Evaluating the Inter-Reviewer Reliability and Evidentiary Grounds for Third-Party Peer-to-Peer Mandated Downgrading of Radiation Therapy Prescriptions

Abstract

<h3>Purpose/Objective(s)</h3> Health plans employ utilization management strategies to control access to certain treatments in a bid to cut health care spending, frequently requiring prior authorization (PA) and subsequent peer-to-peer (P2P) discussion if the prescribed studies or treatments are not initially approved. In theory, P2P reviewers should follow current, evidence-based clinical guidelines and have knowledge of novel treatments to optimize patient care. We examine P2P determinations to downgrade prescriptions (Rx) of radiotherapy (RT) and evaluate both the evidentiary basis and internal consistency of these decisions, as applied to patients at a large academic radiation medicine department. <h3>Materials/Methods</h3> De-identified departmental billing records from 1/12/21 to 8/12/21 were used to query cases in which an Rx for RT was denied PA and ultimately downgraded on P2P in terms of RT technique, fraction number, or use of image-guided radiation therapy (IGRT). These were cross-identified with patient charts in an IRB-approved electronic medical record, and clinical details reviewed. The P2P record was searched for pair matches for each downgraded Rx (i.e., anatomic site, modality, fractionation), such that the match was approved unaltered. PubMed searches were performed for literature supporting the initial Rx in terms of control, survival, or toxicity outcomes. <h3>Results</h3> 1620 Rx were prescribed during the analyzed period, of which 697 cases were referred for PA. 123 (17.6%) of the latter were denied and referred to P2P. 31 of the 123 (25.2%) resulted in a downgraded Rx, of which 13 (41.9%) were for curative treatment, 8 (25.8%) for treatment of oligometastatic disease (OMD), and 10 (32.3%) for non-OMD palliative treatment. No Rx were downgraded for fraction number. 15 downgraded Rx (48.4%) were pair-matched with Rx that were approved unaltered on P2P. 3 (9.6%) downgraded Rx were matched with approved Rx for higher grade modality (e.g., IMRT over 3DCRT) for equivalent indications. 18 of 31 downgraded Rx (58.1%) were matched with approvals for identical or upgraded Rx, including 10 curative cases, 7 OMD cases, and 2 of 5 cases in which IGRT alone was excluded on P2P. For 17 downgraded Rx (54.8%), literature in support of the original Rx was identified, including at minimum a phase II study, a meta-analysis of > 1000 subjects, or a retrospective review with between 86 and 202 subjects. Multiple phase II studies supported all Rx for OMD that were downgraded. <h3>Conclusion</h3> Our analysis shows that more than half of treatment downgrades resulting from the P2P process can be matched with P2P approvals of the same or upgraded treatment for the same indication. We further show that published evidence could have upheld the initial prescriptions in more than half of P2P downgrades. These results suggest a high degree of inter-reviewer variability and inconsistent fidelity to evidence-based management in P2P decisions to downgrade RT Rx. Multi-institutional quality review of ultimate P2P dispositions is warranted.