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 After discussion, the order is authorized, modified, withdrawn, or recommended for denial.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 Some patients with withdrawn orders receive PAR if claudication does not resolve.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.

Modification and Reinitiation of Lower Back Imaging Orders After Evidence-Based Collaborative Consultation.

RATIONALE AND OBJECTIVES: Practice guidelines suggest most patients should wait at least 28 days from the onset of low back pain before receiving imaging. This study evaluates a nondenial prior authorization program's performance in modifying lower back imaging orders. Ordering physicians were asked by a consulting physician to modify any order that did not meet guidelines through collaborative consultation. If original orders were not reinitiated, it could signify that modified orders met clinical objectives. MATERIALS AND METHODS: Prior authorization and claims data from 2014 to 2017 were analyzed to determine the rate of reinitiation within 28 days for modified computed tomography and magnetic resonance imaging orders. Chi-square tests were used to evaluate whether modification or reinitiation was associated with several factors. RESULTS: Across the four sequences of interaction between ordering physicians and the program examined, 533,768 orders were placed, leading to 6855 completed consultations (1.3% of orders), 1380 modifications (20.1% of consultations), and 224 reinitiations (16.2% of modifications). Modification led to reinitiation 7.1%-20.6% of the time, depending upon the sequence. Orders from primary care physicians were significantly more likely to be modified. Reinitiation was significantly more likely for urban orders. CONCLUSION: Low back imaging orders modified by the program were infrequently reinitiated within 28 days. Some reinitiation may have been consistent with evidence-based practice, as orders may have been placed after the onset of pain.

Inductive effects of 10 and 12-vertex closo-carborane anions: cluster size and charge make a difference.

A phosphine containing a 10-vertex carborane anion substituent and its subsequent ligation to a Rh(I) carbonyl complex is reported. The complex is characterized by NMR spectroscopy and a single crystal X-ray diffraction study. In addition, the inductive effects of both 10 and 12 vertex C-functionalized closo-carborane anions are elucidated via I.R. analysis of the CO stretching frequencies of two Rh carbonyl complexes. Unlike C-functionalized neutral o-carborane the 10 and 12-vertex carborane anions are both strong electron donor substituents.

Synthesis of a hybrid m-terphenyl/o-carborane building block: applications in phosphine ligand design.

A hybrid terphenyl/o-carborane ligand building block is synthesized by the reaction of m-terphenylalkyne with B10H14. This sterically demanding substituent can be installed into ligands, as demonstrated by the preparation of carboranylphosphine. The bulky phosphine reacts with [ClRh(CO)2]2 to produce monophosphine complex ClRhL(CO)2, which subsequently extrudes CO under vacuum to afford the dimeric species [ClRhL(CO)]2. The latter complex does not react with excess phosphine and is resistant toward cyclometalation, which is in contrast to related o-carborane phosphine complexes. Data from a single-crystal X-ray diffraction study are utilized to quantify the steric impact of the ligand via the percent buried volume approach.

Molecular and structural basis for the roles of hepatitis C virus polymerase NS5B amino acids 15, 223, and 321 in viral replication and drug resistance.

Resistance to the 2'-F-2'-C-methylguanosine monophosphate nucleotide hepatitis C virus (HCV) inhibitors PSI-352938 and PSI-353661 was associated with a combination of amino acid changes (changes of S to G at position 15 [S15G], C223H, and V321I) within the genotype 2a nonstructural protein 5B (NS5B), an RNA-dependent RNA polymerase. To understand the role of these residues in viral replication, we examined the effects of single and multiple point mutations on replication fitness and inhibition by a series of nucleotide analog inhibitors. An acidic residue at position 15 reduced replicon fitness, consistent with its proximity to the RNA template. A change of the residue at position 223 to an acidic or large residue reduced replicon fitness, consistent with its proposed proximity to the incoming nucleoside triphosphate (NTP). A change of the residue at position 321 to a charged residue was not tolerated, consistent with its position within a hydrophobic cavity. This triple resistance mutation was specific to both genotype 2a virus and 2'-F-2'-C-methylguanosine inhibitors. A crystal structure of the NS5B S15G/C223H/V321I mutant of the JFH-1 isolate exhibited rearrangement to a conformation potentially consistent with short primer-template RNA binding, which could suggest a mechanism of resistance accomplished through a change in the NS5B conformation, which was better tolerated by genotype 2a virus than by viruses of other genotypes.

Placenta Derived Adherent Cell (PDAC) Interaction and Response on Extracellular Matrix Isolated from Human Placenta t.

A method was developed to isolate extracellular matrix from the human placenta (pECM). The isolated material is composed primarily of collagen, in addition to, elastin, fibronectin, laminin, and glycosaminoglycans (GAGs). The pECM is isolated as a water insoluble paste. This paste can be molded into sheets, tubes, and other 3-D structures that are stable at room temperature. This report describes the interaction of the pluripotent progenitor cells (PDACs) with the isolated pECM. The stem cells used in this study are of human placental origin (placenta derived adherent cells or PDACs) and have a phenotype described as CD200+, CD105+, CD10+, CD34-, and CD45-. The PDACs bind to and proliferate on the pECM, and are stimulated to secrete soluble fibronectin. They actively assemble the soluble fibronectin into a complex network of detergent-insoluble extracellular matrix fibrils. While proliferating on the pECM, PDACs secrete key cytokines at levels well above that observed on tissue-treated tissue culture plates. These cytokines included monocyte chemoattractant protein (MCP-1), IL-6, and IL-8, all of which are important participants in wound healing processes. These results suggest the feasibility of designing a combination product of pECM with PDACs to augment repair processes in nonhealing deep wounds and in diabetic ulcers.