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Principal Investigator: Robert John Wong
Organization: PALO ALTO VETERANS INSTIT FOR RESEARCH
Fiscal Year: 2024
Award: $633,897
Funding agency: National Institute on Minority Health and Health Disparities
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.
Terms: <Abdomen><Access to Care><Active Follow-up><Acute><Adherence><Affect><Alcohol abuse><Attitude><COVID crisis><COVID epidemic><COVID pandemic><COVID-19><COVID-19 crisis><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 pandemic><COVID-19 pandemic affected><COVID-19 pandemic consequence><COVID-19 pandemic effects><COVID-19 pandemic impact><COVID-19 pandemic impacted><COVID-19 period><COVID-19 predisposition><COVID-19 public health crisis><COVID-19 susceptibility><COVID-19 vulnerability><COVID-19 years><CV-19><Cancer Cause><Cancer Etiology><Caring><Cessation of life><Cirrhosis><Clinic><Clinical><Clinical Trials><Collaborations><Community Health Networks><Complex><Coronavirus Infectious Disease 2019><Coronavirus disease 2019 predisposition><Coronavirus disease 2019 susceptibility><Coronavirus disease 2019 vulnerability><Data><Death><Decrease disparity><Detection><Deterioration><Development><Diagnostic Services><Disparate><Disparities><Disparity><Drug usage><Economic Income><Economical Income><Educational Achievement><Educational Status><Electronic Health Record><EtOH abuse><Familiarity><Future><Gastroenterology><General Hospitals><Geography><Goals><Guidelines><Health><Health Services Accessibility><Health system><Healthcare Delivery><Hepatic Cirrhosis><Hepatic Disorder><Hepatocarcinoma><Hepatocellular Carcinoma><Hepatocellular cancer><Hepatoma><High Prevalence><Hospitals><Household><Immigrant><Income><Individual><Intervention><Intervention Strategies><Knowledge><Laboratories><Link><Liver Cells Carcinoma><Liver Cirrhosis><Liver diseases><Long-Term Effects><Longterm Effects><Lower disparity><Mediating><Mediation><Methods><Monitor><Nature><Negotiating><Negotiation><Outcome><Patients><Pattern><Persons><Phase><Population><Predisposed to COVID-19><Predisposed to SARS-CoV-2><Predisposed to Severe acute respiratory syndrome coronavirus 2><Primary Care><Primary carcinoma of the liver cells><Process><Provider><QOC><Quality of Care><Recovery><Research><Risk><Role><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-CoV-2 predisposition><SARS-CoV-2 susceptibility><SARS-CoV-2 vulnerability><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><San Francisco><Screening Result><Screening for cancer><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Severe acute respiratory syndrome coronavirus 2 predisposition><Severe acute respiratory syndrome coronavirus 2 susceptibility><Severe acute respiratory syndrome coronavirus 2 vulnerability><Site><Stage at Diagnosis><Stereotyping><Structure><Substance Use Disorder><Survey Instrument><Surveys><System><T-Stage><Techniques><Telemedicine><Tumor stage><Underinsured><Underserved Population><Vulnerable Populations><access to health services><access to services><access to treatment><accessibility to health services><active followup><alcohol co-abuse><alcohol problem><alcohol use disorder><analytical method><availability of services><care access><care delivery><chronic hepatic disease><chronic hepatic disorder><chronic liver disease><chronic liver disorder><cirrhotic><clinician factors><clinician-level factors><co-morbid><co-morbidity><cohort><comorbidity><coronavirus disease 2019><coronavirus disease 2019 crisis><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 pandemic><coronavirus disease 2019 pandemic consequence><coronavirus disease 2019 pandemic impact><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19><coronavirus disease-19 global pandemic><coronavirus disease-19 pandemic><coronavirus infectious disease-19><design><designing><developmental><diagnosis service><disparities in race><disparity due to race><disparity in ethnic><disparity reduction><drug use><early cancer detection><educational level><effects following the COVID-19 pandemic><electronic health care record><electronic health medical record><electronic health plan record><electronic health registry><electronic medical health record><ethanol abuse><ethanol use disorder><ethnic based disparity><ethnic disadvantage><ethnic disparity><ethnic diversity><ethnic inequality><ethnic inequity><ethnic minority><ethnic minority group><ethnic minority individual><ethnic minority people><ethnic minority population><ethnically diverse><ethnicity disparity><follow up><follow-up><followed up><followup><hazardous alcohol use><health and care delivery><health care delivery><health care service><health delivery systems><health service access><health services availability><health services delivery><healthcare service><hepatic disease><hepatopathy><high risk><high risk behavior><impact of the SARS-CoV-2 pandemic><improved><incomes><inequality due to race><inequity due to race><innovate><innovation><innovative><interventional strategy><liver carcinoma><liver disorder><liver function><low SES><low socio-economic position><low socio-economic status><low socioeconomic position><low socioeconomic status><mitigate disparity><novel><pandemic><pandemic caused disruption><pandemic containment><pandemic control><pandemic created disruption><pandemic disease><pandemic disruption><pandemic effect><pandemic impact><pandemic induced disruption><pandemic mitigation><pandemic outcome><pandemic related disruption><pandemic repercussions><pandemic response><physician factors><physician-level factors><post-COVID><post-COVID-19><post-coronavirus disease 2019><predisposed to Coronavirus disease 2019><problem alcohol use><problem drinking><problematic alcohol consumption><problematic alcohol use><prospective><provider factors><provider-level factors><race based disparity><race based inequality><race based inequity><race disparity><race related disparity><race related inequality><race related inequity><racial disparity><racial inequality><racial inequity><racially unequal><reduce disparity><reduction in disparity><response><safety net><screening><screening cancer patients><screening disparities><screening program><screening services><screenings><service availability><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><social role><social vulnerability><socio-economic><socio-economically><socioeconomically><socioeconomics><substance use and disorder><susceptible to COVID-19><susceptible to Coronavirus disease 2019><susceptible to SARS-CoV-2><susceptible to Severe acute respiratory syndrome coronavirus 2><synergism><system-level barriers><training achievement><training level><training status><treatment access><tumor><ultrasound><under served group><under served individual><under served people><under served population><underserved group><underserved individual><underserved people><vulnerable group><vulnerable individual><vulnerable people><vulnerable to COVID-19><vulnerable to Coronavirus disease 2019><vulnerable to SARS-CoV-2><vulnerable to Severe acute respiratory syndrome coronavirus 2>