An assessment of the association between patient race and prior authorization program determinations in the context of radiation therapy.

BACKGROUND: When a physician determines that a patient needs radiation therapy (RT), they submit an RT order to a prior authorization program which assesses guideline-concordance. A rule-based clinical decision support system (CDSS) evaluates whether the order is appropriate or potentially non-indicated. If potentially non-indicated, a board-certified oncologist discusses the order with the ordering physician. After discussion, the order is authorized, modified, withdrawn, or recommended for denial. Although patient race is not captured during ordering, bias prior to and during ordering, or during the discussion, may influence outcomes. This study evaluated if associations existed between race and order determinations by the CDSS and by the overall prior authorization program. METHODS: RT orders placed in 2019, pertaining to patients with Medicare Advantage health plans from one national organization, were analyzed. The association between race and prior authorization outcomes was examined for RT orders for all cancers, and then separately for breast, lung, and prostate cancers. Analyses controlled for the patient's age, urbanicity, and the median income in the patient's ZIP code. Adjusted analyses were conducted on unmatched and racially-matched samples. RESULTS: Of the 10,145 patients included in the sample, 8,061 (79.5%) were White and 2,084 (20.5%) were Black. Race was not found to have a significant association with CDSS or prior authorization outcomes in any of the analyses. CONCLUSIONS: CDSS and prior authorization outcomes suggested similar rates of clinical appropriateness of orders for patients, regardless of race. IMPLICATIONS: Prior authorization utilizing rule-based CDSS was capable of enforcing guidelines without introducing racial bias.

A Description of Outcomes Experienced by Patients Whose Orders for Peripheral Artery Revascularization Were Reviewed by a Nondenial Prior Authorization Program.

OBJECTIVE: After a nondenial prior authorization program evaluates orders for peripheral artery revascularization (PAR), ordering physicians sometimes withdraw their orders based upon program recommendations. Some patients with withdrawn orders receive PAR if claudication does not resolve. To characterize patient outcomes under this program, we evaluated whether associations existed between the withdrawal of patients' initial PAR orders and the presence of claims for PAR and claims mentioning intermittent claudication (IC) in the following 16 weeks. METHODS: Orders for PAR placed from 1/1/19 to 9/30/19 for patients with Medicare Advantage health plans were extracted from a national healthcare organization's database. Claims data from 0 to 16 weeks following the order were reviewed to determine if patients had downstream PAR claims, or if they had emergency department or hospital claims mentioning IC. Chi-square tests were used to assess the association between order withdrawal and downstream PAR, as well as claims mentioning IC. Multivariate logistic regressions were run to assess the same, controlling for patient age, sex, urbanicity, local median income, state obesity rate, type of PAR, ordering physician specialty, and whether PAR was ordered in a hospital setting. RESULTS: Of 1588 orders meeting inclusion criteria, 71.9% (1038/1444) of authorized orders and 61.1% (88/144) of withdrawn orders were followed by PAR within 16 weeks, a significant difference (P < .01). Relatedly, 69.8% (1008/1444) of authorized orders and 70.8% (102/144) of withdrawn orders were followed by IC claims, an insignificant difference. Multivariate logistic regressions showed patients with withdrawn PAR orders had significantly lower adjusted odds of PAR (OR: 0.63; 95% CI: 0.44-0.91), but an insignificant difference in their adjusted odds of IC (OR: 1.10; CI: 0.76-1.64). CONCLUSIONS: Although patients with withdrawn PAR orders were significantly less likely to receive PAR in the subsequent 16 weeks, no association was found between withdrawn PAR orders and subsequent claims mentioning IC.

Characterizing Cardiac Catheterization Utilization in a US Population with Commercial or Medicare Advantage Health Plans.

Background: Health plans and health systems need to understand the demand for common healthcare services to ensure adequate access to care. Utilization of cardiac catheterization is of particular interest, because it is relatively common and has the potential for variation across subpopulations, similar to the level of geographical variation in heart disease in the United States. Objectives: To illustrate how the utilization of cardiac catheterization has changed over time in a US population with commercial and Medicare Advantage health plans, and how it differs between subpopulations. Methods: Cardiac catheterization claims data from 2012 to 2018 were extracted from the database of a national healthcare organization offering commercial and Medicare Advantage health plans. Contemporaneous health plan enrollment data and government data were used to determine the patients' characteristics. Annual catheterizations per 1000 patients for the population as a whole and for subpopulations were determined using claims data. Spearman's rank-order correlation was used to assess the monotonicity of trends. Catheterization utilization for each subpopulation was compared with that of the population average. A second, patient-level analysis was used to determine the factors predictive of patients' catheterization utilization in 2018. Results: Across the overall population, the rate of cardiac catheterization was stable from 2012 to 2018. An adjusted analysis of 2018 data showed that catheterization utilization was significantly associated with older age, male sex, residence in a rural zip code, residence in a lower-income zip code, and residence in a state with a high obesity rate. The trendlines of the relative utilization of catheterization in subpopulations over time revealed similar patterns. Conclusion: Marked differences were observed in the rates of cardiac catheterization utilization between the subpopulations in our study. Overall, these data show a direct correlation between geographic residence, obesity level, wealth, and the rate of cardiac catheterization utilization. To ensure adequate access to care, health plans and health systems should explore the implications of disproportionately high demand for cardiac catheterization in populations from lower-income areas, higher obesity rate states, rural patients, and older patients.