A close loop audit of hepatocellular carcinoma surveillance: impact of COVID pandemic

Thakkar, Rudrik Aqeel Jamil

IntroductionCirrhosis is a significant risk factor for hepatocellular carcinoma (HCC). HCC develops rapidly and asymptomatic until advanced stage.1 The incidence of HCC in patients with cirrhosis is 2.5% per year.2 NICE guidelines recommend offering HCC surveillance to patients with cirrhosis using ultrasound scan (US) and serum alpha fetoprotein (AFP) every six months.1 We undertook a close loop audit to assess performance of HCC surveillance at the local hospital and assessed the impact of the COVID pandemic on the service.MethodData was collected on patients admitted to hospital with cirrhosis in 1st cycle (16/12/18–05/04/19) and 2nd cycle (4/12/19–31/05/20). Intervention was performed on 04/12/2020 which included departmental posters and informing the doctors on Gastroenterology ward of the NICE guidelines. Data was collected on US and AFP follow up six months after the discharge. Exclusion criteria were patients under the age of 18, patients with known metastasis and on palliative management.ResultsTotal number of patients were 55 and 42 in the 1st and 2nd cycle respectively. Average age was 65 in the 1st cycle and 61 in the 2nd cycle. Overall, 48.5% were male and 51.5% were female patients. 6 monthly ultrasound follow up in patients reduced from 30.9% in 1st cycle to 23.8% in 2nd cycle during the COVID pandemic. Similarly, 6 monthly AFP follow-ups reduced from 34.5% in 1st cycle to 23.8% in 2nd cycle during the COVID pandemic. Although US and AFP follow-ups organised by the gastroenterology ward on discharge were 50% of all outpatients in six months in the 2nd cycle.DiscussionCOVID Pandemic, with the 1st UK lockdown taking place on 23/03/2020, has had a significant impact on the HCC surveillance of patients who were discharged from hospital. This could be due to disruption to the service provided by the hospital or the patients’ choice to avoid attending hospital during the COVID pandemic. The audit demonstrated that despite the disruption to the overall surveillance, the change implemented has resulted in people being followed up for HCC surveillance than previously when no follow up was organised by the discharging team at the hospital as this is mostly managed by the outpatient nurses. A re-audit following COVID pandemic would be useful to understand any benefit of such inpatient intervention on outpatient follow-up of patients with cirrhosis.ReferencesQuality statement 4: Surveillance for hepatocellular carcinoma ;Liver disease ;Quality standards ;NICE [Internet]. Nice.org.uk. 2021 [cited 28 June 2021]. Available from: https://www.nice.org.uk/guidance/qs152/chapter/Quality-statement-4-Surveillance-for-hepatocellular-carcinoma#quality-statement-4Mancebo A, González–Diéguez M, Cadahía V, Varela M, Pérez R, Navascués C, et al. Annual incidence of hepatocellular carcinoma among patients with alcoholic cirrhosis and identification of risk groups. Clinical Gastroenterology and Hepatology 2013;11(1):95–101.