Insurance and racial disparities in prior authorization in gynecologic oncology.

While prior authorization aims to reduce unnecessary care, it may limit or delay medically necessary care. Delays in cancer care can impact survival and are more common in historically-marginalized populations. Our objective was to examine to what extent disparities occurred in prior authorizations for gynecologic oncology. Using electronic medical records, we performed a retrospective review of prior authorization occurrence during gynecologic oncology care and analyzed the association with patient race and insurance in a multivariate regression model. In this cohort of 1,406 patients treated at an academic gynecologic oncology practice, patients with Medicare Advantage and patients of Asian descent were more likely to experience prior authorization. Addressing insurance-mediate disparities, such as in the occurrence of prior authorization, may help reduce disparities in gynecologic cancer care.

Prior authorization in gynecologic oncology: An analysis of clinical impact.

BACKGROUND: Prior authorization was designed to minimize unnecessary care and reduce spending but has been associated with delays in necessary care. Our objective was to estimate the occurrence of prior authorization, and impact on cancer care, in gynecologic oncology. METHODS: We performed a retrospective cross-sectional study of patients seen in University of Pennsylvania gynecologic oncology practices (January-March 2021). Using electronic medical records, we measured the incidence of prior authorization during the 3-month period and prior experience of prior authorization for cancer care overall and by type of order (chemotherapy, imaging, surgery, prescription drugs). We assessed the impact of prior authorization occurrence on clinical outcomes (time to service, changes in care). RESULTS: Of the 2112 clinic visits of 1406 unique patients, 5% experienced prior authorization during the 3-month study period. An additional 20% faced prior authorization requests earlier in cancer care. Of the 83 prior authorization requests, imaging accounted for the majority (54%) followed by supportive medications (29%) and chemotherapy (17%). After appeal, 79% of cases were approved. For patients whose prior authorizations were approved, there was a mean of 16 days from order placement to care delivery (95% CI 11-20, range 0-98 days). Of the 17 denials, 3 (18%) led to a substantial change in care (i.e., not receiving planned treatment). CONCLUSION: 25% of gynecologic oncology patients experienced prior authorization during their cancer care. While 80% of claims were ultimately approved, patients experienced over a 2-week delay in care when prior authorization occurred. Reform is needed to reduce the burden of prior authorization in oncology.

Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage.

BACKGROUND: One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis. METHODS: Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate. RESULTS: 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64-0.92] compared to 0.59 [0.41-0.73] for cardiac output (CO), 0.68 [0.49-0.80] for cardiac index (CI), and 0.63 [0.36-0.80] for heart rate (HR) for predicting hospital admission. CONCLUSIONS: CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.