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