Evaluation of a Trainee Physician-Led Outreach to Increase HCC Screening Rates in Veterans Using the RE-AIM Framework

Introduction: Hepatocellular carcinoma (HCC) is the leading cause of morbidity and mortality among patients with cirrhosis. Guideline recommended biannual HCC screening in patients with cirrhosis and chronic hepatitis B infection with abdominal ultrasound and serum alpha-fetoprotein can improve survival. At our single VA healthcare system, 38% of 1385 at-risk Veterans received uP-to-date HCC screening in the past year. A pareto chart analysis identified a lack of imaging orders as the most common cause of overdue screening. We decided to empower trainee-physicians to serve as patient navigators (PNs) offering HCC screening to Veterans via phone and/or mail with the aim of improving screening rates. Methods: Trainees were recruited and underwent an onboarding session with a process map, phone script, and note/letter templates provided. The PNs were assigned 10-25 Veterans monthly. Two calls were attempted and if unsuccessful, a letter was sent. Each attempt was documented in the electronic medical record. We tracked call duration and discussed feedback monthly. RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was used to evaluate the project. We measured Implementation as the average call duration and Maintenance was tracked as the percentage of Veterans uP-to-date with screening at 3, 6, 9, and 12 months. Results: During the first 3 months, 7 PNs were recruited with 5-6 PNs active per month. Out of the 191 Veterans intended for outreach at the time of data collection, 119 Veterans (62.3%: 102 by phone, 17 by mail) were reached. Effectiveness (% of orders placed for Veterans reached) was 58.8% (70/119) with 11.4% (8/70) ultrasounds completed. Adoption (% of Veterans agreeable to screening out of Veterans reached) was 71.4% (85/119). The average time spent with Veterans on the phone was 5 minutes. Maintenance data collection is ongoing. One Veteran was diagnosed with HCC. Conclusion: Leveraging academic affiliations can close critical gaps in patient care and engage trainees in quality improvement efforts. A 3-month radiology wait time at the time of data collection confounded the low percentage of ultrasounds tests completed per orders. Ultimately, when HCC screening was discussed, majority of Veterans opted for screening efforts, reinforcing that identification of at-risk populations and outreach can potentially sustain long-term health outcomes. Using this project's data supports dedicated staff as navigators, promoting sustainment.