Prior Authorization Research Articles

Abstract 4120515: Impact of 2022 AHA/ACC/HFSA Heart Failure Guideline Value Statement Publication on Medicare Drug Coverage Policies

Background: Patients with heart failure (HF) often have difficulty obtaining life-saving medications due to coverage barriers, such as prior authorizations (PA) and high out of pocket (OOP) costs. To promote better insurance coverage of high value therapies, the AHA/ACC/HFSA added Value Statements to HF guidelines to inform policymakers about medication cost effectiveness. We assessed whether these guidelines influenced Medicare drug coverage policies for two life-saving, costly HF medications: angiotensin receptor neprilysin inhibitors (ARNI – guideline “high value”) and sodium glucose cotransporter 2 inhibitors (SGLT2i – guideline “intermediate value”). Methods: We performed an observational study of Medicare drug plans from 4/2020-4/2023 to assess for changes in ARNI and SGLT2i coverage after Value Statement publication (4/2022), and subsequent Medicare plan online update (10/2022). The primary outcome was any barrier to drug coverage (PA, tier ≥ 3 OOP cost-sharing, step therapy, or no coverage). Analysis utilized interrupted time series and difference-in-difference (DiD) approaches. DiD analyses used direct oral anticoagulants as a control due to similar cost and utilization as ARNI and SGLT2i, but with no Value Statement. Results: Among 7,396 Medicare drug plans, 94.3%-97.4% had coverage barriers to ARNI and 93.2%-96.6% to SGLT2i. The majority of barriers were due to tier ≥ 3 OOP cost-sharing requirements (ARNI: 94.3%-95.8%; SGLT2i: 93.2%-95.6%). Coverage barriers remained stable in 4/2022, and declined slightly in 10/2022 (Figure). In DiD analyses, the presence of a Value Statement was associated with a ~1 percentage point decline in coverage barriers for ARNI and SGLT2i. Conclusion: Coverage barriers to ARNI and SGLT2i were common and did not change much in response to Value Statements in HF Guidelines. Increased consideration for Value Statements by Medicare policy-makers is needed to meaningfully improve access to high value therapies.

Utilization management and physician burnout.

This study was designed to assess physician experiences with utilization management and burnout and investigate whether they are linked. We conducted an electronic survey with items related to demographics, profession, utilization management, burnout, and potential policy solutions. The survey was sent to 7222 physicians working in outpatient settings who were recruited from a large, opt-in database. Outcome measures were responses to categorical and Likert-style survey items related to demographics, utilization management, burnout, and potential policy solutions. Of 7222 requests sent, 501 physicians completed the survey and were included in the final data set (77% men; mean [SD] age, 57 [9.8] years; mean [SD] years in practice, 24 [8.9]). Of these, 200 were general practitioners and 301 were nonhospital specialists. Physicians indicated that utilization management procedures for prior authorization (81%), step therapy (79%), and nonmedical switching (69%) were major or significant barriers to their clinical and patient care. More than half (52%) reported spending 6 to 21 or more hours per week on paperwork related to health insurance utilization management, 67% had experienced burnout at some point in their careers, and 64% indicated that utilization management had been a contributing factor to feelings of burnout, with an additional 8% citing it as the main factor. Physicians favored streamlining prior authorization practice (77%), requiring step therapy to be based on science (73%), and ensuring that peer-to-peer reviews are done by qualified medical experts (67%). These findings indicate that utilization management has a detrimental impact on physicians and patient care and contributes to physician burnout.

Addressing health disparities in food allergy: APosition Statement of the AAAAI Prior Authorization Task Force.

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

The Interplay between EU Competition Law and Professional Sports: Recent Developments and Their Potential Impact on Small States

In its December 2023 judgements delivered in the European Superleague Company and International Skating Union v Commission cases, the Court of Justice of the European Union concluded that the rules established by such sports governing bodies as FIFA, UEFA, and the International Skating Union with regard to prior authorisation of alternative competitions falling outside their jurisdiction were restrictive ‘by object’ under the union’s competition law, thus forming a pathway to creating such alternative competitions in one respect. Analysing these rulings’ potential impact on professional sports, the article discusses possible harmful effects that certain alternative competitions could have on sports in small states in particular. The author advocates taking the potential for such effects into account when national courts direct their attention to further assessing the governing bodies’ pre-authorisation rules and their specific refusals to authorise certain alternative competitions.

Prior Authorization Requirements and Medicaid Enrollees’ Use of Tobacco Cessation Medications, Colorado, 2023

Despite tobacco cessation medications being a first-line treatment for quitting smoking, a majority of Medicaid programs require health care providers to obtain prior authorization before prescribing them. We examined the impact of Colorado’s Medicaid program removing its prior authorization requirement for these drugs on their use and estimated the additional number of Coloradoans who used these therapies in 2023 because of the policy change. The findings indicate that these requirements decrease low-income people’s use of these medications. ( Am J Public Health. Published online ahead of print October 24, 2024:e1–e5. https://doi.org/10.2105/AJPH.2024.307868 )

VirtualPharm: Bridging healthcare through telepharmacy

The word "telepharmacy" refers to a type of pharmaceutical care in which patients and pharmacists communicate by information and communication technology (ICT) even though they are not in the same location. Telepharmacy has been used to solve the scarcity of pharmacists and offer pharmaceutical services to underprivileged communities. Due to geographic and demographic constraints, however, rural inhabitants and towns frequently may not have easy access to healthcare services. A more recent term for pharmaceutical service delivery is telepharmacy, which allows patients who live far from a hospital, pharmacy, or other healthcare facility to receive healthcare services from a qualified pharmacist, including medication review, patient counseling, and prescription verification. Increased comfort with the medication-use system, patient safety, and job satisfaction were shown by nurses' survey results.Actually, after a pharmacist's intervention, there has been evidence of better control over hypertension, dyslipidemia or diabetes, successful smoking cessation, and a decrease in hospitalization among heart failure patients. Telepharmacy services are developed and offered using a range of technology, care models, and interventions, catering to a diverse range of individuals with various clinical conditions. Video conferencing is used in pharmacy for management, instruction, and training needs. The telephone has evolved from a device for dialing and speaking to a multimodal communication tool. Refill authorization, prior authorization, prescription counseling, and formulary compliance monitoring are all provided by call centers, while medical equipment are being connected to phone lines to provide remote monitoring and therapy. Telepharmacy is a useful tool for community pharmacies to improve drug dispensing safety and lessen the strain on the healthcare system.

Medicaid managed care restrictions on medications for the treatment of opioid use disorder.

To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine-naloxone and injectable naltrexone are related to key state Medicaid program policy decisions. We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021. In this cross-sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported. Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15-0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12-0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: -0.30, 95% CI: -0.43 to -0.18). Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder.

8230 Adrenal Crisis, Unrevealing the Impact of Immigration on Central Adrenal Insufficiency

Abstract Disclosure: D.H. Sacoto: None. K. Madani: None. D. Patel: None. A. De Rosairo: None. G. Rai: None. R. Belokovskaya: None. A.A. Franco-Akel: None. Introduction: Even though patients with secondary adrenal insufficiency (AI) may go through life without an episode of adrenal crisis, there is a 50% chance of developing it. Around 90% have a known precipitating, with infections and surgery being frequent causes. However, emotional stress is unrecognized. With the recent increase in worldwide immigration, it is important to recognize these as potential triggers in those with AI. Here, we present a case of adrenal crisis triggered by immigration. Case presentation: A 41-year-old female diagnosed eighteen years ago with Sheehan syndrome, with unknown replacement therapy status, is brought to ED for altered mental status. One week before, she crossed the Mexican-US border as an illegal immigrant and was hospitalized in Arizona after developing mutism and mood lability. She was initiated and discharged on hormone replacement therapy. She arrived in New York confused with flat affect and impaired recent memory. She was hypotensive (BP: 92/64 mmHg), hyponatremic (Na: 133 mEq/L), and anemic (Hb: 10.6 g/dL). She had an inappropriate normal ACTH of 25 pg/mL (7.2-63.3 pg/mL). MRI findings confirmed empty sella, suggestive of central AI. Additional studies revealed central hypothyroidism (low normal TSH (1.36 uIU/mL), low-normal Free T4 (1.4 ng/dL), gonadotroph dysfunction with low FSH (2.7 IU/L), and low estrogen levels (20 pg/mL) for her age, and low normal prolactin (4.6 ng/mL). After initiating a stress dose of IV hydrocortisone and IV levothyroxine, her affect, memory, mental status, and vital signs (BP: 128/80 mmHg) improved. She was educated regarding the need for maintenance doses as an outpatient. At the one-month follow-up, she continued with a positive response. Discussion: Patients with chronic AI are unable to produce sufficient cortisol and are at risk of acute adrenal crisis when under stress. Stressful situations, including accidents, job interviews, or death in the family, have been described. However, with almost doubling the number of people entering the US without prior authorization between 2022 and 2023, immigration, which poses physical and emotional stress, certainty will become a matter of importance for those with AI. Guidelines to manage cortisol replacement in times of fever, infections, trauma, surgery, or severe pain are available. However, it is more difficult to define how emotional and psychological challenges affect the stress response, mainly because each challenge is unique. Therefore, it is important to advocate for policies to provide medical alert bracelets to immigrants with known AI in addition to providing education about emergency injection kits in cases of impending crisis. Presentation: 6/3/2024

7536 Missed Silent Retroperitoneal Paraganglioma

Abstract Disclosure: S. Lamichhane: None. D.T. Price: None. J.J. Faria-Briceno: None. A. Kaur: None. Introduction: Paragangliomas are rare neuroendocrine tumors comprising about 15-20% of all chromaffin cell tumors and can arise anywhere along the sympathetic and parasympathetic ganglionic chain from skull base to the pelvic floor. About 75% of sympathetic paragangliomas arise in the abdomen out of which majority are functional and secrete catecholamines responsible for the typical clinical features. While the diagnosis is usually made by clinical features and lab elevation of catecholamines, it is estimated that 10-15% of paragangliomas are non-functional and another 10% do not manifest clinically according to the hormone activity, thus posing a significant diagnostic challenge. We report a case of a retroperitoneal paraganglioma diagnosed by biopsy as it was initially missed owing to its silent nature clinically and biochemically. Case report:A 48-year-old smoker with panic disorder, remote history of spontaneous pneumothorax, and exploratory laparotomy for motor vehicle accident visited ER due to left-sided abdominal fullness and weight loss of 10-20 pounds for several months. Review of systems was negative except for mild constipation. He denied taking any medications and BP had been normal. CT abdomen showed a large 13.3 cm mixed cystic and solid mesenteric mass. Core biopsy revealed pheochromocytoma and patient was referred to Endocrinology. Labs showed elevated plasma free metanephrines (MN) 80 pg/ml, normetanephrines (NMN) 190 pg/ml, total MN 270 pg/ml, all less than twice the upper limit of normal and inconclusive, non-elevated 24-hour urine MN and NMN but with inadequate collection, and normal plasma catecholamines. MRI revealed a 13.5 cm mass in the left retroperitoneal sympathetic chain separate from the left adrenal gland and inferior to the left kidney. After pre-op optimization with alpha and beta blocker, patient had an uncomplicated open resection of the mass along with the retroperitoneal lymph nodes (LN). Pathology resulted in 3 benign LNs, a 16.5 cm paraganglioma negative for margin, lymph-vascular invasion, and necrosis. Genetic panel was negative. Follow-up post-surgery at 1 and 3 months with mildly elevated catecholamines and MRI abdomen at 3 months without evidence of recurrent or residual mass and metastasis. PET scan is pending prior authorization. Conclusion: Silent retroperitoneal paragangliomas are exceedingly rare. The diagnosis is often missed when the tumors are asymptomatic, and biomarkers are not elevated. The lack of specific imaging characteristics also adds to the diagnostic challenge. Early recognition can avoid the potential risk of life-threatening hypertensive crisis during surgical intervention. Our case highlights the importance of considering this rare entity in the differential diagnosis of retroperitoneal mass. Presentation: 6/1/2024

8707 Are We Adequately Prescribing Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) Or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) In Patients With Type 2 Diabetes Mellitus (T2DM) And Established Atherosclerotic Cardiovascular Disease (ASCVD) Or Chronic Kidney Disease (CKD) In An Outpatient Setting: A Community Center Experience

Abstract Disclosure: R.K. Maan: None. A. Sawhney: None. A. Hayat: None. S. Kc: None. A. Madan: None. S. K c: None. L. Williams: None. A. Zweben: None. A. Rana: None. Introduction: The American Diabetes Association (ADA) recommends prescribing Sodium-Glucose Cotransporter 2 inhibitors (SGLT2i) or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) in patients with Type 2 Diabetes Mellitus (T2DM) and established Atherosclerotic Cardiovascular Disease (ASCVD) or Chronic Kidney Disease (CKD) for its cardiovascular benefits. Methods: Our retrospective study analyzed data from 511 T2DM patients who visited the outpatient clinic between 7/1/22 to 6/30/23. Using Microsoft Excel, we assessed adherence to ADA guidelines by collecting data for SGLT2i, GLP-1 RA and statin prescriptions, urine microalbumin creatinine ratio measurements, and appropriate management of albuminuria. The study also investigated patients on dipeptidyl peptidase-4 inhibitors (DPP-4i) who were eligible for SGLT2i or GLP-1 RA. Results: Out of the 511 patients, 478 were eligible for SGLT2i or GLP-1 RA, and only 60% were prescribed these medications. Out of 479 patients eligible for statin prescription, only 85% were on it. Albuminuria was appropriately managed in 76% of eligible patients with Angiotensin-Converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs). Additionally, 8 out of 11 patients on DPP-4i were eligible for SGLT2i or GLP-1 RA. Conclusion: We concluded that 60% of the patients eligible for SGLT2i or GLP-1 RA were prescribed the medication in our outpatient settings. The barriers identified were issues with insurance prior authorization and knowledge gaps. We aim to improve adherence to guidelines through multifaceted education strategies combined with audits and feedback.

Racial and ethnic disparities in prior authorizations for patients with cancer.

Prior authorization is used to ensure providers treat patients with medically accepted treatments. Our objective was to evaluate prior authorization decisions in cancer care by race/ethnicity for commercially insuredpatients. Retrospective study of 18,041 patients diagnosed with cancer between January 1, 2017, andApril1,2020. Using commercial longitudinal data from a large national insurer, we described the racial and ethnic composition in terms of prior authorization process outcomes for individuals diagnosed with cancer. We then used linear regression models to evaluate whether disparities by race or ethnicity emerged in prior authorization process outcomes. The self-identified composition of the sample was 85% White, 3% Asian, 10% Black, and 1% Hispanic; 64% were female, and the mean age was 53 years. The average prior authorization denial rate was 10%, and the denial rate specifically due to no medical necessity was 5%. Hispanic patients had the highest prior authorization denial rate (12%), and Black patients had the lowest prior authorization denial rate (8%). Regressions results did not identify racial or ethnic disparities in prior authorization outcomes for Black and Hispanic patients compared with White patients. We observed that Asian patients had lower rates of prior authorization denials compared with White patients. We observed no differences in the prior authorization process for Black and Hispanic patients with cancer and higher rates of prior authorization approvals for Asian patients compared with White patients.

Effect of streamlining prior authorization processes for systemic cancer treatments on efficiency and financial losses.

412 Background: Prior authorizations (PAs) for systemic cancer treatments are a barrier to timely quality cancer care delivery. The high administrative burden to complete peer to peer’s (P2P) and appeals leads to care delays and revenue losses. At our tertiary academic cancer center, in partnership with our cancer registry and Epic teams, we shifted the clerical work required for PAs from clinicians to certified tumor registrars (CTRs) to increase authorization efficiency and decrease financial losses from denials. Methods: Clinicians place the treatment plan order which goes to the CTR work queue. We leveraged the Epic staging smart form to consolidate and auto-populate common elements needed for PA. The CTRs then complete and validate the form prior to the authorization specialists obtaining the PA. We compared the pre (1/2022-9/2022) and post-implementation (11/2022-4/2024) periods on our primary outcomes: average monthly number of PAs pending review (including P2P, appeals and authorizations requiring clarifying clinical documentation), average monthly denial rate and average time spent on PAs by the authorization specialists. We compared the financial losses from denied PAs from calendar year 2022 to 2023. Analyses were conducted using descriptive statistics. Results: There was a 1.4% reduction in the average monthly number of PA’s pending review (350 vs 345). The average monthly authorized rate was steady from the beginning of the intervention (94%) to present time (95%). The average monthly denial rate was 2.9% at the beginning of the intervention and 0.9% at present time. There was a consistent decrease in the average time a PA was spent in pending review status: 118 hours in 2022, 102 hours in 2023 and 79 hours in quarter 1 of 2024. Despite the overall increase in volume of authorizations submitted, there was an overall cost savings of $27,392,894 from 2022 ($49,964,703) to 2023 ($22,571,809) from the decrease in denials. In 2022, 6.2% of total approved charges were denied and this decreased to 2.7% in 2023. Conclusions: By leveraging the EHR and optimizing existing non-clinical staff workflows, we maintained sustained average authorized and denial rates despite overall volume going up due to improved authorization efficiency and reduced financial losses due to denials. Additionally, there were overall cost savings for the institution due to the decreased percent of denials of total approved charges. Future work will include further refinement of treatment and disease specific optimizations.

How automated insurance authorization affects transparency, provider burden, and payer policies and processes: The true impact of prior authorization.

5 Background: Insurance prior authorization (PA) is pervasive in modern oncology treatment, with both Medical and Radiation Oncology ranked among the top 5 in a survey of PA burdens across all medical specialties. The cumbersome process delays patient care and increases provider friction, with a major contributor being the perceived lack of transparency regarding PA decisions. Challenges arise because policies are often located behind portal logins, are inaccessible within the clinical workflow, or are too broad to capture patient nuances. We hypothesized that integrating automated insurance authorization software into the clinical workflow would enhance transparency to payer policies. Additionally, we investigated whether these policies could predict whether authorizations would be issued. Methods: We tracked radiation medicine treatment PA requests at a multisite academic healthcare network. Cases were tracked utilizing a standard clinical EMR. We concurrently implemented InsightRT (Siris Medical, Division of TurningPoint Healthcare), an EMR-integrated software system, to automate authorization documentation by capturing and transmitting patient and treatment characteristics. The online portal informed whether a prescribed treatment met the payer policy and tracked the approval process. A pilot subset of physicians was transitioned to using InsightRT. Results: A total of 1418 non-Medicare/Medicaid PA requests were tracked, with 1235 using the traditional clinical workflow and 183 utilizing InsightRT. The software system indicated 162 (88.5%) were “in policy” and only 2 prescriptions were eventually denied. Of the 21 (11.5%) prescriptions that were "Out of Policy" as indicated by the software, only 1 was denied. Sensitivity and specificity of Insight RT policy determination was 98.8% and 97.6% respectively. Overall, there were 43 denials across a total of 1418 cases with payer review only downgrading or changing 4 cases out of 1418, or 0.3%. The other 39 denials were overturned, with 23 (59%) by peer-to-peer (P2P), and 16 (41%) by documentation review. Conclusions: Automated insurance prior authorization provides increased transparency to the provider with high sensitivity and specificity. However, improvements to payer policies and processes are needed to decrease unnecessary burden and delays to care, as the true impact of PA is limited to 0.3% in this cohort. All cases from 12/23 - 5/24. All Cases from non Medicare/Medicaid 1418 Cases processed in InsightRT 183 Cases processed in EMR and not InsightRT 1235 Denials 43 Overturned denials that went to P2P 23 Overturned denials that only needed clinical documentation 16 Cases with confirmed P2P that were downgraded 4 The True Impact of PA - % of all cases changed due to PA 0.30%

Accelerating access: The power of gold carding in reducing treatment delays.

114 Background: Delays in time to treatment initiation (TTI) for cancer patients have been shown to impact survival/mortality/outcomes, and cause patient distress. The process of obtaining prior authorizations (PA) often leads to significant treatment delays, affecting patient outcomes and posing administrative challenges for healthcare providers. PAs have become a ubiquitous part of modern healthcare, aimed at ensuring appropriate utilization of medical treatments and reducing costs. In recent years, the concept of gold carding (GC), a practice where payers waive PA on services and prescription drugs ordered by providers with a proven track record of PA approvals based on guideline concordance or pathway adherence, has gained attention as a potential solution to provide administrative relief to all stakeholders affected by the PA process. This abstract seeks to explore the impact of GC on TTI for a large multi-site community-based oncology practice in The US Oncology Network having a GC contract with a regional payer. Methods: Using administrative claims data from 2021 to 2023, we derived a population of cancer patients who initiated chemotherapy as their first treatment, calculated the TTI (time from the date of first consultation to the date of treatment initiation), and compared TTI between GC and non-GC patients. Results: The average TTI for 4,836 patients that met the inclusion criteria was 26.3 days. Patients initiating therapy under a GC eligible payer coverage started therapy 4.5 days earlier (22.13 days vs 26.68 days, p<0.00001, Kruskal–Wallis test). 80% of GC eligible patients started their treatment within 30 days of their initial consultation. Conclusions: The findings indicate that gold carding has the potential to expedite the time to treatment initiation for cancer patients. Further research is needed to quantify the cost savings, patient and provider satisfaction, and other intangible benefits from GC. Gold carding offers a viable approach to balance guideline concordant care with lowering administrative burden. We enthusiastically support legislative reforms that encourage gold carding and selectively implement prior authorization requirements based on stratification of health care providers’ performance and adherence to evidence-based medicine. Patient Count Average TTI (days) GC 401 22.13 Commercial 217 21.13 Managed Medicare 184 23.32 Non-GC 4435 26.68 Commercial 1610 25.41 Managed Medicare 1405 27.37 Medicare 959 26.48 Managed Medicaid 254 29.06 Medicaid 112 29.54 All Other 95 30.15

Coordinating expensive, difficult-to-obtain prophylactic medications before discharge: A quality improvement project in an academic stem cell transplant unit.

337 Background: Infections are a significant source of morbidity/mortality in allogeneic stem cell transplant (alloSCT) patients and antimicrobial prophylaxis has reduced deaths. Between July 2022 and July 2023, 21% of new alloSCT recipients were discharged from UVA Medical Center without posaconazole or isavuconazonium +/- letermovir in-hand at the time of hospital discharge necessitating daily oral drug administration at the infusion center until medication could be obtained. This led to excess cost for UVA, burden on clinic staff, missed doses, and patient frustration. We sought to decrease the number of new alloSCT recipients discharged without appropriate prophylaxis in-hand from 21% to 10% by November 2024. Methods: Per the 2023 ASCO Quality Training Program associated with this project, a Model for Improvement and Plan Do Study Act (PDSA) methodology was utilized. The population included alloSCT patients with new prescriptions (Rxs) for posaconazole or isavuconazonium +/- letermovir. The outcome measure was percentage of newly discharged alloSCT patients requiring oral prophylaxis at the infusion center. The process measure was Time to Affordable Medication (TAM) defined as days from Rx prior-authorization (PA) request to paid claim with an affordable copay (defined as a copay the patient was able/willing to pay, including free drug approvals or assistance programs). The counter measure consisted of initiating the Rx PA process 10 days prior to planned admission via a discharge test Rx order set instead of waiting until admission. This standardized process allowed for clearer communication and more time for pharmacy technicians to process the Rx for PA, copays, free drug applications, and pharmacy logistics. Upon admission, the official Rx was released to the discharge pharmacy. If Rx shipment was required, this was set up the week prior to discharge. An I-chart (3-sigma) statistical process control (SPC) chart was used to assess the intervention. Results: The baseline TAM was assessed retrospectively in 22 Rxs over 3 months prior to intervention for a mean of 7.5 days. PDSA cycle 1 was implemented Nov. 2023. TAM for the first 35 Rxs was 4.3 days and the SPC upper control limit decreased from 26.3 days to 13.3 days demonstrating overall markedly decreased variation despite data from early 2024 having greater variability due to new insurance deductibles. Rxs requiring 10 or more days were due to free drug application processes. Importantly, no newly discharged alloSCT patients have required drug administration at the infusion center. Conclusions: PDSA #1 resulted in a decrease in TAM of 3.2 days, decreased variation in the process, and no patients discharged without drug in hand. Since we have already surpassed our aim, next steps include demonstrating sustainability of the process and a survey requesting feedback to identify balance measures.

S695 Topical Steroids in Lymphocytic Esophagitis: Worthy of the Prior Authorization?

S695 Topical Steroids in Lymphocytic Esophagitis: Worthy of the Prior Authorization?

ThP5.6 - Intraoperative blood transfusion and postoperative infective complications in patients who undergo pancreatoduodenectomy for malignancy

Abstract Background Prior authors have suggested that patients who receive an intraoperative blood transfusion (IOBT) are at increased risk of postoperative infective complications (transfusion-related immunomodulation). This study aimed to investigate whether pancreatoduodenectomy (PD) patients who received IOBT were more likely to develop an infective complication than those who did not. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres from 8 countries, n=1484). Patients who received IOBT were identified and compared to those who did not. The primary outcome measure was the development of at least one postoperative infective complication, including: hospital acquired pneumonia, cholangitis, Clostridium difficile, intra-abdominal collection, liver abscess, sepsis of unknown origin, surgical site infection and urinary tract infection. The Mann-Whitney U test and Fisher exact test were used for statistical analysis. Results Blood transfusion data was available from 907 patients (61.1%). In total, 165 patients (18.1%) received IOBT. The median number of units given was two (range: 1-36, interquartile range (IQR): 1). Patients who received IOBT were similar to those who did not in terms of median age (68 vs 67 years, p=0.5), median BMI (23.8 vs 25.3 kg/m2, p=0.0001) and ASA grade (33.3% vs 34.5% grade >II, p=0.8). These patients also had similar rates of preoperative diabetes (24.8% vs 20.9%, p=0.3), cardiac (41.2% vs 45.9%, p=0.3) and respiratory disease (7.9% vs 12.1%, p=0.01) compared to patients without IOBT. Transfused patients experienced more infective complications but this was not statistically significant (24.2% vs 17.6%, p=0.06). Conclusion In our multicentre study, there was a trend amongst patients undergoing PD who received IOBT to develop more infective complications. Blood transfusions should only be given when strictly indicated.

Evaluation of a Quality Measure for Multiple Sclerosis Care: Disease-Modifying Therapy Initiation at the University of North Carolina's Outpatient Neurology Clinic.

Multiple sclerosis (MS) is a neurological condition leading to significant disability and challenges to quality of life. To slow progression and reduce relapses, it is critical to rapidly initiate disease-modifying therapy (DMT) after diagnosis. Patient demographics may play a role in timely DMT initiation. Financial barriers may also result in delays in DMT access. This retrospective, single-center, cross-sectional study included patients seen at a neurology clinic at a large academic medical center for an initial evaluation of MS between January 1, 2022, and June 30, 2022. As an indicator of the quality of care, the primary study outcome was whether patients were offered DMT initiation on their first clinic visit. Secondary outcomes evaluated the time to DMT initiation, including differences in care based on demographic factors and financial coverage. Of the 49 eligible individuals studied, 45 (91.8%) were offered DMT at their initial MS visit. Descriptive statistics appeared to demonstrate that demographic factors did not impact whether DMT was offered. However, the majority of patients experienced access barriers relating to prior authorization requirements (80.0%) and/or the need for co-pay assistance (52.0%). DMT was appropriately offered to a majority of patients at their initial MS visit, regardless of demographic considerations. No offer of DMT and delays in initiation were primarily due to the need for imaging and specialty referrals, as well as financial barriers. Medication assistance teams may play a crucial role in limiting delays and financial hurdles associated with insurance coverage and co-pay assistance.

Socioeconomic Barriers to Receiving Early Salvage Radiotherapy for Locally Advanced Prostate Adenocarcinoma: A Retrospective Single-Center Study.

Purpose This study aimed to identify factors associated with delays in initiating early salvage radiation therapy in prostate cancer patients with prostate-specific antigen (PSA) failure after prostatectomy. Methods We conducted a single-institution, retrospective study of patients receiving salvage radiation therapy after radical prostatectomy from 2011 to 2022. Patient demographics and clinical data were examined to identify factors that may have influenced the time to start of radiation therapy after surgery. Utilizing a PSA cut off of 0.25 ng/ml or less, we classified patients as receiving either early "PSA low" or late "PSA high" salvage therapy depending on their PSA at the time of initiating treatment. Results Of the 81 patients evaluated, the median age was 61.9 years (IQR 57.9 - 66.5), with most presenting with pT3 (65.4%), Grade Group 2 disease (35.8%), and positive margins 55%). Median PSA at salvage radiation therapy commencement was 0.30 ng/mL (0.18 - 0.48). 40 patients completed early salvage and 41 patients completed late salvage in the overall cohort. A significant association was found between patient insurance carrier and pre-radiation PSA levels. Patients with HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) insurance were more likely to complete late salvage radiation compared to non-managed Medicare patients (HMO OR 4.0, p <0.05 & PPO OR 3.3 p <0.05 vs non-managed Medicare). All uninsured patients in the cohort received late salvage radiation. Conclusions Insurance type was significantly associated with the timing of salvage radiation therapy post-prostatectomy, suggesting a relationship with providers requiring prior authorization (HMO and PPO coverage). This study supports proper PSA surveillance, in particular for those with HMO or PPO coverage.

Use of SGLT-2 Inhibitors in Adults (Age ≥ 65) with Type 2 Diabetes and Cardiovascular Disease is Lower in Alberta and Manitoba than in Ontario (2018-2020): A Cross-Sectional Study of Different Drug Funding Policies

ObjectivesSodium-glucose cotransporter 2 inhibitors (SGLT2i) provide heart and kidney benefit in adults with diabetes and cardiovascular disease (CVD). Public drug coverage policies for SGLT2i differ by province in Canada. Our study aimed to describe the potential effects of prior authorization / step therapy (PA/ST) and relatively high income-based deductibles, compared to regular benefit status with modest co-pay, on SGLT2i prescriptions in high-risk adults. MethodsCross-sectional study of individuals age ≥ 65 years with type 2 diabetes and CVD, taking ≥ 1 antihyperglycemic agent from 2019 to 2020, using electronic medical record data from primary care practices. We compared SGLT2i use (2019-2020) in Alberta (PA/ST, modest co-pay), and Manitoba (PA/ST, relatively high income-based deductible), to Ontario (regular benefit status, modest co-pay). Poisson regression was used to adjust for confounders, including age, sex, glycated hemoglobin, and other medication use. Other diabetes medications were estimated as control cases. ResultsWe included 3,191 adults (average age 75 years, 31% female). SGLT2i use was lowest in Manitoba (15.6%), then Alberta (25.9%), and highest in Ontario (31.9%). After adjustment, compared to Ontario, SGLT2i prescriptions were lower in Alberta (prevalence ratio [PR] 0.80, 95% CI [0.71-0.91], p < 0.001) and Manitoba (PR 0.48 [0.39-0.59], p < 0.001). ConclusionsPA/ST and relatively high deductibles are associated with reduced SGLT2i prescribing – PA/ST by approximately 20% in Alberta and Manitoba, and relatively high deductibles by an additional relative reduction of 40% in Manitoba. PA/ST and cost-sharing policies should be flexible and responsive to changing evidence of clinical benefit.