Disparities in Presentation at Time of Hepatocellular Carcinoma Diagnosis: A United States Safety-Net Collaborative Study

Background: While hepatocellular carcinoma (HCC) is ideally diagnosed outpatient by screening at-risk patients, many are diagnosed in Emergency Departments (ED) due to undiagnosed liver disease and/or limited access-to-healthcare. This study aims to identify sociodemographic/clinical factors associated with being diagnosed with HCC in the ED to identify patients who may benefit from improved access-to-care. Methods: HCC patients diagnosed between 2012 and 2014 in the ED or an outpatient setting [Primary Care Physician (PCP) or hepatologist] were identified from the US Safety-Net Collaborative database and underwent retrospective chart-review. Multivariable regression identified predictors for an ED diagnosis. Results: Among 1620 patients, median age was 60, 68% were diagnosed outpatient, and 32% were diagnosed in the ED. ED patients were more likely male, Black/Hispanic, uninsured, and presented with more decompensated liver disease, aggressive features, and advanced clinical stage. On multivariable regression, controlling for age, gender, race/ethnicity, poverty, insurance, and PCP/navigator access, predictors for ED diagnosis were male (odds ratio [OR] 1.6, 95% confidence interval [CI]: 1.1–2.2, p = 0.010), black (OR 1.7, 95% CI: 1.2–2.3, p = 0.002), Hispanic (OR 1.6, 95% CI: 1.1–2.6, p = 0.029), > 25% below poverty line (OR 1.4, 95% CI: 1.1–1.9, p = 0.019), uninsured (OR 3.9, 95% CI: 2.4–6.1, p < 0.001), and lack of PCP (OR 2.3, 95% CI: 1.5–3.6, p < 0.001) or navigator (OR 1.8, 95% CI: 1.3–2.5, p = 0.001). Conclusions: The sociodemographic/clinical profile of patients diagnosed with HCC in EDs differs significantly from those diagnosed outpatient. ED patients were more likely racial/ethnic minorities, uninsured, and had limited access to healthcare. This study highlights the importance of improved access-to-care in already vulnerable populations.