Denial Of Requests Research Articles

Sepsis-2.5: Resolving Conflicts Between Payers and Providers.

Competing definitions of sepsis have significant clinical implications and impact both medical coding and hospital payment. Although clinicians may prefer Sepsis-2, payer use of Sepsis-3 to validate clinical diagnoses may result in denial of payment or requests to recoup previously paid funds from healthcare providers. The Sepsis-2.5 project was a cooperative effort between a hospital system and a private payer to develop a community-based, literature-supported consensus definition for sepsis characterized by the presence of clinical illness, a source of infection, and evidence of organ dysfunction. This new definition ("Sepsis-2.5") has been instrumental in resolving provider-payer conflicts in defining clinical sepsis and reimbursing care.

Barriers and facilitators to the inclusion of deaf people in clinical trials.

This article discusses the barriers that prevent deaf people from participating in clinical trials and offers recommendations to overcome these barriers and ensure equal access to study participation. Between April and May 2022, we conducted six focus groups with 20 deaf adults who use American Sign Language, all of whom had previous experience as research study participants. Focus group prompts queried community awareness of clinical trial opportunities, barriers and facilitators to deaf people's participation in clinical trials, and recommended resources to improve clinical trial access. This qualitative focus group data is supplemented by survey data gathered from 40 principal investigators and clinical research coordinators between November 2021 and December 2021. The survey queried researchers' prior experiences with enrolling deaf participants in clinical trials and strategies they endorse for enrollment of deaf participants in future clinical trials. Focus group participants unanimously agreed that, compared to the general hearing population, deaf sign language users lack equivalent access to clinical trial participation. Reported barriers included lack of awareness of clinical trial opportunities, mistrust of hearing researchers, and refusal by clinical trial staff to provide accessible communication (e.g. denial of requests for sign language interpreters). Survey data from 40 principal investigators and clinical research coordinators corroborated these barriers. For example, only 2 out of 40 survey respondents had ever enrolled a deaf person in a clinical trial. Respondents indicated that the most helpful strategies for including deaf sign language users in future clinical trials would be assistance with making recruitment information accessible to deaf sign language users and assistance in identifying qualified interpreters to hire to help facilitate the informed consent process. The lack of communication accessibility is the most common factor preventing deaf sign language users from participating in clinical trials. This article provides recommendations for hearing researchers to improve deaf people's access to clinical trials moving forward, drawing from mixed-methods data.

Sincerely Held: American Secularism and Its Believers by Charles McCrary

Reviewed by: Sincerely Held: American Secularism and Its Believers by Charles McCrary Hannah Scheidt Charles McCrary, Sincerely Held: American Secularism and Its Believers (Chicago: University of Chicago Press, 2022) A recently-published report from the Pew Research Center relates that two-thirds of US adults doubt the sincerity of religious objections to COVID-19 vaccine mandates. In other words, a healthy majority of Americans believe that people who refuse COVID vaccination for religious reasons are simply using religion as an excuse, and that the true basis of their objection lies in some source not as protected or sacrosanct as religious belief. Charles McCrary's Sincerely Held: American Secularism and Its Believers undertakes an overdue examination of the figure at the center of this and similar debates: the "sincere believer." As McCrary explains, starting in the 1940s, courts have evaluated petitions for religious freedom according to the "sincerity test," putting aside the question of whether or not a belief is true and asking instead if the claimant believes "sincerely." But what does it mean to be sincere when it comes to religious belief? Who gets to determine sincerity, and by what standards? McCrary homes in on this ubiquitous but contentious construction in a collection of historical case studies and cultural analyses, showing how sincerity operates as an important element in the legal construction of religion as a disciplinary category. McCrary suggests that the story of sincerity, in the context of free exercise jurisprudence, is a story about secularism. Sincerity is a key component in the [End Page 122] "secular metalanguage" by which judges and other authorities determine what passes as (good, true) religious belief and, therefore, what beliefs and behaviors are protected by law (12). Ultimately, McCrary suggests, sincerity is a linguistic and conceptual tool for a historically white Protestant regime to determine what is legible and acceptable as religion. Thus, this work contributes to a growing body of scholarship that critiques the secular regime, bringing to light its histories, strategies, and injustices. As McCrary explains, we come to know the sincere believer through her "others." The sincere believer has two essential foils: the knave and the fool. The knave is duplicitous, knowingly deceptive, and does not herself hold sincere religious beliefs but peddles religion for personal gain. On the other hand, the fool lacks the agency to hold sincere belief—his belief is not really his own. McCrary writes: "The knave is not authentically religious, because he is duplicitous and insincere. The fool is not authentically secular, for his insufficiently buffered self is irrational and credulous" (47). This constellation of characters—the sincere believer, the knave, and the fool—says a lot about how religion is imagined in a secular world, and McCrary's explanation of these types is clear and compelling. Truly, this trio is a valuable tool through which to understand (and to teach) about the disciplining of selfhood in the modern world. These types teach us about the characteristics and boundaries of proper, Protestant-ish, religion: belief-centric, individual, private. But alongside—or, rather, co-constituting—this understanding of religion is a belief in secularism and a concept of the proper secular subject: one who is truthful, agentic, and buffered. Thus, to freely exercise religion in the United States, McCrary shows, one must be properly religious and properly secular. He illustrates this dynamic through a critical telling of Frank Africa's 1981 case, in which Africa requested dietary accommodation in prison in accordance with his belief in the principles outlined by MOVE (a mostly Black group following the teachings of John Africa). The court's denial of Africa's request for accommodation—by essentially denying MOVE the status of religion—shows how, according to McCrary, "the Protestant secular is enmeshed in whiteness" (234). This narrative is one of the greatest contributions of Sincerely Held, illustrating the co-constitution of religion, secularism, and race through the modern politics of sincerity. To understand how right (proper, acceptable) religion is about race, McCrary argues, we must also see how right secularism is about race as well. One wonders where we go from here. McCrary's assertion that "what comes after the critique of secularism … is more critique of secularism" is...

Impact of Genetic and Genomic Testing on the Clinical Management of Patients with Autism Spectrum Disorder.

Research has shown that genetics play a key role in the development of autism spectrum disorder (ASD). ASD has been linked to many genes and is a prominent feature in numerous genetic disorders. A genetic evaluation should be offered to any patient who receives a diagnosis of ASD, including deep phenotyping and genetic testing when clinically indicated. When insurance does not cover genetic testing for ASD patients, the lack of medical utility is often cited as a reason for prior authorization request denial. However, ample evidence exists that genetic testing has the power to change clinical management in many of these patients. Genetic testing that results in a diagnosis guides clinicians to screen for associated medical conditions and can direct targeted medical interventions. Given the potential for clinically actionable results, it is important that genetic testing be available and accessible to all patients with ASD.

OCR: College's denial of request wasn't discriminatory

Case name: Letter re: Keuka College, No. 02‐21‐2022 (OCR 05/03/21).

Associations Between Patient-Provider Secure Message Content and Patients' Health Care Visits.

Background:Between-visit communications can play a vital role in improving intermediate patient outcomes such as access to care and satisfaction. Secure messaging is a growing modality for these communications, but research is limited about the influence of message content on those intermediate outcomes. We examined associations between secure message content and patients' number of health care visits.Methods:Our study included 2,111 adult patients with hypertension and/or diabetes and 18,309 patient- and staff-generated messages. We estimated incident rate ratios (IRRs) for associations between taxonomic codes assigned to message content, and the number of office, emergency department, and inpatient visits.Results:Patients who initiated message threads in 2017 had higher numbers of outpatient visits (p < 0.001) compared with patients who did not initiate threads. Among patients who initiated threads, we identified an inverse relationship between outpatient visits and preventive care scheduling requests (IRR = 0.92; 95% confidence interval [CI]: 0.86-0.98) and requests for appointments for new conditions (IRR = 0.95; 95% CI: 0.92-0.99). Patients with higher proportions of request denials or more follow-up appointment requests had more emergency department visits compared with patients who received or sent other content (IRR = 1.18; 95% CI: 1.03-1.34 and IRR = 1.14; 95% CI: 1.07-1.23, respectively). We identified a positive association between outpatient visits and the proportion of threads that lacked a clinic response (IRR = 1.02; 95% CI: 1.00-1.03).Discussion:We report on the first analyses to examine associations between message content and health care visits.Conclusions:Our findings are relevant to understanding how to better use secure messaging to support patients and their care.

Dynamic Sectorization and parallel processing for device-to-device (D2D) resource allocation in 5G and B5G cellular network

Beyond Fifth Generation (B5G) network aims to provide a very high data rate with minimum latency to an ultra-dense user environment. To achieve this demand, the possible approaches are network-centric and device-centric approach. In a network-centric approach, a new frequency band is introduced, and the existing network infrastructure is modified. The device-centric approach does not require any modification in the existing network infrastructure, and the demand of B5G network is achieved through optimum resource allocation methodology. Device-to-Device (D2D) is an effective device-centric approach that supports the B5G network. In this paper, we propose a dynamic sectorization technique in which eNodeB (eNB) varies the number of sectors dynamically in the network and allocates the Resource Block (RB) to D2D users. Sectoring improves Signal-to-Interference-Noise-Ratio (SINR) and network performance. We derive an expression for the probability of successful transmission and threshold to make a decision on the number of sectors based on available RBs and D2D users in the network. Further, dynamic sectoring helps eNB to perform parallel processing for reducing the denial of the request. Simulation results validate the probability of successful transmission of D2D pairs with available RBs and the effectiveness of parallel processing to reduce the denial of request with improved SINR.

Persons with Chronic Mental Illness Navigating the Legal System Pro Se

In State v. Meyers , 434 P.3d 224 (Idaho 2019), the Idaho Supreme Court affirmed the District Court of the Fourth Judicial District's ruling that the denial of Richard Meyers' request for self-representation did not violate his Sixth Amendment rights. The court reasoned that Mr. Meyers' letter to

When Physicians Say No: Predictors of Request Denial and Subsequent Patient Satisfaction.

Physician denial of patient requests is associated with lower patient satisfaction. Our objective was to explore factors that influence physician request denial and patient satisfaction after request denial. Cross-sectional observational study of 1141 adult patients seen during 1319 outpatient visits with 56 primary care physicians. We measured patients' postvisit self-report of requests and request fulfillment, visit satisfaction, sociodemographics, health status, symptom burden, life satisfaction, medical skepticism, and whether patients saw their usual physician and a faculty or resident physician. We used mixed-effects regression analyses to identify predictors of request denial and visit satisfaction among patients who had a request denied. Patients made at least 1 request at 867 visits (65.7%) with at least 1 denied request reported at 182 visits (21.0%). Patients who saw their usual physician were less likely to report a request denial (adjusted Odds Ratio [aOR], 0.61; 95% CI, 0.42 to 0.88), and patients with the highest symptom burden (aOR, 2.21; 95% CI, 1.38 to 3.55) or greater medical skepticism (aOR, 1.35; 95% CI, 1.03 to 1.78) were more likely to report request denials. After request denials, patients seeing their usual physicians reported significantly greater visit satisfaction compared with not seeing their usual physician (adjusted percentile rank in visit satisfaction: 12.4%; 95% CI, 3.5% to 21.2%). Approximately one fifth of visits in primary care have a denied request. Having an office visit with one's usual physician is associated with reduced likelihood of request denial and may mitigate the adverse impacts of request denial on patient visit satisfaction.

Medicaid Managed Care and Providers' Perceptions of Quality of Care for Children with Chronic Conditions in Georgia.

Medicaid managed care plans employ cost containment tools such as prior authorization and preferred drug lists to achieve cost savings. Little is known about these tools' effects on quality of care for beneficiaries with chronic conditions. We surveyed physicians and nurse practitioners based in federally qualified health centers (FQHCs) in Georgia to capture how they perceive these tools affect care and health outcomes for Medicaid-enrolled patients with chronic illnesses. We received 63 completed surveys, representing 19 (58%) of FQHCs in Georgia. Across multiple measures, 56.1-71.7% reported difficulties with prior authorization request denials, preferred medication prescribing, and specialist referrals "sometimes," "often," or "very often" when caring for patients with asthma. Greater difficulties with prior authorization request denials were associated with perceived poorer care quality (p=.03). Further research is needed to inform state policymaker decisions about potential restrictions on Medicaid managed care plans' use of cost containment tools with medically vulnerable beneficiaries.

Service now Based Advanced Issue of No Fee Due Certificate

The main goal of this project is to generate a NO FEE DUE CERTIFICATE from all departments such as Computer Center, Hostel, Library System, IRP, Placement Cell, Central Library, Alumni, HOD, Dept. Head, FED, Exam Section, Physical Education for the final years after graduating from our college. The application allows the registered user to log in and the new user is allowed to register. The application makes it convenient for registered users to apply for certificate. In today's time, we need to wait for higher authorities to sanction a request. In order to reduce the period that we use this form, the status of approval or denial of request will be notified immediately by e-mail.After all departments approve the request, the user can download a PDF, otherwise he will not be able to access it and the user will have to pay the balance due.

12 jours réal. by Raymond Depardon

Reviewed by: 12 jours réal. by Raymond Depardon Mariah Devereux Herbeck Depardon, Raymond, réal. 12 jours. Wild Bunch, 2017. In 2013, France enacted legislation whereby, twelve days after being involuntarily interned in a psychiatric facility, patients appear with legal counsel before a "liberty and detention"judge and state their desire to leave or remain in the hospital. Informed by the patients' testimony, doctors' input, and medical charts, the judge determines the appropriate course of action. Depardon's documentary provides access to the heartbreaking hearings of ten patients (whose names have been changed to protect their privacy) interned in a psychiatric facility in Lyon. After an intertitle describes the aforementioned recent changes made to French mental health law, the film begins with a painfully slow three-minute tracking shot down the facility's corridors, seemingly replicating the sensation of entering the facility on a hospital gurney. Contrasted with subsequent similar scenes of (the monotony of) daily life in the facility, the hearings provide the most dynamic moments of the film. As the patients plead their case, hope fills the screen since most of them argue that they are fit to leave the facility. Quite swiftly, as the patients describe their current state and respond to the judge's pointed questions, it becomes apparent that, on the contrary, they are not healthy enough to return to the"outside world." Some patients argue that they should leave because a family member can care for them. Others reveal insight into their delusional thinking by making impossible claims. One patient believes he has political supporters waiting for him to organize his party, while another is sure he will become a famous soccer player. Occasionally, mental health aides accompany the patients. [End Page 260] When the latter contribute to the hearings, it is invariably to emphasize the patient's need to remain in the facility. The film, with its consistent use of three cameras during each hearing (one on the patient, one on the judge, and one of the hearing room), does not necessarily pass judgment on the new legal procedure, but instead encourages humanization of these individuals confined against their will as well as reflection on the power struggles inherent to the hearings. Whose voice is to be trusted? That of the (most likely heavily medicated) patient? Legal counsel? Doctors and aides? The judge? With each denial of a patient's request to be discharged, it is hard not to see the hearings as a formality, created to appease patients' desire to have a say in their treatment. Alternatively, given the disturbing nature of what is revealed in the majority of the hearings, it is hard to imagine lives for the patients beyond the walls of the facility. What percentage of these hearings end with the patient afforded the right to leave? Can options other than internment or freedom be imagined? Although 12 jours inspires more questions than it answers regarding recent changes to the French mental health care system, without doubt, spectators will be hard-pressed to forget this haunting portrayal of the ways in which modern society grapples with mental illness and its victims. Mariah Devereux Herbeck Boise State University (ID) Copyright © 2019 American Association of Teachers of French

Association of Clinician Denial of Patient Requests With Patient Satisfaction: Jerant A, Fenton JJ, Kravitz RL, et al. JAMA Intern Med 178;1:85-91

Association of Clinician Denial of Patient Requests With Patient Satisfaction: Jerant A, Fenton JJ, Kravitz RL, et al. JAMA Intern Med 178;1:85-91

Association of Clinician Denial of Patient Requests With Patient Satisfaction

Prior studies suggesting clinician fulfillment or denial of requests affects patient satisfaction included limited adjustment for patient confounders. The studies also did not examine distinct request types, yet patient expectations and clinician fulfillment or denial might vary among request types. To examine how patient satisfaction with the clinician is associated with clinician denial of distinct types of patient requests, adjusting for patient characteristics. Cross-sectional observational study of 1319 outpatient visits to family physicians (n = 56) by 1141 adults at one Northern California academic health center. We used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the visit physician. Standardized items were averaged to form the satisfaction score (Cronbach α = 0.80), which was then percentile-transformed. Seven separate linear mixed-effects models examined the adjusted mean differences in patient satisfaction percentile associated with denial of each of the following requests (if present)-referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test-compared with fulfillment of the respective requests. The models adjusted for patient sociodemographics, weight, health status, personality, worry over health, prior visit with clinician, and the other 6 request categories and their dispositions. The mean (SD) age of the 1141 patients was 45.6 (16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%) included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107 (8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%); radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with fulfillment of the respective request type, clinician denials of requests for referral, pain medication, other new medication, and laboratory test were associated with worse satisfaction (adjusted mean percentile differences, -19.75 [95% CI, -30.75 to -8.74], -10.72 [95% CI, -19.66 to -1.78], -20.36 [95% CI, -29.54 to -11.18], and -9.19 [95% CI, -17.50 to -0.87]), respectively. Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.

Shining a Spotlight on EU Political Group Spending: Legal Guide on Access to Document Requests

The purpose of this legal memorandum is to provide advice to organisations and individuals interested in submitting a request for public access to documents under Regulation (EC) No 1049/01 (“Regulation 1049/01”) to the European Parliament for documents related to the spending of political groups covered by Budget Item 400 appropriations under Chapter 7. Requests for those documents may face rejection on grounds related to exceptions provided for in Regulation 1049/01, specifically those found in Articles 4(1)b, 4(2), and 4(3) pertaining to privacy and integrity of the individual, commercial interests, and institution’s decision-making process respectively. This legal memorandum addresses the applicability of those exceptions to the documents requested for potential use in a confirmatory request to be submitted to the European Parliament subsequent to the initial rejection in line with Article 7 of Regulation 1049/01. The memo also provides arguments for overcoming these exceptions in light of: 1) recent developments in the case law of the Court of Justice of the European Union (“CJEU”) relating to the privacy exception; and 2) the strict legal requirements for triggering the commercial interests and institutional decision-making exceptions. The last section of the memo is structured to provide draft responses to the denial of requests for documents and should be tailored to the specific situation in question.

Public Records Denials

Transparency and openness in our national, state and local governments is a cardinal principle in our democratic system. Since 1967, the Freedom of Information Act has been the primary applicable law which enables citizens to obtain public information from executive branch agencies of the federal government. Essentially every state also has a freedom of information act, public records law, or similar law which allows citizen access to public documents and records. A largely unexplored area of the academic literature involving freedom of information laws relates to the sanctions or penalties which may exist for noncompliance. This Article advocates for changes and revisions to existing state laws to provide for more stringent penalties in the event a public records request is knowingly denied. Enhanced penalties and legal consequences for improper public records request denials are critical to ensure open and transparent access to public information.

Observed Mother and Father Rejection and Control: Association With Child Social Anxiety, General Anxiety, and Depression

The parent–child relationship has been recognized as an important micro-ecological context that is thought to influence child anxiety and depression. Much contemporary research has examined child-reports of broad parenting behaviors (e.g., rejection, overprotection) and has overwhelmingly focused on the mother–child relationship. Little research has examined specific parenting behaviors that may be associated with child anxiety and depression, and whether these processes are similar for mothers and fathers and boys and girls. Using a parent–child interaction task, we examined associations among specific mother and father behaviors and child-reported general anxiety, social anxiety, and depression, and explored whether these associations were moderated by child gender. Participants were 90 children (50 % female) aged 9–12 years (Mage = 10.28, SD = 1.22), 90 fathers (Mage = 43.78, SD = 6.31) and 90 mothers (Mage = 40.67, SD = 4.97). Children completed measures of social anxiety, general anxiety, and depression. Families participated in a video-recorded blindly rated interaction task that provided indices of verbal and nonverbal rejection and controlling behaviors. Mothers’ physical takeovers (unsolicited physical assistance) were associated with greater child social anxiety and mothers’ denial of requests for reassurance were associated with greater child general anxiety. Fathers’ critical statements were associated with child-reported depression. Several child gender differences were noted. Findings from our study suggest that mothers’ and fathers’ specific parenting behaviors are differentially associated with children’s social anxiety, general anxiety and depression—and these processes may vary by child gender.

Attending to physical health in mental health services in Australia: aqualitative study of service users' experiences and expectations.

Evidence is unequivocal: the premature death of people with severe mental health problems is attributable primarily to cardiovascular disease, and healthcare provided is often suboptimal. With the overarching aim of improving outcomes, policies and guidelines oblige mental health services and psychiatrists to monitor cardio-metabolic health of patients and intervene as appropriate. Practice is highly variable; however, with ongoing debate about resourcing and responsibilities dominated by clinicians who have identified disinterest among patients as influencing practice. Seeking to balance discussion, we posed the question 'what do patients experience and expect of mental health services in relation to their physical health?' To answer it, we interviewed a convenience sample of 40 service users recruited from a mental health service in Australia, early in 2015. Data were analysed using the framework approach. With few regarding themselves as healthy, participants were commonly concerned about side effects of medication, weight and fitness but rarely mentioned tobacco smoking. Participants' accounts reinforce extensive research demonstrating variability in attention to physical health in mental health services. Reports by some participants of comprehensive care are encouraging, but widespread uncertainty about reasons for various assessments and denial of requests for management of medication side effects, including weight gain, gives cause for concern. Although participants in this study wanted to improve their health and health-related quality of life, they acknowledged that their motivation and ability to do so fluctuated with mental health. They expected clinicians to work proactively, especially when symptoms compromised capacity for self-care, and mental health services to provide or enable access to health-promoting interventions. Attention should be given, as a matter of priority, to creating conditions (culture and infrastructure) needed to support sustained attention to physical health within services and, importantly, to full engagement of service users in management of their physical health.

Improving Medical Oncology Quality Through Peer-to-Peer Consultation.

This study describes how the use of peer-to-peer (P2P) physician consultation improves medical oncology care quality by preventing non-evidence-based and potentially morbid chemotherapy treatments. New Century Health (NCH) has adapted a physician audit and feedback model to strengthen adherence to clinical guidelines. In the NCH oncology program, P2P consultation complements clinical pathways and an online prior authorization platform. Payers are adopting the use of clinical pathways as a management strategy for managing costs and improving quality. Managing medical oncology is a complex process, because evidence evolves rapidly, and almost one third of chemotherapy is prescribed off label. The use of prior authorization, combined with standardized protocols for patients with specific cancer diagnoses, is one way for payers to reduce unnecessary treatment variation. [Table: see text] Methods: NCH completed a retrospective analysis of the chemotherapy treatment requests (CTRs) submitted by payers' oncologists for prior authorization between January and December 2012. The objectives of the clinical impact analysis were to measure the CTR disposition rate, identify the CTR intervention rate resulting from P2P consultation, and identify the types of drug triggering the interventions. Analysis of the 13,078 CTRs associated with the 1,116 unique Medicare and commercial patients of a national health plan determined that CTRs voluntarily withdrawn or recommended adverse determination (RAD; ie, NCH recommendation to member's health plan to not authorize treatment as requested; after review of health plan policy and compendia, NCH was not able to resolve provider's request through P2P consultation and could not recommend approval of treatment plan as requested, therefore recommending denial of request) by the submitting physician as a result of a P2P consultation with an NCH board-certified oncologist comprised 11.6% of all CTRs. Further analysis identified the types of medication associated with the 1,521 CTRs withdrawn/RAD as a consequence of P2P consultation. Interventions on chemotherapeutic medications and supportive care were evenly distributed at 51.2% and 48.8%, respectively. Interventions on medications that had received US Food and Drug Administration approval within the last 2 years (initial approval or for new indications) represented 12.1%. [Table: see text] Conclusion: Using P2P consultation to complement a pathway-driven prior authorization process improves medical oncology quality. In addition, P2P consultation can be an effective collaborative physician engagement strategy by supporting oncologists with critical clinical information and mitigating concerns about pathway implementation and about payer involvement in drug use management.

Effects of an antipsychotic restriction policy in a veteran population

Introduction: Recent trials have failed to demonstrate differences in efficacy between first generation antipsychotics (FGAs) and second generation antipsychotics (SGAs). To reduce costs, many health care systems have restricted the availability of SGAs through use of prior authorizations. Restrictions for the off-label use of SGAs and the use of dual-antipsychotic therapy have also been implemented in many health care systems. At the South Texas Veterans Health Care System (STVHCS), a restricted drug request (RDR) method has been implemented to manage costs and improve patient safety. Risperidone, due to its lower cost and equal efficacy, is the first-line option of SGAs. If one wishes to prescribe an SGA other than risperidone, an RDR is submitted and reviewed by Veterans Integrated Service Network (VISN) pharmacists. Since the introduction of these policies at the STVHCS, the impact of the RDR has not been assessed. Rationale: The primary aim of this study was to determine the effects of the RDR policy on the care of STVHCS veterans as evidenced by changes in hospitalization rates of veterans with a denied request for an SGA due to initial criterion failure. Secondary outcomes included: impact of antipsychotic RDR denial on mental health as evidenced by changes in no-shows and cancellations for follow-up psychiatric appointments, psychiatric emergency department visits, presence of suicidal ideation, change in weight, hemoglobin A1c, number of psychotropic medications prescribed, and extrapyramidal symptoms. Methods: A retrospective chart review of veterans denied an initial SGA request was conducted from 3 months prior to denial to 3 months post request denial (index date). Data collected included: patient demographics, indication for SGA request, reason for SGA denial, length of time for request evaluation, number of psychiatric hospitalizations, number of no-shows and cancellations for mental health appointments, number of psychiatric emergency department visits, number of reports of suicidal ideation or attempts, weight, hemoglobin A1c lab results, presence of extrapyramidal symptoms, and number of prescribed psychotropic medications. The health care utilization data collected pre- and post-index date, were compared. Results were analyzed using Fisher's Exact, 2-tailed standardized t-tests, and descriptive statistics appropriately matched to data type. Results: Results for both primary and secondary outcomes were not statistically significant. No differences were found in the number of veterans hospitalized pre- versus post-index date [0/33 (0%) versus 2/33 (6%), p=0.492.] The most requested indication for an SGA was PTSD [22/33 (66.7%)] and the most frequently denied SGA was quetiapine [16/33 (48.5%)]. Conclusions: Although outcomes were not statistically significant, several valuable conclusions were drawn from this research. Positive outcomes from a RDR policy were seen by the limitations placed on inappropriate medication prescribing. Also, it was observed that the number of approvals for SGAs was almost three times higher than denials. A subsequent finding from this research is the apparent lack of metabolic monitoring for veterans prescribed SGAs. Further research on these observations, as well as conducting a pharmacoeconomic analysis on the RDR policy, would also be beneficial information for health care providers.