Racial and Ethnic Disparities in Hepatocellular Carcinoma Surveillance Among Patients with Cirrhosis Across Five Safety Net Organizations

五个安全网组织的肝硬化患者肝细胞癌监测中的种族和民族差异

• 批准号: 10543525
• 负责人: Robert John Wong
• 金额: $ 63.91万
• 依托单位: PALO ALTO VETERANS INSTIT FOR RESEARCH
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-12-22 至 2026-11-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10543525
• 关键词: Abdomen; Acute; Adherence; Affect; Alcohol abuse; Attitude; COVID-19; COVID-19 pandemic; COVID-19 pandemic effects; Cancer Etiology; Caring; Cessation of life; Cirrhosis; Clinic; Clinical; Clinical Trials; Collaborations; Community Health Networks; Complex; Data; Detection; Deterioration; Development; Diagnostic Services; Disparate; Disparity; Drug usage; Educational Status; Electronic Health Record; Familiarity; Future; Gastroenterology; General Hospitals; Geography; Goals; Guidelines; Health; Health Services Accessibility; Health system; High Prevalence; Hospitals; Household; Immigrant; Income; Individual; Intervention; Knowledge; Laboratories; Learning; Link; Liver Cirrhosis; Liver diseases; Long-Term Effects; Mediating; Mediation; Methods; Monitor; Nature; Outcome; Patients; Pattern; Persons; Phase; Population; Primary Care; Primary carcinoma of the liver cells; Process; Provider; Quality of Care; Recovery; Research; Risk; Role; San Francisco; Screening Result; Screening for cancer; Site; Stage at Diagnosis; Stereotyping; Structure; Substance Use Disorder; Surveys; System; Techniques; Telemedicine; Tumor stage; Underinsured; Underserved Population; Vulnerable Populations; alcohol use disorder; analytical method; care delivery; chronic liver disease; cohort; comorbidity; design; disparity reduction; ethnic disparity; ethnic diversity; ethnic minority; ethnic minority population; follow-up; health care delivery; health care service; high risk; high risk behavior; improved; innovation; liver function; low socioeconomic status; novel; pandemic disease; pandemic impact; pandemic response; post-COVID-19; prospective; provider factors; racial disparity; response; safety net; screening; screening disparities; screening program; screening services; social vulnerability; socioeconomics; synergism; system-level barriers; tumor; ultrasound

Background: Implementing timely and consistent hepatocellular carcinoma (HCC) screening among cirrhosis patients improves early tumor detection, treatment options, and overall survival. Guideline- concordant HCC screening rates are suboptimal, particularly among ethnic minorities and non-English speaking immigrant populations. The underlying mechanistic drivers of these disparities in HCC screening among ethnic minorities and underserved populations is not clear, and no studies have comprehensively evaluated the mediating roles of patient, provider, and system level factors in contributing to these disparities. Goals: To understand mechanisms of disparities in HCC screening among ethnic minority and underserved populations and how COVID-19 pandemic-related disruptions in healthcare delivery have exacerbated these disparities, we propose three specific aims: 1) Examine racial and ethnic disparities in HCC screening among cirrhosis patients in the pre-COVID-19, COVID-19, and post-COVID-19 recovery periods; 2) Identify provider- specific factors (e.g. knowledge, attitudes, practice patterns, perceived barriers, biases and stereotypes towards ethnic minorities, pandemic-related practice adaptations) contributing to HCC screening disparities; and 3) Conduct multi-level mediational analyses to identify patient, provider, and system level factors that contribute to ethnic disparities in HCC screening, affecting tumor stage at diagnosis, receipt of treatment, and survival. Methods: Contemporaneous longitudinal real-world observational data on 10,500 cirrhosis patients linked to provider survey data from 300 primary care and gastroenterology across five safety net health systems representing broad geographic and ethnic diversity will be used. Patient-level and system-level factors will be retrospectively extracted from electronic health records at each site, and provider-level factors will be assessed using a previously validated survey-based approach. Innovative multi-level mediation analytic methods that incorporate patient, provider, and system level factors will be utilized to evaluate mechanisms of disparities in HCC screening among ethnic minorities and non-English speaking immigrants. To mitigate confounding found in observational analyses, innovative casual inference techniques will be applied. Significance: Despite the high burden of HCC among ethnic minorities and non-English speaking immigrants and the observed lower rates of HCC screening among these populations, it remains unclear what the drivers of these disparities are. To our knowledge, no studies exist that comprehensively evaluate the complex interplay between patient, provider, and system level factors that mediate ethnic disparities in receipt of HCC screening as is proposed by our novel study. Lessons learned from the synergy of our study aims will identify potentially modifiable factors that can be used to design a future multi-level prospective interventional clinical trial to improve HCC screening and HCC outcomes in cirrhosis patients, particularly among ethnic minorities and underserved safety-net populations.

背景：实施及时且一致的肝细胞癌（HCC）筛查 肝硬化患者改善了早期肿瘤检测，治疗选择和整体生存期。指南 - 一致的HCC筛查率是次优的，尤其是在少数民族和非英国 说移民人口。 HCC筛查中这些差异的基本机械驱动因素 在少数民族和服务不足的人群中，尚不清楚，而且没有全面研究 评估了患者，提供者和系统级别因素导致这些差异的中介作用。 目标：了解少数民族和服务不足的HCC筛查中差异的机制 人群以及199年大流行有关的医疗保健分娩中的干扰如何加剧这些 差异，我们提出了三个具体目的：1）检查HCC筛查中的种族和种族差异 肝硬化患者在19岁前19岁，covid-19和covid-19恢复期； 2）确定提供商 - 特定因素（例如知识，态度，实践模式，感知的障碍，偏见和刻板印象 少数民族，与大流行有关的实践适应），导致HCC筛查差异； 3） 进行多层中介分析，以识别贡献贡献的患者，提供者和系统级别的因素 在HCC筛查中的种族差异，影响诊断时肿瘤阶段，接受治疗和生存。 方法：有关10,500名肝硬化患者的同时纵向现实世界观察数据 提供者的调查数据来自五个安全网卫生系统的300个初级保健和胃肠病学 代表广泛的地理和种族多样性将被使用。患者级和系统级别的因素将是 从每个站点的电子健康记录中提取的回顾性，将评估提供商级别的因素 使用先前验证的基于调查的方法。创新的多层次调解分析方法 将患者，提供者和系统级别的因素纳入将用于评估差异机制 HCC在少数民族和非英语移民中进行筛查。减轻发现的混杂 在观察分析中，将应用创新的休闲推理技术。 意义：尽管少数族裔和非英语的HCC负担很高 移民和观察到的HCC筛查发生率较低，目前尚不清楚什么 这些差异的驱动力是。据我们所知，没有研究能够全面评估 患者，提供者和系统级别因素之间介导种族差异的复杂相互作用 正如我们的新研究所提出的那样，HCC筛查的筛查。从我们的研究目的的协同作用中学到的经验教训将 确定可修改的因素，这些因素可用于设计未来的多层次前瞻性介入 临床试验以改善肝硬化患者的HCC筛查和HCC结局，尤其是种族 少数族裔和服务不足的安全网人口。