Interventions
cirrhosis, HCC, fibrosis
CIRRHOSIS, FIBROSIS
Eligible patients were identified and randomized through a series of 3 batches each approximately 3 months apart in September 2020, January 2021, and April 2021. Patients who were eligible and were not opted out of the intervention by their provider were randomized in a 1:2:2 allocation ratio using a computer-generated randomization algorithm stratified by batch. Patients in the Usual care arm received standard of care and were not mailed any study-related outreach. Patients randomized to the Letter + Order arm received a mailed letter describing the importance of HCC surveillance for patients with cirrhosis or advanced fibrosis and with messaging that encouraged them to get a surveillance ultrasound using the included order slip that had already been placed for them (opt-out framing). Patients in the Letter + Order + Incentive arm received the same letter and order slip in addition to a $20 unconditional incentive in the form of a gift card (ClinCard). Abdominal ultrasound orders were placed by a physician member of the research team (Shivani Kastuar), and the patient’s gastroenterology/hepatology provider was listed as the authorizing provider who would receive the results. The orders were then printed by the study team and matched to the personalized letters for mailing. All completed ultrasound results were routed to the patient’s gastroenterologist/hepatologist for follow-up, as per routine practice. At the time of this trial, there were no concurrent and systematic efforts to remind patients who were overdue for HCC surveillance.Patients who did not complete an abdominal ultrasound or other type of imaging within 2 months from the date of the initial outreach received a reminder letter with similar messaging to the original letter and including the ultrasound order slip. A reminder was not sent if the patient had a future ultrasound scheduled or if a different imaging modality (MRI or CT) was newly recommended by their provider. The investigators were blinded to patient data and randomization, but the research staff were not blinded as they were administering the interventions.