Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices.

Importance: Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration. Objective: To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices. Design, Setting, and Participants: Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US. Main Outcomes and Measures: Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures. Results: In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes. Conclusions and Relevance: In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.

Prolonging the return visit interval in primary care.

PURPOSE: Extending the scheduled return visit interval has been suggested as one means to improve clinic access to the provider. However, prolonging the return visit interval may affect quality of care if prevention measures and chronic disease management receive less attention as clinic visits become less frequent. The purpose of this study was to determine whether a comprehensive education program could encourage providers to lengthen their return visit interval without compromising performance on key quality indicators. SUBJECTS AND METHODS: This was a prospective cohort study monitoring scheduling and performance data of primary care providers at the Milwaukee Veterans Affairs Medical Center. Following collection of baseline data (January through June 1999), providers were encouraged to lengthen the return visit interval while increasing reliance on nurses and other clinic staff for interim management of chronic disease. Provider-specific feedback of return visit interval and performance data was utilized to motivate behavioral change. Scheduling and clinical data were abstracted from random medical record audits performed at baseline and from July through December in the years 2000 and 2001. RESULTS: Compared with the baseline period, the percent of patients scheduled > or =6 months was significantly increased among staff providers and medicine residents at 2 years (Staff providers: 31% vs. 62%, P <0.001; Medicine residents: 22 vs. 44%, P <0.001). Colorectal screening, pneumonia immunizations, and achievement of therapeutic goals for diabetes, hypertension, and lipid disorders significantly improved at 2 years compared with baseline measurements. CONCLUSIONS: Educational interventions can successfully retrain providers to extend the return visit interval and reduce the scheduling of routine and perhaps unnecessary appointments. This can be accomplished without compromising important performance monitors for diabetes, lipid disorders, hypertension, and prevention.

Medications in long-term care: when less is more.

Attention has been drawn to the potential risks of several medications in the long-term care setting. Most of these medications deemed as inappropriate affect the central nervous system and are indicated only for select populations with specific conditions. Many of these drugs are prescribed without clear indications and continued indefinitely without critical decision-making about the potentially salutary effects of discontinuing medications. This article describes the increasing awareness of potentially inappropriate prescribing in the long-term care setting and reviews the rationale for why various types of medications are deemed inappropriate, with a focus on agents that affect central nervous system functioning.

Exposure to potentially harmful drug-disease interactions in older community-dwelling veterans based on the Healthcare Effectiveness Data and Information Set quality measure: who is at risk?

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults.

The impact of medical illness on executive function.

Executive function can be defined as one's ability to plan, initiate, sequence, monitor, and inhibit complex goal-directed behaviors. Although executive impairment is generally associated with dementia, recent studies have suggested that patients with chronic diseases, such as hypertension, chronic obstructive pulmonary disease, and diabetes, may also have executive deficits independent of psychiatric comorbidities. Because executive function is associated with functional outcomes, medication compliance, and the capacity to give informed consent, it is important that it be assessed. However, it is the authors' impression that executive function is not adequately assessed in medical settings, despite the availability of reliable measures. This article reviews the impact of medical illness on executive function and discusses practical diagnostic instruments and treatment strategies. The changes in functional status associated with executive impairment as well as pathophysiology and treatment strategies are also discussed.

Prevalence, course, and risk factors for executive impairment in patients hospitalized on a general medicine service.

The purpose of this study was to determine the prevalence, course, and risk factors for executive impairment in patients hospitalized on a general medicine service. One hundred patients were administered the Executive Interview (EXIT25), the Executive Clock Drawing Task (CLOX), and the Mini-Mental State Examination at admission and discharge. Fifty-two percent of the patients at admission and 56% at discharge had scores indicating impairment on at least one measure of executive function. Median scores on every measure improved during hospitalization. Older patients and those with a cardiac or gastrointestinal disorder were more likely to have executive impairment. The prevalence of executive impairment on general medicine services is high. Although improvement in executive function occurs during hospitalization, many patients remained impaired.