Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice.

INTRODUCTION: Insurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials. METHODS: This was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P. RESULTS: Nine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40). CONCLUSIONS: The majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.

Palliative Care Training in Surgical Oncology and Hepatobiliary Fellowships: A National Survey of Program Directors.

BACKGROUND: Despite previous literature affirming the importance of palliative care training in surgery, there is scarce literature about the readiness of Surgical Oncology and hepatopancreaticobiliary (HPB) fellows to provide such care. We performed the first nationally representative study of surgical fellowship program directors' assessment of palliative care education. The aim was to capture attitudes about the perception of palliative care and disparity between technical/clinical education and palliative care training. METHODS: A survey originally used to assess surgical oncology and HPB surgery fellows' training in palliative care, was modified and sent to Program Directors of respective fellowships. The final survey consisted of 22 items and was completed online. RESULTS: Surveys were completed by 28 fellowship programs (70 % response rate). Only 60 % offered any formal teaching in pain management, delivering bad news or discussion about prognosis. Fifty-eight percent offered formal training in basic communication skills and 43 % training in conducting family conferences. Resources were available, with 100 % of the programs having a palliative care consultation service, 42 % having a faculty member with recognized clinical interest/expertise in palliative care, and 35 % having a faculty member board-certified in Hospice and Palliative Medicine. CONCLUSIONS: Our data shows HPB and surgical oncology fellowship programs are providing insufficient education and assessment in palliative care. This is not due to a shortage of faculty, palliative care resources, or teaching opportunities. Greater focus one valuation and development of strategies for teaching palliative care in surgical fellowships are needed.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument.

OBJECTIVES: Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT). METHODS: Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year). RESULTS: Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients. CONCLUSIONS: The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

Palliative care training in surgical oncology and hepatobiliary fellowships: a national survey of the fellows.

BACKGROUND: Surgical oncologists (SO) and hepatobiliary (HPB) surgeons frequently care for patients with advanced diseases near the end of life, yet little is known about their training, comfort, and readiness in the provision of palliative care. This study sought to assess the quality, adequacy, and extent of palliative care training and the readiness of SO and HPB fellows in delivering palliative care. METHODS: A self-administered survey was distributed to all fellows enrolled in Society of Surgical Oncology (SSO) and HPB fellowships during the 2013-2014 academic year. The survey assessed attitudes, training, experience, and readiness of fellows in caring for patients at the end of life. Descriptive analysis was performed, and Chi square, Student's t test, and the Mann-Whitney U test were used to compare mean or median values as appropriate. RESULTS: The response rate was 47.2 %, and 50.9 % of the fellows reported exposure to a palliative care specialty service during their fellowship. Of the study participants, 75 % observed their faculty discussing the side effects of surgery compared with 54 % who observed faculty communication with patients regarding end-of-life goals (p < 0.01). On the other hand, 40 % of the fellows were never observed by faculty discussing symptoms management, goals of care, or hospice referral with patients, and 56.7 % never received feedback on their palliative skills. CONCLUSION: The fellows rated the quality of their palliative care education as poor compared with other aspects of their fellowship training, implying the lack and need of palliative care teaching. Surgical oncology and HPB fellows and ultimately patients may benefit from increased clinical and didactic palliative care training.

The value of process measures in evaluating an evidence-based guideline.

BACKGROUND: Linking the process of evidence-based guidelines to outcomes is difficult. We hypothesized that the process of implementing an evidence-based clinical guideline for blunt splenic trauma would reduce resource consumption and improve outcome. METHODS: Time periods were divided into period 1 (7/1/96-6/30/99) and period 2 (7/1/99-6/30/01). On 7/1/99 our American College of Surgeons-verified level I trauma center instituted an evidence-based approach for managing splenic trauma incorporating hemodynamic normality as the process measure triggering clinical decisions. Outcomes included the number of hemodynamically normal patients treated without operation, patient death, length of stay, and cost. RESULTS: Two hundred thirty-one patients had blunt splenic injury; 115 patients were seen during period 1 and 116 during period 2. Hemodynamically normal patients undergoing splenectomy decreased during period 2 (P<.05). Median length of stay was 8 days in period 1 and 6 days in period 2 (P<.03). Cost per patient was $34,972 US dollars in period 1 and $24,037 US dollars in period 2 (P<.03). The mortality rate was unchanged. CONCLUSIONS: Compliance with evidence-based data in the management of blunt splenic injury improved rates of nonoperative management, decreased hospital days, and did not change mortality rates. An evidence-based clinical guideline evaluated with process measures can reduce resource use and improve outcome in a trauma program.