hepatocellular carcinoma
Credit: Nephron, CC BY-SA 3.0 , via Wikimedia Commons

Researchers from the Perelman School of Medicine at the University of Pennsylvania have shown that uptake of surveillance imaging for hepatocellular carcinoma (HCC) can be doubled by sending at-risk patients a letter with a pre-signed ultrasound order.

“Our findings show that an approach like this can meaningfully increase liver cancer surveillance, which is particularly important in a group of patients who are high risk for liver cancer,” said Shivan Mehta, MD, MBA, an associate professor of Gastroenterology and the associate chief innovation officer at Penn Medicine.

Adding a $20 financial incentive to the letter and preorder did not, however, further improve screening uptake, report Mehta and co-authors in Hepatology Communications.

HCC typically occurs among people with liver cirrhosis and is one of the leading causes of cancer-related death in the United States. Current guidelines recommend that patients with cirrhosis undergo routine surveillance with abdominal ultrasound every 6 months.

“It is so important to screen patients with cirrhosis for liver cancer since early detection improves survival,” said study lead author Kenneth Rothstein, MD, a professor of Gastroenterology and regional director of Hepatology at the University of Pennsylvania Health System. “Unfortunately, only 20 percent of people with cirrhosis in this country are being screened correctly, which results in many early and unnecessary deaths from liver cancer.”

Interventions to improve screening rates are therefore needed, but previous approaches have shown limited effectiveness.

Mehta and team explored whether the relatively new discipline of behavioral economics could address some of the inertia surrounding HCC screening. They employed two key principles: opt-out framing with preordering, which frames screening as the default by providing order slip that had already been placed meaning that the patient would have to actively choose not to participate; and an unconditional financial incentive.

In all, 562 patients (mean age 62.1 years, 57% men, 41% Black) with cirrhosis or advanced fibrosis, who had at least one visit to a specialty practice in the past 2 years and no surveillance in the last 7 months were included in the study. Just over half (51.1%) had Medicare and 26.3% had commercial insurance.

They were randomly assigned to receive usual care, i.e., being offered screening by a gastroenterologist or hepatologist during a routine office visit (n=116), a mailed letter with a signed order for an ultrasound (n=224), or a mailed letter with an order and a $20 unconditional incentive in the form of a gift voucher (n=222).

The letters described the importance of HCC surveillance for patients with cirrhosis or advanced fibrosis and encouraged participants to get a surveillance ultrasound using the included order slip that had already been placed for them. The abdominal ultrasound orders were placed by a physician member of the research team, and the patient’s gastroenterology/hepatology provider was listed as the authorizing provider who would receive the results. Patients who did not complete an abdominal ultrasound or other type of imaging within 2 months from the date of the initial outreach received a reminder letter with similar messaging to the original letter and including the ultrasound order slip.

Mehta et al report that, at 6 months, 27.6% of participants who received usual care had completed ultrasound compared with 54.5% of those who received a letter and signed order, a statistically significant difference.

The observed improvement could be explained by a few factors, the researchers remark. It minimizes the effort for the patient to obtain an order slip and reduces effort for the clinicians who would typically have to sign each individual order. It could also serve as a nudge to remind patients if the HCC surveillance imaging was ordered many months before but was forgotten.

“While more of our patients have access to internet, smartphones, and text messaging, there is still differential access,” said Mehta. “However, most patients are able to receive mailings. Ultimately, our goal is to communicate with patients through the method that they choose or have the best access to.”

The HCC surveillance imaging rate was 54.1% among the participants who received a letter, order, and incentive, which was not significantly different from those who received the letter and order without the incentive.

“There is mixed data on the effectiveness of financial incentives for preventive health activities,” Mehta explained. “It may not be something that patients are used to getting from their clinicians through direct mail, so they were not sure about the context. Also, perhaps larger incentives or a conditional incentive—such as only receiving the cash if the screening is complete—may be more effective.”

Importantly, subgroup analyses did not identify and differential effectiveness by sociodemographic characteristics and the researchers believe that their simple approach would be easy to implement in routine practice.

Of the 298 patients across all three study arms who completed any imaging during follow-up, 14 (4.7%) had abnormal results or required additional follow-up evaluation. Of these, 11 (78.6%) were ordered follow-up imaging, nine (81.8%) completed follow-up imaging, and four (44.4%) were diagnosed with HCC. No cases of cancer were identified in the usual care group.

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