curative intent treatment was the strongest predictor for survival ≥ 5 years among HCC patients. Given the limited availability of liver transplant and limited eligibility for surgical resection, finding curative intent HCC therapies remain critically important.

Survival Benefit of Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

In the United States, nearly 30% of liver transplants (LT) are performed for hepatocellular carcinoma (HCC). Although overall long-term survival is highest with LT, there are limited data on the incremental survival benefit of LT versus other curative options (resection or ablation) due to shunting of patients towards LT.

METHODS

We performed a retrospective cohort study of patients aged 50-69 with cirrhosis and HCC in the Veterans Health Administration (population enriched with 3 curative treatments) from 2008 to 2016. The cohort was restricted to patients who received LT, resection, or ablation and a calculated model for end-stage liver disease score <15 at HCC diagnosis.

RESULTS

Among 2129 veterans in the analytic cohort, 658 (26.7%) received LT, 244 (11.5%) underwent resection, and 1317 (61.59%) received ablation. In multivariable models, patients who underwent resection (hazard ratio: 5.42; 95% confidence interval: 4.15-7.08) or ablation (hazard ratio: 5.50; 95% confidence interval: 4.51-6.71) had significantly increased hazards of death. However, in absolute terms, the incremental survival benefit of LT over resection or ablation was small, between 0.02 and 0.03 years at 1 year, 0.32-0.42 years at 3 years, and 1.04-1.24 years at 5 years follow-up. These results were consistent in sensitivity analyses accounting for possible immortal time bias, as well as a cohort restricted to early/intermediate stage HCC.

CONCLUSIONS

Although LT is associated with significantly increased survival compared to resection and ablation, the absolute incremental survival benefit is small over a 5-year time horizon. Optimal selection of patients for LT is critical for maximizing utilization of a scarce resource.

Economic Evaluations of Anticancer Drugs Based on Medico-Administrative Databases: A Systematic Literature Review

BACKGROUND

Oncology is among the most active therapeutic fields in terms of new drug development projects, with increasingly expensive drugs. The expected clinical benefit and cost effectiveness of these treatments in clinical practice have yet to be fully confirmed. Health medico-administrative databases may be useful for assessing the value of anticancer drugs with real-world data.

OBJECTIVE

The objectives of our systematic literature review (SLR) were to analyse economic evaluations of anticancer drugs based on health medico-administrative databases, to assess the quality of these evaluations, and to identify the inputs from such databases that can be used in economic evaluations of anticancer drugs.

METHODS

We performed an SLR by using PubMed and Web of Science articles published from January 2008 to January 2019. The search strategy focused on anticancer drug cost-effectiveness analyses (CEAs)/cost-utility analyses (CUAs) that were entirely based on medico-administrative databases. The review reported the main choices of economic evaluation methods in the analyses. The quality of the articles was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and risk of bias assessment checklists.

RESULTS

Of the 306 records identified in PubMed, 12 articles were selected, and one additional article was identified through Web of Science. Ten of the 13 articles were CEAs and three were CUAs. Most of the analyses were carried out in North America (n = 11). The economic metric used was the cost per life-year gained (n = 10) or cost per quality-adjusted life-year (n = 3). Reporting of the target analysis population and strategies in the articles was in agreement with the CHEERS guidelines. The structural assumptions underpinning the economic models displayed the poorest reporting quality among the items analysed. Representativeness bias (n = 11) and the issue of censored medical costs (n = 8) were the most frequently analysed risks.

CONCLUSION

A comparison of the economic results was not relevant due to the high heterogeneity of the selected studies. Our SLR highlighted the benefits and pitfalls related to the use of medico-administrative databases in the economic evaluations of anticancer drugs.

Epidemiologic, humanistic and economic burden of hepatocellular carcinoma in the USA: a systematic literature review

AIM

To describe the epidemiologic, humanistic and economic burdens of hepatocellular carcinoma (HCC) in the USA.

MATERIALS & METHODS

Studies describing the epidemiology and economic burden from national cohorts, any economic models, or any humanistic burden studies published 2008-2018 were systematically searched.

RESULTS

HCC incidence was 9.5 per 100,000 person-years in most recent data, but was ∼100-times higher among patients with hepatitis/cirrhosis. Approximately a third of patients were diagnosed with advanced disease. Patients with HCC experienced poor quality of life. Direct costs were substantial and varied based on underlying demographics, disease stage and treatment received. Between 25-77% of patients did not receive surgical, locoregional or systemic treatment.

CONCLUSION

Better treatments are needed to extend survival and improve quality of life for patients with HCC.

Treatment Patterns and Economic Burden by Lines of Therapy Among Patients with Advanced Hepatocellular Carcinoma Treated with Systemic Cancer Therapy

PURPOSE

This study examined clinical and economic outcomes among patients with advanced hepatocellular carcinoma (HCC) treated with systemic agents by line of therapy.

METHODS

Adults with ≥ 2 medical claims for primary diagnosed HCC (from January 1, 2008, through September 30, 2015) and ≥ 1 claim for systemic HCC-related therapy were identified in the IBM MarketScan® Research Databases. Continuous enrollment was required 6 months before and 1 month after diagnosis. Patients were categorized into first- (1L) and second-line (2L) treatment cohorts; those receiving sorafenib as 1L were evaluated. Treatment patterns, healthcare resource utilization, costs, and survival during 1L and 2L therapy were measured. Survival was assessed for patients linked to the Social Security Administration Master Death File.

RESULTS

1459 patients, 758 with death data, met the 1L cohort criteria; 163 patients, 87 with death data, later received 2L therapy. 77.1% had 1L sorafenib, alone or in combination. Median 1L treatment duration was 3.0 months; median survival time from start of 1L to death or censor was 6.8 months. There was no predominant 2L agent. Median 2L treatment duration was 3.0 months; median survival time from start of 2L was 9.3 months. Median total healthcare costs per patient per month were $13,297 for 1L (all), $13,471 for 1L (sorafenib), and $11,786 for 2L.

CONCLUSIONS

Findings confirm high 1-year mortality for advanced HCC, suggesting a high cost burden. While no 2L therapy was available during this analysis, recently approved 2L agents have the potential to improve survival after sorafenib failure or intolerance.

Time-Driven Activity-Based Costing Comparison of CT-Guided Versus MR-Guided SBRT

PURPOSE

Magnetic resonance-guided radiation therapy (MRgRT) has recently become commercially available, offering the opportunity to accurately image and target moving tumors as compared with computed tomography-guided radiation therapy (CTgRT) systems. However, the costs of delivering care with these 2 modalities remain poorly described. With localized unresectable hepatocellular carcinoma as an example, we were able to use time-driven activity-based costing to determine the cost of treatment on linear accelerators with CTgRT compared with MRgRT.

MATERIALS AND METHODS

Process maps, informed via interviews with departmental personnel, were created for each phase of the care cycle. Stereotactic body radiation therapy was delivered at 50 Gy in 5 fractions, either with CTgRT using fiducial placement, deep inspiration breath-hold (DIBH) with real-time position management, and volumetric-modulated arc therapy, or with MRgRT using real-time tumor gating, DIBH, and static-gantry intensity-modulated radiation therapy.

RESULTS

Direct clinical costs were $7,306 for CTgRT and $8,622 for MRgRT comprising personnel costs ($3,752 v $3,603), space and equipment costs ($2,912 v $4,769), and materials costs ($642 v $250). Increased MRgRT costs may be mitigated by forgoing CT simulation ($322 saved) or shortening treatment to 3 fractions ($1,815 saved). Conversely, adaptive treatment with MRgRT would result in an increase in cost of $529 per adaptive treatment.

CONCLUSION

MRgRT offers real-time image guidance, avoidance of fiducial placement, and ability to use adaptive treatments; however, it is 18% more expensive than CTgRT under baseline assumptions. Future studies that elucidate the magnitude of potential clinical benefits of MRgRT are warranted to clarify the value of using this technology.

Do Elderly Patients With Stage I-II Hepatocellular Carcinoma Benefit From More Radical Surgeries? A Population-Based Analysis

Background and Aims: The best treatment modalities for elderly patients with stage I–II HCC (hepatocellular carcinoma) remain controversial in an era of a shortage of liver donors.

Methods: From the SEER database (Surveillance, Epidemiology, and End Results program), 2,371 elderly patients were sampled as Cohort 1. OS (Overall Survival) and CSS (Cancer-Specific Survival) were compared between the Non-surgery and Surgery groups. A stratification analysis in a CSS Cox model was also conducted among sub-groups, and propensity score matching was performed to generate Cohort 2 (746 pairs), reducing the influences of confounders.

Results: For Cohort 1, the median follow-up times of the Non-surgery and Surgery groups were 11 months (95% CI, confidence interval: 9.74–12.26) vs. 49 months (44.80–53.21) in OS, and 14 months (12.33–15.67) vs. 74 months (64.74–83.26) in CSS, respectively. In the stratification analysis, for the elderly patients (age >= 70 years), Larger Resection was associated with a higher HR (hazard ratio) than Segmental Resection: 0.30 (95% CI, confidence interval: 0.22–0.41) vs. 0.29 (0.21–0.38) in 70–74 year-olds; 0.26 (0.18–0.38) vs. 0.23 (0.16–0.32) in 75–79 year-olds; 0.32 (0.21–0.49) vs. 0.21 (0.13–0.32) in those 80+ years old. For Cohort 2, a similar result could be seen in the CSS Cox forest plot. The HRs of Larger Resection and Segmental Resection were 0.27 (0.21–0.33) and 0.25 (0.20–0.31), respectively.

Conclusions: It is cautiously recommended that, when liver transplantation is not available, segmental or wedge liver resection is the better treatment choice for elderly patients with stage I–II HCC (AJCC edition 6), especially those over 70 years old, compared with other surgeries, based on the SEER data.

Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review

Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.

Economic Implications of Hepatocellular Carcinoma Surveillance and Treatment: A Guide for Clinicians

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide, with significant morbidity and associated costs. Treatment allocation depends on the stage of diagnosis; however, resource utilization can be significant across all stages. We aimed to summarize the available data on the cost effectiveness of surveillance of and treatments for HCC in the context of current treatment guidelines. We performed a focused review of studies investigating the economic burden and cost effectiveness of HCC surveillance treatment modalities published between January 2000 and January 2019. The overall economic burden of HCC is increasing in the USA and in several countries worldwide due to its rising incidence and the proliferation of therapies. Liver transplantation is a cost-effective strategy for early-stage HCC treatment in selected patients. In settings where liver transplantation is not available or in patients awaiting transplant, ablative or locoregional therapies are cost effective with increases in quality-adjusted life-years. First-line therapy with sorafenib for advanced stage HCC is cost effective in the treatment of compensated cirrhosis. The cost effectiveness of recently approved systemic therapies for advanced HCC require further investigation. Existing studies have shown that guideline-recommended surveillance techniques and several available therapies for the treatment of HCC are cost effective; however, there are limitations in the literature, including reliance on suboptimal modeling with incomplete/simplified model structure or inadequate inputs. With increasing therapeutic options in patients with HCC, understanding their relative value is critical in designing HCC treatment algorithms.

Use of Claims Data for Cost and Cost-Effectiveness Research

Administrative claims data are big data generated from healthcare encounters. Claims data contain information on insurance payment as well as clinical diagnoses and procedure codes to ascertain medical conditions and treatments, making them valuable sources for economic evaluation research. This paper offers an introductory overview of the use of claims data for oncology-related cost-of-illness, cost comparison, and cost-effectiveness analyses. We reviewed analytical methods commonly employed in these analyses, such as the phase of care approach and net costing method for cost-of-illness studies, propensity score matching methods for cost comparison studies, and net benefit regression models for cost-effectiveness studies. We used published studies to explain each method and to discuss methodological challenges of conducting economic studies using claims data.

Modern Outcomes Following Treatment of Hepatocellular Carcinoma in Hereditary Hemochromatosis: A Matched Cohort Study

OBJECTIVE

Hepatocellular carcinoma (HCC) is a complication of the common genetic condition hereditary hemochromatosis (HH). It is unknown whether HH as an etiology of liver disease impacts the outcome. We compared the results of liver transplantation (LT), surgical resection and locoregional therapies in a matched cohort study and investigated whether HH as an etiology has an impact on survival.

MATERIALS AND METHODS

Consecutive patients with HH and HCC (2000 to 2015) were compared with age, sex and Barcelona Clinic Liver Cancer (BCLC) stage-matched non-HH HCC cases. Patients were offered curative or noncurative treatment according to BCLC stage and Milan criteria. The primary endpoint was all-cause mortality.

RESULTS

A total of 102 patients (52 HH; total cohort median age: 67 [44 to 78] y, 97% male, Model for End-stage Liver Disease: 9 [5 to 31]) were studied with a median follow-up of 22 (3 to 126) months. Of the HH cases, the median serum ferritin at diagnosis of HCC was 326 (27 to 5718) μg/L and α-fetoprotein 33 (2 to 197,926) kIU/L. Five-year survival for HH patients receiving curative therapy was 77% (80% for LT, 67% for resection/radiofrequency ablation), and 15% (23% for transarterial chemoembolization) for those undergoing noncurative therapy. Survival for HH patients compared with controls was similar (hazard ratio=0.949; P=0.839). On multivariate Cox regression survival analysis, BCLC stage, and diagnosis of ischemic heart disease (but not HH diagnosis) were independently associated with reduced survival.

CONCLUSIONS

Patients with HCC and HH can achieve comparable survival rates following curative or LRT modalities to other liver diseases. The BCLC staging system accurately stratifies survival and excellent 5-year survival is possible following LT in selected patients.

Healthcare Costs Related to Treatment of Hepatocellular Carcinoma Among Veterans With Cirrhosis in the United States

BACKGROUND & AIMS

It is important to quantify medical costs associated with hepatocellular carcinoma (HCC), the incidence of which is rapidly increasing in the United States, for development of rational healthcare policies related to liver cancer surveillance and treatment of chronic liver disease. We aimed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system and develop a model for predicting costs that is based on clinically relevant variables.

METHODS

Three years subsequent to liver cancer diagnosis, costs accrued by patients included in the Veteran's Outcome and Cost Associated with Liver disease cohort were compiled by using the Department of Veterans Affairs Corporate Data Warehouse. The cohort includes all patients with HCC diagnosed in 2008-2010 within the VA with 100% chart confirmation as well as chart abstraction of tumor and clinical characteristics. Cancer cases were matched 1:4 with non-cancer cirrhosis controls on the basis of severity of liver disease, age, and comorbidities to estimate background cirrhosis-related costs. Univariable and multivariable generalized linear models were developed and used to predict cancer-related overall cost.

RESULTS

Our analysis included 3188 cases of HCC and 12,722 controls. The mean 3-year total cost of care in HCC patients was $154,688 (standard error, $150,953-$158,422) compared with $69,010 (standard error, $67,344-$70,675) in matched cirrhotic controls, yielding an incremental cost of $85,679; 64.9% of this value reflected increased inpatient costs. In univariable analyses, receipt of transplantation, Barcelona Clinic Liver Cancer (BCLC) stage, liver disease etiology, hospital academic affiliation, use of multidisciplinary tumor board, and identification through surveillance were associated with cancer-related costs. Multivariable generalized linear models incorporating transplantation status, BCLC stage, and multidisciplinary tumor board presentation accurately predicted liver cancer-related costs (Hosmer-Lemeshow goodness of fit; P value ≅ 1.0).

CONCLUSIONS

In a model developed to comprehensively quantify healthcare costs for HCC among patients with cirrhosis in an integrated health system, we associated receipt of liver transplantation, BCLC stage, and multidisciplinary tumor board with higher costs. Models that predict total costs on the basis of receipt of liver transplantation were constructed and can be used to model cost-effectiveness of therapies focused on HCC prevention.

Cancer-directed therapy and potential impact on survivals in nonresected hepatocellular carcinoma: SEER-Medicare population study

Aim: To investigate determinants of receiving cancer-directed therapies and their potential survival impact in nonresected hepatocellular carcinoma (HCC) Materials & methods: Nonsurgically resected HCC patients between 2000 and 2010 were stratified by American Joint Committee on Cancer staging and the type of therapy. Predictors of receiving therapy were identified and implication on survival was evaluated. Results: Out of 9239 patients included, those receiving any therapy demonstrated prolonged overall survival with following median overall survival (months): ablation (30.8), Yttrium-90 (15.6), transcatheter arterial chemoembolization (15.5), Sorafenib (5.6), versus no cancer-directed therapy (3.7; p-values <0.001). Overall, 36% of patients received cancer-directed therapy including 47% with stage I/II. Favorable sociodemographic factors predicted receipt of percutaneous locoregional therapies (p-values <0.05). Discussion & Conclusion: There appears to be significant disparity in care of nonresected HCC patients with significant underutilization of cancer-directed therapies.

Lower Education and Household Income Contribute to Advanced Disease, Less Treatment Received and Poorer Prognosis in Patients with Hepatocellular Carcinoma

Understanding the ways in which socioeconomic status affects prognosis of hepatocellular carcinoma (HCC) is important for building up strategies eliminating the inequalities in cancer diagnosis and treatments among different groups, which, remains undetermined. In the present study, 1485 newly diagnosed HCC patients with complete demographic and clinical data were included. Socioeconomic data, including education, annual household income and residency was also reported by patients or families. In the present study, less educated patients were older, more female involved, poorly paid, more living in rural places, had more advanced tumor burden, received less curative and loco-regional therapies, and thus showed poorer short-term and long-term outcomes (in total or after surgical resection) than the highly educated. Patients with lower income were less educated, less treated, and more likely to live in rural places, had more advanced stages of HCC and thus poorer long-term survival (in total or after surgical resection) than higher income groups. In Cox regression analysis, lower household income was independently associated with poorer outcome (HR=1.2, 95% CI: 1.0-1.4, p=0.036). These results indicate that education and income are critically associated with early diagnosis, treatments and prognosis of HCC. Much more efforts should be taken to support the patients with less education and lower income to improve the outcomes of HCC.

Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

BACKGROUND & AIMS

Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival.

METHODS

We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival.

RESULTS

In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60-2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15-2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98-1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16-0.31), liver resection (HR, 0.38; 95% CI, 0.28-0.52), ablative therapy (HR, 0.63; 95% CI, 0.52-0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74-0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63-0.78), medical oncologists (HR, 0.82; 95% CI, 0.74-0.91), or surgeons (HR, 0.79; 95% CI, 0.71-0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77-0.90), were associated with reduced mortality.

CONCLUSIONS

In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.

Creating an effective clinical registry for rare diseases

The exposure of clinicians to patients with rare gastrointestinal diseases is limited. This hurts clinical studies, which impedes accumulation of scientific knowledge on the natural disease course, treatment outcomes and prognosis in these patients. An excellent method to detect patterns on an aggregate level that would not be possible to discover in individual cases, is a registry study. This paper aims to describe a template to create a successful international registry for rare diseases. We focus mainly on rare hepatic diseases, but lessons from this paper serve other fields in medicine, as well.

Secondary analysis of large databases for hepatology research

Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.

Survival in unresectable AJCC stage I and II HCC and the effect of DEB-TACE: SEER versus tertiary cancer center cohort study

AIM

To evaluate overall survival (OS) in unresectable American Joint Committee on Cancer (AJCC) stage I/II hepatocellular carcinoma (HCC) treated with drug-eluting-bead transarterial chemoembolization (DEB-TACE) versus best supportive care.

MATERIALS & METHODS

OS in consecutive patients with AJCC stage I/II unresectable HCC diagnosed in 2005-2010 who underwent DEB-TACE and similar patients from SEER with no surgery/radiation recommended/performed was evaluated.

RESULTS

Median OS from HCC diagnosis was 28.9 months (DEB-TACE) versus 10.0 months (SEER), p < 0.0001. Median OS was 36.3 months (DEB-TACE) versus 12.0 months (SEER) in AJCC I, and 27.9 months (DEB-TACE) versus 10.0 months (SEER) in AJCC II, p < 0.0001. Significant independent prognostic factors for OS were single primary tumor, no vascular invasion, normal α-fetoprotein and DEB-TACE.

CONCLUSION

DEB-TACE in patients with unresectable AJCC stage I/II HCC was a significant independent prognostic factor for greater OS in a population-based study.

Sociodemographic impact on survival in unresectable hepatocellular carcinoma: a survival epidemiology and end results study

AIM

To investigate outcomes in unresectable hepatocellular carcinoma (HCC) patients stratified by sociodemographic and clinical factors in a population study.

MATERIALS & METHODS

Surveillance, Epidemiology and End Results (SEER) database was used to identify patients diagnosed in 2000-2011. Overall survival (OS) was stratified using patient sociodemographic characteristics and American Joint Commission on Cancer (AJCC) staging. Log-rank test and Cox proportional hazard models were used to identify prognostic factors of OS.

RESULTS

In patients with AJCC stage I and II unresectable HCC, prolonged OS was correlated with being married, younger age, ethnicity, geographic location, living in large urban areas, being insured and higher income and education levels.

CONCLUSION

In AJCC stage I and II unresectable HCC patients with favorable sociodemographic factors, prolonged OS maybe in part related to better access to cancer-directed therapy.

Mortality in hepatectomy: Model for End-Stage Liver Disease as a predictor of death using the National Surgical Quality Improvement Program database

BACKGROUND

The predictive value of the Model for End-stage Liver Disease (MELD) for mortality after hepatectomy is unclear. This study aimed to evaluate whether MELD score predicts death after hepatectomy and to identify the most useful score type for predicting mortality. We hypothesized that an increase in this score is correlated with 30-day mortality in patients undergoing hepatic resection.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for hepatectomy. Original MELD, United Network of Organ Sharing-modified MELD (uMELD), integrated MELD (i-MELD), and sodium-corrected MELD (MELD-Na) scores were calculated. Mortality was analyzed by multivariate logistic regression. MELD types were compared using receiver operating characteristic (ROC) curves.

RESULTS

From 2005 to 2011, 11,933 hepatic resections were performed, including 7,519 partial, 2,104 right, and 1,210 left resections, and 1,100 trisectionectomies. The mean duration of stay was 8.4 ± 22.0 days, and there were 275 deaths (2.4%). The 30-day mortality rates were 1.8%, 6.9%, 15.4%, and 25% according to uMELD strata of 0-9, 10-19, 20-29, and ≥ 30, respectively. Multivariate analysis revealed that increasing MELD stratum was independently associated with higher mortality (P < .001) for all MELD types. The uMELD had the largest effect size (odds ratio [OR], 1.16; 95% CI, 1.10-1.20), whereas i-MELD had the narrowest CI (OR, 1.13; 95% CI, 1.10-1.17) and largest area under the ROC curve.

CONCLUSION

The postoperative 30-day mortality after hepatectomy increases with increasing MELD score across all MELD types. There is a 16% increase in the odds of mortality for each point increase in uMELD.

Health services and policy research in hepatology

PURPOSE OF REVIEW

This article examines recent health services and policy research studies in hepatology and liver transplantation.

RECENT FINDINGS

Critical issues include access to medical care, timeliness of referral and consultation, resource utilization in clinical practice, comparative effectiveness research, and the evaluation of care delivery models. Despite policymaking efforts, there continues to be unwarranted variation in access to subspecialty care and liver transplantation services based on race and geographic location. Variations in primary care and specialist awareness of practice guidelines for liver disease contribute to disparities in appropriateness and timeliness of treatments. Defining the cost-effectiveness of increased resource utilization for novel antiviral therapies and liver transplantation continues to stimulate controversy. Few comparative effectiveness studies in hepatology exist to date, yet a growing number of analyses using national datasets will help inform policy in this arena. Identifying care delivery models that demonstrate high value for populations with chronic liver disease is critical in the context of recent healthcare reform efforts.

SUMMARY

Health services and policy research is a growing field of investigation in hepatology and liver transplantation. Further emphasis on research training and workforce development in this area will be critical for understanding and improving patient-centered outcomes for this population.