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.
