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.

Associations between alcohol demand and both the experience and subjective evaluation of positive and negative alcohol-related consequences.

BACKGROUND: Considerable variation exists in the extent to which alcohol-related consequences are evaluated as positive or negative. These evaluations, in turn, predict subsequent drinking behavior. Understanding the etiological pathways to positive and negative alcohol-related consequences is essential to the design of interventions aimed at reducing drinking consequences. Behavioral economic models posit that excessive alcohol valuation contributes to problematic use. Elevated alcohol demand (i.e., relative alcohol value) is associated with negative alcohol-related consequences; however, it is unclear whether demand is related to positive consequences or subjective consequence evaluations. METHODS: College student drinkers (n = 114; 74.6% female) completed an online survey. Participants indicated whether they had ever experienced any of 24 negative and 14 positive consequences and subjectively evaluated their most recent experience of each consequence endorsed. An alcohol purchase task assessed hypothetical alcohol consumption across 14 prices and three observed demand indices were calculated: intensity (i.e., consumption at zero cost), Omax (i.e., maximum expenditure), and Pmax (i.e., price associated with maximum expenditure). Bivariate correlations and hierarchical regressions were used to test associations between observed demand indices and the number and subjective evaluations of positive and negative (researcher- and participant-defined) consequences. RESULTS: Intensity and Omax , but not Pmax , were bivariately associated with researcher- and participant-defined negative and positive consequences. However, in hierarchical regression models that controlled for the maximum number of drinks consumed in a single day over the past month, only intensity was significantly associated with more negative and positive consequences. Intensity was associated with positive consequence evaluations in bivariate but not regression models. CONCLUSION: Students with higher intensity reported more prior alcohol consequences (positive and negative), independent of drinking level. However, subjective evaluations of recent consequences did not vary as a function of demand. Results support using behavioral economic models to facilitate identifying etiologic pathways to alcohol consequences and suggest that novel interventions incorporating demand manipulation may reduce drinking consequences.

Assessment of Alcohol Use and Consequences: Comparison of Data Collected Via Timeline Followback Interview and Daily Reports.

OBJECTIVE: The aim of this study was to compare data on both alcohol use and alcohol-related consequences between intensive longitudinal data collection and the retrospective Timeline Followback (TLFB) interview. METHOD: Heavy drinking college students (n = 96; 52% women) completed daily reports across a 28-day period to assess alcohol use and positive and negative consequences of drinking. They returned to the lab at the end of this period to complete a TLFB assessing behavior over those same 28 days. First, t tests were used to compare variables aggregated across the full 28 days at the between-person level. Next, hierarchical linear modeling was used to examine within-person differences between methods for each variable in weekly and daily increments. RESULTS: Many alcohol use and consequence variables were significantly different when derived from self-reports during TLFB versus daily reports. In contrast to prior work, we found that higher estimates of drinking were reported retrospectively on the TLFB than on the daily reports. In addition, discrepancies were greater on some variables for heavier drinkers and when more time had elapsed between the end of the daily reporting period and TLFB collection. CONCLUSIONS: Recall of drinking behavior during TLFB and daily reports may differ in systematic ways, with discrepancies varying based on participant and methodological characteristics.

Alcohol demand assessed daily: Validity, variability, and the influence of drinking-related consequences.

BACKGROUND: Alcohol demand, typically assessed at the trait-level, via single administration, reflects individualized alcohol value. We examined correspondence between baseline trait-level and daily brief measures of alcohol demand, and whether demand changes day-to-day in response to recent drinking-related consequences. Understanding whether consequences influence demand fluctuations may provide insight into when demand can be reduced in the context of intervention. METHODS: Heavy drinking college students (n = 95, age 18-20, 52% female) completed a baseline 14-item alcohol purchase task (APT). Observed demand indices were: intensity (consumption at zero cost), Omax (maximum expenditure), and breakpoint (cost whereby consumption is suppressed to zero). Participants subsequently completed 28 daily reports including a 3-item APT (one item corresponding to each baseline index) and prior day drinking and consequences. RESULTS: Intraclass correlations revealed within-person variability (i.e., day-to-day change) across daily demand indices. In hierarchical linear models (HLM), each daily demand index was significantly predicted by its corresponding baseline full APT index, when all three baseline indices were entered, suggesting convergent validity of the daily measure. Lower day-level intensity was predicted by more prior day negative consequences, controlling for several day- and person-level variables in HLM. Recent positive consequences did not impact intensity, and daily Omax and breakpoint were not predicted by any tested day- or person-level variables. CONCLUSIONS: APT indices collected daily map on well to traditional single-administration APT metrics and change in response to recent consequences. Intensity demonstrated the greatest within-person variability, the strongest association with its corresponding full APT index, and theoretically-consistent prediction by negative consequences of drinking.

A qualitative examination of contextual influences on negative alcohol consequence evaluations among young adult drinkers.

Alcohol misuse and associated negative consequences experienced by college students persists as a public health concern. Quantitative studies demonstrate variability in subjective evaluations of consequences, and how positively or negatively consequences are evaluated is associated with drinking behavior. Lacking is a qualitative exploration of how drinkers evaluate consequences and what influences those evaluations. We conducted a series of single-gender focus groups (13 groups; 3-7 per group; n = 62, 48% female) with college student drinkers. Questions focused on: (a) types of negative and positive consequences experienced (b) personal perceptions of negative consequences and (c) factors influencing those perceptions. Verbatim transcripts were content analyzed using applied thematic analysis with NVivo software. Several negative consequences not included in current assessment tools emerged. Reactions to these "negative" consequences of alcohol misuse were not labeled as uniformly negative by participants. Contextual influences on reactions to consequences included: social factors (e.g., normative perceptions, social context, discussions with friends), level of intoxication, concurrent positive consequences, time, and alcohol as an excuse. Future research should focus on consequence measure development and examine interactions between contextual and individual influences on subjective consequence evaluations. (PsycINFO Database Record

Trajectories and correlates of reasons for abstaining or limiting drinking during adolescence.

INTRODUCTION: Our aim was to enhance understanding of the trajectory of reasons for abstaining and limiting drinking (RALD) over the course of adolescence and how RALD levels or trajectories may differ based on lifetime experience with alcohol and/or gender. METHODS: Participants were 1023 middle school students (52% female) who completed online surveys at baseline and five follow-ups over a 3-year period, assessing lifetime sip and full drink of alcohol and RALD. Hierarchical linear models were used to estimate change over time in total RALD and RALD subscales (upbringing, performance/control). Between-person (gender and drinking status) correlates of average RALD and change in RALD over time were considered. RESULTS: RALD total and subscale scores significantly decreased over time (ages 10.5-16.5). Drinking experience in both milestones (sip, full drink) was found to be a significant moderator of change in RALD over time; decline was fastest among adolescents reporting lifetime experience with drinking. Boys reported lower RALD, though the pace of change in RALD across time did not differ by gender. CONCLUSIONS: This was the first study to report prospective changes in the cognitive domain of RALD among young adolescents. That change over time in RALD is moderated by drinking experience suggests an increased risk among those with earlier drinking experience. Findings highlight the importance of considering sipping, not just consumption of a full drink, as a pivotal developmental milestone. Prevention efforts that target RALD are implicated and parent-based intervention strategies may be beneficial.

Using Ecological Momentary Assessment (EMA) to Assess Situation-Level Predictors of Alcohol Use and Alcohol-Related Consequences.

Ecological momentary assessment (EMA) has afforded several important advances in the field of alcohol research, including testing prominent models of alcohol abuse etiology in "high resolution." Using high-tech methods for signaling and/or assessment, such as mobile electronic diaries, personal data assistants, and smartphones, EMA approaches potentially can improve understanding of precipitants of drinking, drinking patterns, and consequences. For example, EMA has been used to study complex drinking patterns and dynamic predictors of drinking in near-real time. Compared with other methods, EMA can better sample and capture changes in these phenomena that occur in relatively short time frames. EMA also has several potential applications in studying the consequences of alcohol use, including physical, interpersonal, behavioral, and legal problems. However, even with all these potential capabilities, EMA research in the alcohol field still is associated with some limitations, including the potential for measurement reactivity and problems with acceptability and compliance. Despite these limitations, electronically based EMA methods are versatile and are capable of capturing data relevant to a variety of momentary influences on both alcohol use and consequences. Therefore, it will be exciting to fully realize the potential of future applications of EMA technologies, particularly if the associated costs can be reduced.

Transient ischemic dilation ratio in 82Rb PET myocardial perfusion imaging: normal values and significance as a diagnostic and prognostic marker.

UNLABELLED: In myocardial perfusion SPECT, transient ischemic dilation ratio (TID) is a well-established marker of severe ischemia and adverse outcome. However, its role in the setting of (82)Rb PET is less well defined. METHODS: We analyzed 265 subjects who underwent clinical rest-dipyridamole (82)Rb PET/CT. Sixty-two subjects without a prior history of cardiac disease and with a normal myocardial perfusion study had either a low or a very low pretest likelihood of coronary artery disease or negative CT angiography. These subjects were used to establish a reference range of TID. In the remaining 203 patients with an intermediate or high pretest likelihood, subgroups with normal and abnormal TID were established and compared with respect to clinical variables, perfusion defect scores, left ventricular function, and absolute myocardial flow reserve. Follow-up was obtained for 969 ± 328 d to determine mortality by review of the social security death index. RESULTS: In the reference group, TID ratio was 0.98 ± 0.06. Accordingly, a threshold for abnormal TID was set at greater than 1.13 (0.98 + 2.5 SDs). In the study group, 19 of 203 patients (9%) had an elevated TID ratio. Significant differences between subgroups with normal and abnormal TID ratio were observed for ejection fraction reserve (5.0 ± 6.4 vs. 1.8 ± 7.9; P < 0.05), difference between end-systolic volume (ESV) at rest and stress (ΔESV[stress-rest]; 1.8 ± 7.4 vs. 12.3 ± 13.0 mL; P < 0.0001), difference between end-diastolic volume (EDV) at rest and stress (ΔEDV[stress-rest]; 10.8 ± 11.5 vs. 23.8 ± 14.6 mL; P < 0.0001), summed rest score (1.8 ± 3.8 vs. 3.8 ± 7.6; P < 0.05), summed stress score (3.0 ± 5.4 vs. 7.5 ± 9.8; P < 0.002), summed difference score (1.3 ± 2.6 vs. 3.7 ± 5.3; P < 0.02), and global myocardial flow reserve (2.1 ± 0.8 vs. 1.7 ± 0.6; P < 0.02). Additionally, TID-positive patients had a significantly lower overall survival probability (P < 0.05). In a subgroup analysis of patients without regional perfusion abnormalities, TID-positive patients' overall survival probability was significantly smaller (P < 0.03), and TID was an independent predictor (exponentiation of the B coefficients [Exp(b)] = 6.22; P < 0.009) together with an ejection fraction below 45% (Exp[b] = 6.16; P < 0.002). CONCLUSION: The present study suggests a reference range of TID for (82)Rb PET myocardial perfusion imaging that is in the range of previously established values for SPECT. Abnormal TID in (82)Rb PET is associated with more extensive left ventricular dysfunction, ischemic compromise, and reduced global flow reserve. Preliminary outcome analysis suggests that TID-positive subjects have a lower overall survival probability.

Can lifestyle interventions do more than reduce diabetes risk? Treating depression in adults with type 2 diabetes with exercise and cognitive behavioral therapy.

The epidemic of metabolic syndrome, prediabetes, and type 2 diabetes is global in scope and comprehensive in its impact on individuals, health care systems, and societies. One in four patients with diabetes will experience depression in their lifetime. Comorbid depression is associated with poorer outcomes, greater functional disability, and early mortality. Prior studies have demonstrated beneficial effects of exercise as an efficacious form of treatment for depression in the general population. Few studies have evaluated this strategy in patients with prediabetes or type 2 diabetes. Program ACTIVE (Appalachians Coming Together to Increase Vital Exercise) was designed to treat depression among adults with type 2 diabetes by pairing aerobic activity with individual cognitive behavioral therapy. This combination treatment approach has been shown to be feasible to implement in a rural environment and promising in terms of depression, diabetes, and cardiovascular outcomes. Data from this study suggest that exercise can be used to achieve multiple benefits for adults with type 2 diabetes. Future work to compare this approach to singular treatment strategies for adults at risk for type 2 diabetes is needed.

PET/CT assessment of symptomatic individuals with obstructive and nonobstructive hypertrophic cardiomyopathy.

UNLABELLED: Patients with obstructive hypertrophic cardiomyopathy (HCM) exhibit elevated left ventricular outflow tract gradients (LVOTGs) and appear to have a worse prognosis than those with nonobstructive HCM. The aim of this study was to evaluate whether patients with obstruction, compared with nonobstructive HCM, demonstrate significant differences in PET parameters of microvascular function. METHODS: PET was performed in 33 symptomatic HCM patients at rest and during dipyridamole stress (peak) for the assessment of regional myocardial perfusion (rMP), left ventricular ejection fraction (LVEF), myocardial blood flow (MBF), and myocardial flow reserve (MFR). Myocardial wall thickness and LVOTG were measured with an echocardiogram. Patients were divided into the following 3 groups: nonobstructive (LVOTG < 30 mm Hg at rest and after provocation test with amyl nitrite), obstructive (LVOTG ≥ 30 mm Hg at rest and with provocation), and latent HCM (LVOTG < 30 at rest but ≥ 30 mm Hg with provocation). RESULTS: Eleven patients were classified as nonobstructive (group 1), 12 as obstructive (group 2), and 10 as latent HCM (group 3). Except for age (42 ± 18 y for group 1, 58 ± 7 y for group 2, and 58 ± 12 y for group 3; P = 0.01), all 3 groups had similar baseline characteristics, including maximal wall thickness (2.3 ± 0.5 cm for group 1, 2.2 ± 0.4 cm for group 2, and 2.1 ± 0.7 cm for group 3; P = 0.7). During peak flow, most patients in groups 1 and 2, but fewer in group 3, exhibited rMP defects (73% for group 1, 100% for group 2, and 40% for group 3; P = 0.007) and a drop in LVEF (73% for group 1, 92% for group 2, and 50% for group 3; P = 0.09). Peak MBF (1.58 ± 0.49 mL/min/g for group 1, 1.72 ± 0.46 mL/min/g for group 2, and 1.97 ± 0.32 mL/min/g for group 3; P = 0.14) and MFR (1.62 ± 0.57 for group 1, 1.90 ± 0.31 for group 2, and 2.27 ± 0.51 for group 3; P = 0.01) were lower in the nonobstructive and higher in the latent HCM group. LVOTGs demonstrated no significant correlation with any flow dynamics. In a multivariate regression analysis, maximal wall thickness was the only significant predictor for reduced peak MBF (ß = -0.45, P = 0.003) and MFR (ß = -0.63, P = 0.0001). CONCLUSION: Maximal wall thickness was identified as the strongest predictor of impaired dipyridamole-induced hyperemia and flow reserve in our study, whereas outflow tract obstruction was not an independent determinant.

Rubidium-82 PET-CT for quantitative assessment of myocardial blood flow: validation in a canine model of coronary artery stenosis.

PURPOSE: Absolute quantification of myocardial blood flow expands the diagnostic potential of PET for assessment of coronary artery disease. (82)Rb has significantly contributed to increasing utilization of PET; however, clinical studies are still mostly analysed qualitatively. The aim of this study was to reevaluate the feasibility of (82)Rb for flow quantification, using hybrid PET-CT in an animal model of coronary stenosis. METHODS: Nine dogs were prepared with experimental coronary artery stenosis. Dynamic PET was performed for 8 min after (82)Rb(1480-1850 MBq) injection during adenosine-induced vasodilation. Microspheres were injected simultaneously for reference flow measurements. CT angiography was used to determine the myocardial regions related to the stenotic vessel. Two methods for flow calculation were employed: a two-compartment model including a spill-over term, and a simplified retention index. RESULTS: The two-compartment model data were in good agreement with microsphere flow (y = 0.84x + 0.20; r = 0.92, p<0.0001), although there was variability in the physiological flow range <3 ml/g per minute (y = 0.54x + 0.53; r = 0.53, p = 0.042). Results from the retention index also correlated well with microsphere flow (y = 0.47x + 0.52; r = 0.75, p = 0.0004). Error increased with higher flow, but the correlation was good in the physiological range (y = 0.62x + 0.29; r = 0.84, p = 0.0001). CONCLUSION: Using current state-of-the-art PET-CT systems, quantification of myocardial blood flow is feasible with (82)Rb. A simplified approach based on tracer retention is practicable in the physiological flow range. These results encourage further testing of the robustness and usefulness in the clinical context of cardiac hybrid imaging.

Lowering radiation dose for integrated assessment of coronary morphology and physiology: first experience with step-and-shoot CT angiography in a rubidium 82 PET-CT protocol.

BACKGROUND: Reduction of radiation exposure from computed tomography coronary angiography (CTA) will be a key factor for more liberal use in cardiac hybrid positron emission tomography (PET)-computed tomography (CT). We report our initial experience with a new algorithm for low-dose CTA based on a prospectively gated step-and-shoot technique. This limits acquisition to the diastolic phase and minimizes exposure time versus the previous standard of retrospectively gated helical acquisitions. METHODS AND RESULTS: In 15 consecutive patients referred for integrated functional and morphologic workup by rubidium 82 perfusion PET-CTA, step-and-shoot CTA (SnapShot Pulse; GE Medical Systems) (120 kV, 600-800 mA) was acquired on a 64-slice GE Discovery Rx VCT PET-CT scanner and compared with a group of patients with conventional helical CTA (120 kV, with modulation of the milliampere level) who were matched with regard to clinical variables. Effective dose was estimated from dose-length product. The American Heart Association 15-segment coronary tree model was used to determine study interpretability. Potential for fusion with Rb-82 perfusion PET was tested by use of commercial software. In addition, direct dose measurements were conducted by use of an anthropomorphic phantom for more accurate dosimetry. The dose-length product-derived effective patient dose for step-and-shoot and helical CTA was 5.5 +/- 0.1 mSv versus 20.5 +/- 3.5 mSv (P < .0001). The mean number of evaluable segments per patient for the best phase of helical CTA was 12.5 +/- 2.8 (83.3% +/- 18.7%) versus 13.3 +/- 2.2 (88.7% +/- 14.7%) (P = not significant vs helical) for step-and-shoot CTA. Review of multiple phases increased the number for helical CTA to 13.7 +/- 1.7 (91.3% +/- 11.3%; P = not significant vs step-and-shoot CTA, for which this was not an option). Semiautomated fusion with corresponding PET was feasible for all studies. Phantom data confirm effective doses of 5.4 mSv for step-and-shoot CTA and 19.6 mSv for helical acquisition. CONCLUSIONS: Low-dose prospectively gated CTA reduces radiation exposure by nearly 70% versus the previous standard of helical acquisition, without significant loss in interpretability and integrative potential with Rb-82 perfusion PET. This represents a step toward a broader, routine integration of CTA and perfusion PET for assessment of coronary morphology and physiology by cardiac PET-CT.