The Association Between the Use of Low-Slice Computed Tomography Machines and Downstream Care: Comparative Study of 16-Slice and 64-Slice Computed Tomography Angiography.

BACKGROUND: Although computed tomography (CT) studies on machines with more slices have reported higher positive and negative predictive values, the impact of using low-slice (16-slice) CT machines on downstream testing has not been well studied. In community outpatient settings, low-slice CT machines remain in use, although many hospitals have adopted higher-slice machines. OBJECTIVE: This study examines the association between the use of low-slice CT machines and downstream invasive testing in the context of the CT angiography of the neck. METHODS: Included health insurance claims pertained to adults with commercial or Medicare Advantage health plans who underwent the CT angiography of the neck. Site certification data were used to assign counts of slices to claims. Claims that were made in the 60 days after CT were examined for cervicocerebral angiography. The association between the number of slices and cervicocerebral angiography was evaluated by using a chi-square test and multivariate logistic regression. RESULTS: Claims for 16-slice CT had a 5.1% (33/641) downstream cervicocerebral angiography rate, while claims for 64-slice CT had a 3.1% (35/1125) rate, and a significant difference (P=.03) was observed. An analysis that was adjusted for patient demographics also found a significant relationship (odds ratio 1.64, 95% CI 1.00-2.69; P=.047). CONCLUSIONS: The use of low-slice CT machines in the community may impact the quality of care and result in more downstream testing.

Rate of Whole-Breast Hypofractionated Radiation Therapy Before Versus After Virtual Tumor Board Implementation.

PURPOSE: The virtual tumor board (VTB) is a multidisciplinary group of specialist physicians who remotely educate the treating physician on the development of an evidence-based cancer treatment plan that will enhance patient outcomes according to the available literature. The use of hypofractionated (HF) radiation therapy (RT) is a preferred approach according to National Comprehensive Cancer Network guidelines and is encouraged by the VTB, when appropriate. MATERIALS AND METHODS: An observational, cohort study using prior authorization and claims data were conducted to show how the relative use of HF and conventional fractionated (CF) RT changed after the implementation of the VTB. Orders and claims for qualifying patients from 1 year before launch (August 2016) to 1 year after launch (August 2018) of the VTB were extracted. Claims were examined to observe which patients received CF (28-35 fractions) versus HF (15-21 fractions) RT. χ2 tests were used to assess the association between time period and the ordering and use of HF RT. Logistic regressions were used to test the association, after adjusting for the patient's age, urbanicity, local average income, and the RT modality used. RESULTS: After implementation, we observed a significantly higher percentage of orders for HF RT (60.3% [n = 1,254 of 2,079] v 53.2% [n = 1,010 of 1,899]; P < .001) and claims for HF RT (71.5% [n = 1,143 of 1,598] v 59.0% [n = 941 of 1,595]; P < .001). Relative to before implementation, the adjusted odds of an order for HF RT was 1.35 (CI, 1.19 to 1.54), and the adjusted odds of a claim for HF RT was 1.76 (CI, 1.52 to 2.04). CONCLUSION: After the VTB was implemented, there was a significant increase in HF RT orders and claims.

Discordance in Clinical Recommendations Regarding the Use of Imaging.

As physicians strive to provide evidence-based care, challenges arise if different entities disseminate divergent Appropriate Use Criteria (AUC) or clinical guidelines on the same topic. To characterize these challenges in one field, this study reviews the literature on comparisons of clinical recommendations regarding medical imaging. The PubMed database was searched for the years 2013-2018 for studies describing discordance among clinical recommendations regarding the performance of imaging. Of the 406 articles identified, 15 met the selection criteria: 8 qualitative and 7 quantitative. Reasons for discordance varied, with lack of evidence often cited. Quantitative studies often found that different decisions would be reached depending on the clinical recommendation followed. Nonetheless, quantitative studies also tended not to consider one set of recommendations superior to another. The findings of this review might help clinicians seek guidance more thoughtfully and could inform use of guidelines and AUC for quality improvement and clinical decision support.

The Association Between Use of Hypofractionation and Treatment Completion Among Recipients of Radiation Therapy Post-Mastectomy.

PURPOSE: Although there is some evidence to support the use of hypofractionated (HF) radiation therapy (RT) postmastectomy, it is not currently the standard of care. RT noncompletion and delayed completion have been shown to lead to inferior outcomes. This study assesses the association between the choice of an HF versus conventionally fractionated regimen and completion. METHODS AND MATERIALS: RT orders placed in 2016 and 2017 for patients with a national health plan, along with the associated claims, were extracted. Each order was assigned a target date for timely completion, as well as a date 30 days after the target, which was used to assess delayed completion. Univariate analyses and logistic regressions were conducted to test for an association between regimen and completion. A Poisson regression was used to examine the association between regimen and length of treatment delay among patients completing RT. RESULTS: Of the 743 orders meeting inclusion criteria, 56 (7.5%) were for HF. Unadjusted analyses found that the timely and delayed completion rates were significantly (P < .001) higher for patients receiving HF. The adjusted odds ratios (HF order versus CF order) were 3.96 (95% confidence interval, 2.23-7.01) for timely completion and 2.64 (95% confidence interval, 1.43-5.15) for completion within 30 days of the target. Among completers, an order for HF was significantly (P < .001) associated with less delay. CONCLUSIONS: When an HF regimen was ordered, patients were more likely to complete therapy without a delay, to complete therapy overall, and, if experiencing a delay, to experience a shorter delay.

Health Care Utilization and Pain Outcomes Following Early Imaging for Low Back Pain in Older Adults.

BACKGROUND: Professional societies have provided inconsistent guidance regarding whether older patients should receive early imaging for low back pain, in the absence of clinical indications. The study assesses the implications of early imaging by evaluating its association with downstream utilization in an elderly population. METHODS: Patients were included if they had a Medicare Advantage plan, had claims-based evidence of low back pain in 2014, and lacked conditions justifying early imaging. The outcomes examined were short-term, nonchronic, and chronic opioid use, steroid injections, and spinal surgery in the following 730 days, and persistent low back pain at 180 to 365 days. Morphine dose equivalents of opioid use was used as a measure of intensity. Logistic and γ regressions were used to assess the association between imaging in the first 6 weeks and the outcomes. RESULTS: Among the 57,293 patients meeting inclusion criteria, the mean age was 71.2, and 26,606 (46.4%) received early imaging. Early imaging was associated with increased adjusted odds of short-term (odds ratio [OR], 1.21; 95% CI, 1.15 to 1.28), nonchronic (OR, 1.78; 95% CI, 1.69 to 1.88), and chronic (OR, 1.13; 95% CI, 1.07 to 1.18) opioid use, as well as steroid injections (OR, 2.55; 95% CI, 2.28 to 2.85) and spinal surgery (OR, 3.40; 95% CI, 2.97 to 3.90). Patients that received early imaging were more likely to experience persistent pain (OR, 1.09; 95% CI, 1.05 to 1.14) and used significantly more morphine dose equivalents if they had nonchronic opioid use. CONCLUSIONS: Early imaging for low back pain in older individuals was common, and was associated with greater utilization of downstream services and persistent pain.

Outpatient facility-based order variation in combined imaging.

OBJECTIVE: Combined computed tomography (CT) occurs when one anatomical area is simultaneously imaged both without and with contrast, or two overlapping anatomical areas are imaged concurrently. While this has been studied in a Traditional Medicare population, it has not been studied in other populations subject to prior authorization. This study explores between-facility variation in ordering and receiving orders to render combined CT in a mixed commercial and Medicare Advantage population. METHODS: Orders for CT abdomen (without/with contrast), CT thorax (without/with contrast), and concurrent CT brain and sinus authorized by a prior authorization company from 2013-2017, pertaining to patients with commercial or Medicare Advantage health plans from one national insurer, were extracted. Orders were issued and rendered by both hospitals and nonhospitals. The analysis was performed separately for each anatomical area in two ways: orders were grouped by ordering facility, and by designated rendering facility. For each facility, the ratio of combined to total orders was calculated, and analysis of variance was used to determine whether there were significant differences in this rate by year. The association between health plan type and combined imaging rates was assessed. RESULTS: Combined rates [ratio±standard deviation] for abdomen, thorax, and brain/sinus were 0.306±0.246, 0.089±0.142, and 0.002±0.01 respectively when the analysis was conducted according to ordering facility, and 0.311±0.178, 0.096±0.113, and 0.001±0.006 when the analysis was conducted according to designated rendering facility. Combined CT abdomen and CT thorax rates decreased monotonically from 2013 to 2017, decreases that were significant (P < .01) regardless of whether orders were grouped by ordering or rendering facility. Combined CT abdomen and CT thorax rates significantly differed between orders pertaining to people with commercial and Medicare Advantage plans. DISCUSSION: Variability was greater when orders were grouped by ordering facility, rather than rendering facility. Health plan type may influence whether a patient receives combined CT.

Modification and Reinitiation of Lower Back Imaging Orders After Evidence-Based Collaborative Consultation.

RATIONALE AND OBJECTIVES: Practice guidelines suggest most patients should wait at least 28 days from the onset of low back pain before receiving imaging. This study evaluates a nondenial prior authorization program's performance in modifying lower back imaging orders. Ordering physicians were asked by a consulting physician to modify any order that did not meet guidelines through collaborative consultation. If original orders were not reinitiated, it could signify that modified orders met clinical objectives. MATERIALS AND METHODS: Prior authorization and claims data from 2014 to 2017 were analyzed to determine the rate of reinitiation within 28 days for modified computed tomography and magnetic resonance imaging orders. Chi-square tests were used to evaluate whether modification or reinitiation was associated with several factors. RESULTS: Across the four sequences of interaction between ordering physicians and the program examined, 533,768 orders were placed, leading to 6855 completed consultations (1.3% of orders), 1380 modifications (20.1% of consultations), and 224 reinitiations (16.2% of modifications). Modification led to reinitiation 7.1%-20.6% of the time, depending upon the sequence. Orders from primary care physicians were significantly more likely to be modified. Reinitiation was significantly more likely for urban orders. CONCLUSION: Low back imaging orders modified by the program were infrequently reinitiated within 28 days. Some reinitiation may have been consistent with evidence-based practice, as orders may have been placed after the onset of pain.

Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity.

BACKGROUND: In many situations, evidence-based guidelines cannot provide definitive guidance on the appropriateness of diagnostic catheterization. One specialty benefit management company has taken a 2-step approach to address this ambiguity by evaluating the appropriateness of diagnostic catheterization orders using a rule-based decision support system, and then having reviewers provide input through the consult system of a nondenial prior authorization program that involves peer discussion. OBJECTIVE: To describe the outcomes of a 2-step approach to evaluating the appropriateness of elective diagnostic catheterization orders. METHOD: This program evaluation used data from elective diagnostic catheterization orders from 2015 that pertained to 1 health insurer's Medicare Advantage plans. The classifications of orders by the rule-based system and the approval rates after review by the consult system are presented for these plans. Chi-square tests were conducted to examine whether classifications of the orders by the rule-based and consult systems were independent of plan type, specialty of the ordering physician, or state of residence of the patient. RESULTS: A total of 3808 orders for elective diagnostic catheterization in 2015 met the inclusion criteria. Inadequate initial justification was provided for 699 (18.4%) of the orders; after inquiry through the consult system, 509 (72.8%) of the remaining orders were approved. Among the 344 (9%) orders that were deemed potentially nonindicated according to the rule-based system, the consult system approved 298 (86.6%). Of the 2765 (72.6%) orders that were deemed potentially appropriate by the rule-based system, the consult system approved 2740 (99.1%). Chi-square tests did not show a significant association between plan type or physician specialty and the classification produced by the rule-based system or the consult system. The patients' state of residence was significantly associated with the classification of orders for the rule-based system (P <.001), but not for the consult system. CONCLUSION: Rule-based decision support can be combined with consult-based peer discussion to determine whether care is appropriate when guidelines are ambiguous. Poorly justified orders are often supportable after gathering information on the patient's presentation.

Determinants of outcomes following outpatient placement of implantable cardioverter defibrillators in a Medicare Advantage population.

BACKGROUND: Recipients of ICD are likely to have several risk factors that could interfere with successful use of implantable cardioverter defibrillators (ICDs). HYPOTHESIS: Age, sex, and factors indicated in claims are associated with one-year mortality and complications after ICD placement. METHODS: Adult Medicare Advantage patients who underwent outpatient ICD implantation from January 2014 to September 2015 were included. Age, sex, Charlson Comorbidity Index (CCI), prior year hospitalization and emergency department (ED) visit, diabetes, heart failure, ischemic heart disease, and indicators of the need for pacing were evaluated as risk factors. Mortality and device-related complications (lead and nonlead) were assessed at one-year post-procedure using Kaplan-Meier and Cox Proportional Hazard analysis. RESULTS: Among 8450 patients who underwent implantation, 1-year event-free survival was 80.1%, based on an overall composite measure of complications and mortality. Adjusted survival analysis showed that age ≥ 65, male sex, incremental increase in CCI, heart failure, prior year hospitalization, ED visit, and prior year pacing procedure were significant predictors of mortality. Age ≥ 65, male sex, and prior year hospitalization were significant predictors of a composite measure of device-related complications. CCI and prior hospitalization were significant predictors of a composite measure of any adverse outcome. CONCLUSIONS: Results suggest most patients in an older population do not experience adverse outcomes in the year following ICD implantation. The risk of mortality may be greater in men, patients over the age of 65, and patients with greater general morbidity, heart failure, or a history of a pacing procedure.

An exploration of the association between ischemic etiology and the likelihood of heart failure hospitalization following cardiac resynchronization therapy.

BACKGROUND: Myocardial scarring resulting from cardiomyopathy with ischemic etiology may interfere with effective lead placement during implantation of multi-lead cardioverter-defibrillators for cardiac resynchronization therapy (CRT-D). Extensive scarring is known to be associated with poorer physiological and survival outcomes in patients who undergo CRT-D. HYPOTHESIS: Ischemic CRT-D recipients respond as well as nonischemic recipients, using hospital admission for heart failure (HF) as a measure of response. METHODS: Patients who underwent CRT-D between February 1, 2013, and February 1, 2014, were identified in an insurer's claims. Inclusion required 1 year of enrollment pre- and post-CRT-D. The sample was divided into nonischemic and ischemic groups, and a subset of the ischemic group with a history of ST-segment elevation myocardial infarction (STEMI) was identified. The likelihood of HF hospital admissions in the year before and after CRT-D was computed for each group, as well as for the subset of patients with HF admissions prior to CRT-D. RESULTS: A significant (P = 0.02) association was found between ischemic etiology and the post-CRT-D HF admission likelihood. No association was found between history of STEMI vs nonischemic status and likelihood of post-CRT-D HF admission. All groups had significantly lower risk of HF admissions after CRT-D. None of the comparisons involving only patients with a HF hospitalization in the year prior to CRT-D were significant. CONCLUSIONS: Patients with nonischemic etiology were significantly less likely to experience a HF admission after CRT-D, but the risk of HF admission improved significantly in all groups after CRT-D.