Underutilization of Treatments for Hepatocellular Carcinoma (HCC) in Medicare Population/ Geographic Disparity and Association with Social Determinants of Health

Introduction

Despite the availability of multiple treatment options for patients with hepatocellular carcinoma (HCC), several studies have suggested rates of HCC treatments in the US are low. We evaluated geographic disparities in utilization of treatments for HCC and examined the association of treatment utilization with social determinants of health (SDOH).

Methods

We identified patients diagnosed with HCC between 2014-2018 from 100% Medicare Fee-for-Service claims ending in September 2019. Curative or non-curative treatments for HCC included surgical resection, liver transplant, ablation, chemoembolization, radiation-based therapy, or systemic therapy. Underutilization of treatment was measured as the proportion of patients not receiving any HCC treatment among all patients diagnosed with HCC within each county. SDOH information at the county level was sourced from a proprietary database and linked to Medicare claims. Heatmaps were constructed to examine geographic variations in underutilization of treatment for HCC by county. SDOH variables displayed in heatmaps included race/ethnicity, median income, poverty, English proficiency, and vehicle ownership. A linear regression model was used to assess the association between underutilization of treatment and SDOH.

Results

A total of 30,875 patients with HCC residing in 2,630 counties were identified. Counties were placed in quantiles based on level of underutilization of treatments. An average of 54% of patients were untreated, varying substantially from 0% to 100% across counties. Geographic variations were visualized in heatmaps. Proportions of untreated patients were significantly higher in counties with a larger percentage of African American residents, older residents, and lower median household income.

Conclusions

Among Medicare beneficiaries with HCC, many patients failed to receive treatments in clinical practice. Geographic disparities exist in this population and are potentially associated with social and economic factors. Future efforts should focus on assessing barriers to treatment and identifying appropriate intervention targets to reduce health disparities.