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2019 HSR&D/QUERI National Conference Abstract

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4093 — Facilitating the Delivery of Treatment for Hepatocellular Carcinoma using Multidisciplinary Tumor Boards in United States Veterans

Lead/Presenter: Jessica Davila,  COIN - Houston
All Authors: Davila JA (Center for Innovations in Quality, Effectiveness, and Safety (Houston, TX)), Sansgiry S (Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX), Strayhorn MT (Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX) Aguilar JK (Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX) Sada YH (Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX)

Objectives:
Hepatocellular carcinoma (HCC) treatment requires multidisciplinary care. Multidisciplinary Tumor Boards (MTB) facilitate the delivery of timely, guideline-based treatment. However, there is no standardized process for MTB evaluation or implementing recommendations. The aims of this study were to examine the treatment delivery process following MTB review, factors impacting timeliness of treatment, and impact on survival.

Methods:
During 2010-2015, we identified a national cohort of patients diagnosed with HCC from VA administrative files. Eligibility criteria included ages 18-80 years at diagnosis, confirmed HCC, and HCC MTB recommendation for treatment. Retrospective chart review was conducted. Information ascertained included patient demographics, clinical features, MTB recommendations and receipt of treatment. Generalized Estimating Equations model with binomial distribution, clustered on facility was used to examine the association between delays ( > 60 days from MTB to treatment) and clinical factors. Cox proportional hazard analyses were conducted to examine survival.

Results:
A total of 352 patients comprised our study cohort. Approximately 27% of non-liver transplant patients had a greater than 60-day delay in receiving initial treatment following MTB review. Patients with early stage disease were less likely to experience a delay compared to patients with more advanced disease (p < 0.01). Delays were significantly higher in patients who were recommended potentially curative treatment (p < 0.01). Patients who had at least one no-show visit to an HCC specialist following MTB were also more likely to experience delay (p < 0.01). Among patients in whom treatment was recommended but no treatment received, the most common reasons were medical contraindication (27%), co-morbidity (23%), and patient refusal (17%). Survival did not differ between patients with (median 2.1 years, CI 1.4-2.5) and without delays (median 2.2 years, CI 1.9-2.6) (p > 0.05).

Implications:
Timely treatment was received by over 70% of veterans with HCC who were reviewed by MTB. Patients receiving curative therapy were most likely to experience delay. Standardizing processes for care coordination and communicating recommendations to patients following MTB review may further reduce time to treatment.

Impacts:
MTB is an important mechanism for delivering high quality, guideline-based cancer care in the VA. Supporting MTB efforts to improve efficiency and communication with patients may improve outcomes.