Delay in prior authorization of biologic therapy: Another possible cause of healthcare disparity in IBD patients.

BACKGROUND: Biologics, a mainstay in inflammatory bowel disease (IBD) treatment, typically require prior authorization from insurance companies. Multiple studies show that African Americans are less likely to be prescribed biologics. The prior authorization process may perpetuate disparities in healthcare. This study evaluated the approval time for biologics in IBD. METHODS: A chart review of IBD patients seen in a university gastroenterology clinic over 5 years was performed. Patient gender, race, IBD subtype, biologic use, and insurance type were recorded. Insurance type was classified as private or public (Medicaid or Medicare). Biologic agents evaluated included infliximab, adalimumab, vedolizumab and ustekinumab. Length of time to approval (TTA) and length of time to first infusion or administration (TFI) were recorded. Analysis was performed using t-testing, Fisher's exact testing, and ANOVA with significance set at p<0.05. The study was IRB approved. RESULTS: 458 charts were analyzed. 66 patients were being treated with a biologic. 42 had private insurance, 16 Medicaid and 8 Medicare. 37 patients had ulcerative colitis, 27 Crohn's disease, and 2 indeterminate colitis. There were 38 men and 28 women. 32 patients were white, 26 African American, 1 Asian, 5 other, and 2 declined identification. Average TTA was 30.5 days (range 1-145) and average TFI was 45.3 days (range 2-166). African Americans were more often on public insurance compared to whites (p=0.0001). Crohn's disease compared to ulcerative colitis patients were more often on public insurance (p=0.017). Significantly more private compared to public insurance patients were on infliximab (p=0.001). Medicaid and Medicare patients had significantly longer mean TTAs than private insurance patients (49.1 and 52.7 vs 19.4 days, p=0.007). African Americans had significantly longer mean TTA compared to whites (45.9 vs 24.8 days, p=0.044). Crohn's disease compared to ulcerative colitis patients had significantly longer mean TTA (39.7 vs 21.8 days, p=0.050). DISCUSSION: This study shows that prior authorization for biologic therapy was longer for African Americans. Patients on public insurance also tend to have a longer TTA, and more African Americans were on public insurance compared to White patients in this study which may explain the difference in biologic access for African Americans.

Elsberg syndrome in HSV-2 infection.

Elsberg syndrome (ES) is a neuroinflammatory disease that causes acute or subacute lumbosacral radiculitis, with or without myelitis which accounts for approximately 5-10% of cauda equina syndrome and myelitis. We herein present a case of a middle-aged female who recently returned from the Dominican Republic and presented to the emergency room with complaints of a 10-day history of progressive lower extremity sensory changes and weakness preceded by transient bilateral arm pain and neck and head pressure. Based on clinical, radiographic, and serological testing the patient was diagnosed with HSV2 lumbosacral radiculitis (ES). After 21 days of Acyclovir, 5 days of high dose IV methylprednisolone, and one month of inpatient rehab, our patient was discharged home walking with a cane. As ES is poorly defined and rarely reported, it can be unrecognized in patients with acute cauda equina syndrome (CES). Appropriate testing for viral infection in a timely manner facilitates reaching a definitive diagnosis and prompt initiation of treatment, which is essential for resolution of symptoms.

Clinical outcomes of patients with mild COVID-19 following treatment with hydroxychloroquine in an outpatient setting.

We appreciate the efforts of the authors in their study on the clinical outcome of hydroxychloroquine (HCQ) therapy in mild coronavirus disease 2019 (COVID-19) (Mokhtari et al., 2021). We would like to make some comments based on our understanding of the study.

Expanding telehealth options during the COVID pandemic eliminated racial and age disparities in electronic communication by inflammatory bowel disease patients.

BACKGROUND: Electronic messaging and telemedicine visits increased during the COVID pandemic. African-Americans and older patients have less frequently used electronic messaging with their physicians. This study compares the utilization of virtual health care before and during the COVID pandemic for inflammatory bowel disease (IBD) patients. METHODS: A chart review of all IBD patients seen at an academic medical center from 2014-2020 was conducted to evaluate the use of telehealth options (e-messaging, e-visits) during a pre-COVID and COVID timeframe. Analysis of telehealth use from March - August 2018 and March - August 2020 was performed. Patient age, gender, race, IBD type, electronic messaging and telehealth visits were obtained. A confidential database was created. Statistical analysis was performed using Fisher Exact test with significance set at p < 0.05. The study was IRB approved. RESULTS: 392 patients were in the pre-COVID cohort. There were 204 White, 99 African-American, 11 Asian, and 78 racially un-identified patients. 160 (40.8%) initiated E-communication with their physicians. There was a significant difference in the use of e-messaging based upon age (51.1% < 50 vs 39.7% ≥ 50; p = 0.0396) and race (62.3% White vs 28.2% African-American; p < 0.00001).There were no significant differences in the use of e-messaging based upon patient gender (p = 0.6840) or IBD type (p = 0.6374). There were 295 patients in the COVID cohort. There were 155 White, 83 African American patients, 24 Hispanic patients, 10 Asian patients, and 22 racially un-identified patients. 109 (36.9%) utilized a telehealth option (53 via e-messaging; 56 via telemedicine visit). There was no significant difference in the use of a telehealth option based upon age (36.8% < 50 vs 37.25% ≥ 50 years; p = 1.00), race (42.6% White vs 35.9% African-American; p = 0.2693) or IBD type (p = 0.331). Males used telehealth more than females (46.1% vs 29.7%, respectively; p = 0.0051). DISCUSSION: The COVID pandemic emergency increased e-visits and e-messaging for care delivery. Expanded telemedicine options for IBD patients eliminated previously identified racial and age disparities in virtual medical care. African Americans utilized electronic communication as frequently as Whites during the pandemic. Post-pandemic policy consideration for continued telemedicine options may expand patient-physician engagement and eliminate disparities in health care.