Quality Improvement Measures and Electronic Medical Record Alerts Increase Liver Cancer Screening in Patients with Cirrhosis

Background: Patients with cirrhosis are at high risk for developing liver cancer/hepatocellular carcinoma (HCC). Adherence to HCC surveillance guidelines with abdominal ultrasound (US) and alpha-fetoprotein (AFP) blood test every six months improves detection of HCC in the early stages, providing opportunities for potentially curative treatments. However, the guidelines are underused, and literature shows that less than 10% of cirrhotic patients undergo surveillance in primary care settings. Objectives: This DNP project aimed to assess the effectiveness of implementing the quality improvement (QI) measures and electronic medical record (EMR) alerts along with patient education to improve HCC surveillance rates for cirrhosis patients in community-based primary care clinics. Methods: An evidence-based practice (EBP) QI project with a pre-and post-intervention cohort study was conducted in federally qualified primary care clinics. Seventy-five cirrhotic patients were identified using the International Classification Diseases (ICD) 10th code before the intervention. The EMR alerts were built to assist providers in ordering surveillance tests (abdominal US & FP) when the surveillance becomes overdue or due. Patient education was incorporated by the providers using the HCC surveillance education brochure in English and Spanish. In addition, and data-driven HCC QI measures were created to monitor HCC surveillance status. Results: The HCC surveillance QI project began in September 2021. Over six months of the study period, 86 cirrhotic patients were enrolled in the HCC surveillance program. Before the intervention, the baseline surveillance rate was 6.7% (5/75). However, the surveillance rate increased to 22.4 % (19/85) after the intervention. In addition, in the comparisons by race/ethnicity within the post-intervention period, the Hispanic group had the highest number of cirrhotic patients. However, patients who did not report race/ethnicity had the highest post-intervention HCC surveillance rate. Conclusion: Implementing the HCC QI measures and EMR alerts effectively increased HCC surveillance rates among cirrhotic patients in federally qualified primary care clinics. The QI measures and EMR alert with patient education using a concise HCC surveillance education brochure are inexpensive, easy to use, and practical strategies to improve HCC surveillance, especially targeting PCPs in primary care settings. Keywords: Liver cancer, Screening, EMR alert, Clinical Reminders, Primary Care Clinics