Adherence to diagnostic guidelines of hepatocellular carcinoma: 12-year experience in a veterans affairs medical center

Background Noninvasive diagnostic criteria for cirrhotic hepatocellular carcinoma (HCC) were first established in 2001 by the European Association for the Study of the Liver. Objectives The aim of this study was to evaluate adherence to the HCC diagnostic algorithm over time and identify factors associated with nonadherence. Methods Between 2001 and 2013, 224 consecutive cirrhotic HCC cases were retrospectively reviewed. Nonadherent biopsy (NAB) was defined as cases diagnosed either by biopsy despite meeting noninvasive criteria for HCC or by biopsy in place of an optional second imaging modality. Nonadherent nonbiopsy (NANB) was defined as cases diagnosed without performing biopsy when noninvasive criteria were not met. Factors associated with nonadherence were identified using multivariate analysis. Results Nonadherence rate decreased from 52 to 30% over the study period (P=0.003). Among all patients, there were 34% NAB and 13% NANB cases. Compared with the adherence group, both NAB and NANB groups were likely to undergo only computed tomography scanning [odds ratio (OR) 3.08, 95% confidence interval (CI) 1.71-5.66 and OR 3.18, 95% CI 1.28-8.27, respectively] and were less likely to undergo MRI (OR 0.29, 95% CI 0.16-0.53 and OR 0.26, 95% CI 0.10-0.66, respectively). In addition, the NAB group was less likely to be presented in a multidisciplinary tumor conference (OR 0.12, 95% CI 0.02-0.61). Conclusion This is the first study to report adherence to HCC diagnostic guidelines over time in a veteran hospital. Despite overall improvement, nonadherence at the present time is still high (∼30%). Underutilization of MRI and the multidisciplinary tumor conference is associated with nonadherence, representing a potential area for improvement.