Discordance Between Inflammatory Bowel Disease Specialists and Insurance Authorization Denials-A Survey of Specific Inflammatory Bowel Disease Treatment Scenarios.

Background: Prior authorizations are generally required by insurers for gastroenterologists to prescribe biologics and small-molecule drugs to treat inflammatory bowel disease (IBD). Authorization denials occur in a wide variety of clinical scenarios, including denials of standard and nonstandard medication dosing. Methods: We performed a national cross-sectional survey on a broad variety of specific clinical scenarios to assess experience and opinions on whether or not insurance authorization denials are in accordance with clinical expertise. Results: Eighty-four gastroenterologists completed the survey. Denial experience was common for infliximab dose modifications, vedolizumab dose modifications, ustekinumab first-time therapy, and maintenance dosing. The bulk of disagreement with authorization denials involved scenarios of dose escalation and re-induction guided by both loss of clinical response and/or therapeutic drug monitoring, denial of re-authorizations of stable dosing, and use of non-anti-TNFs in specific patient populations including the elderly and patients with multiple comorbidities. Respondents unanimously agreed that insurance companies do not play an adequate role in helping patients obtain PA. Furthermore, most of the respondents agree that to decrease the burden of the PA process, peer-peer processes should be between other IBD-trained providers who understand these complex treatment strategies. Conclusions: Our cross-sectional survey highlights the degree of discordance in clinical decision-making between insurers and gastroenterologists. Further engagement between gastroenterologists and insurers is needed to foster common understanding on these discordant authorization denials in these real-world clinical IBD scenarios.

Liver transplantation for refractory hepatic hydrothorax is associated with a greater survival benefit compared to other complications of cirrhosis.

Hepatic hydrothorax (HH) is a significant complication of cirrhosis associated with increased mortality. Liver transplantation (LT) remains the best treatment modality. We aim to assess predictors of mortality and the survival benefit of LT in patients with HH. A prospectively maintained cohort of adult patients with cirrhosis, being evaluated for LT at our institution, was retrospectively reviewed from 2015 to 2020. The primary outcome was death or LT. Cox proportional hazard regression identified associations between covariates and death. We calculated the years saved due to LT by comparing patients who were on the waiting list with patients who received an LT. This was done by calculating the area under the Kaplan-Meier curve. Censoring occurred at the time of the last follow-up or death. Patients with refractory HH had the lowest median survival of only 0.26 years. Within the HH group, having a refractory HH group was significantly associated with an increased risk of mortality (HR 1.73; 95% CI 1.06-2.81; p -value 0.03). Refractory HH was also significantly associated with mortality when evaluated in the entire cohort and after adjusting for other covariates (HR 1.48, 95% CI 1.03-2.11; p -value 0.03). Patients with refractory HH had the highest 1-year survival benefit with LT (0.48 y), followed by patients with non-refractory HH (0.28 y), then patients with other complications of cirrhosis (0.19 y). In this large study evaluating the prognostic impact of HH on patients with cirrhosis, refractory HH was an independent predictor of mortality. LT provides an additional survival benefit to patients with HH compared with those without HH.

Critical presentation and management of an acute gastrointestinal haemorrhage as a result of an arterioenteric fistula secondary to a failed pancreatic allograft.

We present a case of a 60-year-old woman status post failed pancreatic transplant, presenting with right lower extremity pain and large volume rectal bleeding. The team initiated a massive transfusion protocol. Investigations revealed an arterioenteric (AE) fistula between the right external iliac artery and terminal ileum. The patient was then emergently sent for right iliac artery stent placement, successfully stopping the active arterial haemorrhage. Afterwards, the surgical team transected the pancreatic jejunal anastomosis, subsequently resecting 7 cm of jejunum. On postoperative day 1, the patient became unstable, going into disseminated intravascular coagulation evidenced by low platelet count, elevated prothrombin time and bloody output from multiple sites. Resuscitation with pressors and blood product transfusion was unsuccessful. She was made comfort measures only and expired shortly after extubation. Although a rare aetiology, it is important to consider AE fistulas in patients presenting with vascular and gastrointestinal symptoms in the setting of a failed allograft.