Could an artificial intelligence approach to prior authorization be more human?

Prior authorization (PA) may be a necessary evil within the healthcare system, contributing to physician burnout and delaying necessary care, but also allowing payers to prevent wasting resources on redundant, expensive, and/or ineffective care. PA has become an "informatics issue" with the rise of automated methods for PA review, championed in the Health Level 7 International's (HL7's) DaVinci Project. DaVinci proposes using rule-based methods to automate PA, a time-tested strategy with known limitations. This article proposes an alternative that may be more human-centric, using artificial intelligence (AI) methods for the computation of authorization decisions. We believe that by combining modern approaches for accessing and exchanging existing electronic health data with AI methods tailored to reflect the judgments of expert panels that include patient representatives, and refined with "few shot" learning approaches to prevent bias, we could create a just and efficient process that serves the interests of society as a whole. Efficient simulation of human appropriateness assessments from existing data using AI methods could eliminate burdens and bottlenecks while preserving PA's benefits as a tool to limit inappropriate care.

Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study

BACKGROUND

Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers.

METHODS

We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality.

RESULTS

Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight).

CONCLUSIONS

Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.

Evaluating the appropriateness of elective surgery: The case of spinal fusion (arthrodesis)

INTRODUCTION

Appropriateness is an essential element of quality of care. Several methods and tools have been developed to measure the appropriateness of care, however, none of these could be used to systematically support providers in keeping the appropriateness under control. Our study aimed to develop a framework to evaluate the appropriateness of care that took into account four dimensions of appropriateness: clinical dimension, equity, service delivery model, outcome.

METHODS

We employed mixed-method approaches. These included a retrospective analysis of administrative data collected from Kinetika Sardinia (Italy) and a qualitative analysis of stakeholders' experiences and perspectives aimed at supporting data collection, identification of improvement actions and definition of performance indicators. We used arthrodesis as a paradigmatic example of potentially inappropriate elective surgery.

RESULTS

We collected data from 2,584 patients that underwent arthrodesis between January 1, 2010 and April 30, 2015. Based on the analysis and the exchanges with professionals, we identified 11 improvement actions. Monitoring and evaluation actions were finally conducted for 171 patients that underwent spinal fusion during the first semester of 2016 in order to assess if the improvement actions identified were put into practice and acquired desirable outcomes.

CONCLUSIONS

Our work provides a definition of appropriateness that goes beyond the clinical perspective and includes other perspectives (equity, service delivery and outcome); develops a framework and an approach that can be a valid help to systematically assess the appropriateness of elective surgery, adopt improvement actions, and monitor their impact; discusses what are the competencies necessary for measuring the appropriateness.

The challenge of determining appropriate care in the era of patient-centered care and rising health care costs

Objective

To expand the appropriateness of care methodology to include patient preferences and resource utilization, and the impact of care appropriateness on patient outcomes.

Data Sources/Study Setting

Primary data from expert panels, focus groups, chiropractors, chiropractic patients with chronic low back pain (CLBP) and chronic cervical pain (CCP), and from internet “workers” via crowdsourcing. Study setting is a cluster sample of 125 chiropractic clinics from six US regions.

Study Design

This multicomponent methods study includes analysis of longitudinal data on patient outcomes, preferences, CLBP and CCP symptoms and healthcare utilization.

Data Collection/Extraction Methods

Data were collected bi-weekly for 3 months via online surveys that included both new and legacy measures, including PROMIS and CAHPS.

Principle Findings

Appropriateness panels generated ratings for 1800 CLBP and 744 CCP indications which will be applied to patient charts. Data from 2025 patients are being analyzed.

Conclusions

Patient-centered care is a significant policy initiative but translating it into policy that has been clinician and research-expert based, poses significant methodological issues. Nonetheless, we make the case that patient preferences, self-reported outcomes, and financial burden should be considered in the evaluation of the appropriateness of healthcare.

Screening for new primary cancers in patients with metastatic breast cancer: a provincial analysis of the Choosing Wisely Canada recommendations

Introduction

Patients with metastatic cancer have a decreased life expectancy, and with screening and surveillance for new primary cancers, they run the risk of immediate harm with little chance of any benefit. Choosing Wisely Canada therefore recommends that such investigations be avoided in patients with metastatic disease.

Methods

We examined cancer screening practices in a subset of patients with metastatic cancer in Newfoundland and Labrador. Patients with metastatic breast cancer seen at the provincial cancer clinic during 2014-2016 were identified from the Newfoundland and Labrador Cancer Registry. For each patient, we assessed whether any one or a combination of screening mammography, Pap (Papanicolaou) test, flexible sigmoidoscopy or colonoscopy, or fecal immunohistochemical test were performed at any point after the diagnosis of metastatic disease.

Results

Of 305 patients with metastatic breast cancer, 114 (37.4%) underwent at least 1 screening investigation (mean: 2.92 investigations per screened patient). The most common screening investigations were mammography (n = 197) and Pap test (n = 107). Primary care providers ordered most of the screening investigations (70%); oncology specialists ordered 14%, and other specialists, 12%. Median overall survival for patients with breast cancer after a diagnosis of metastatic disease was 42 months, with a 5-year overall survival of 35.9%.

Conclusions

A significant proportion of patients with metastatic breast cancer in Newfoundland and Labrador are still undergoing screening for new primary malignancies, which is discordant with oncology guidelines from Choosing Wisely Canada. Increased education strategies are needed if the Choosing Wisely Canada recommendations are to be implemented into routine clinical practice.

Can the appropriateness of eye care be measured through cross-sectional retrospective patient record review in eye care practices in Australia? The iCareTrack feasibility study

OBJECTIVES

The CareTrack study found that a wide range of appropriateness of care (ie, care in line with evidence-based or consensus-based guidelines) was delivered across many health conditions in Australia. This study therefore aimed to demonstrate the feasibility of using the CareTrack method (a retrospective onsite record review) to measure the appropriateness of eye care delivery.

DESIGN

Cross-sectional feasibility study.

SETTING AND PARTICIPANTS

Two hundred and thirteen patient records randomly selected from eight optometry and ophthalmology practices in Australia, selected through a combination of convenience and maximum variation sampling.

METHODS

Retrospective record review designed to assess the alignment between eye care delivered and 93 clinical indicators (Delphi method involving 11 experts) extracted from evidence-based clinical practice guidelines.

PRIMARY OUTCOME MEASURE

Number of eligible patient records, sampling rates and data collection time. This feasibility study also tested the ability of 93 clinical indicators to measure percentage appropriate eye care for preventative, glaucoma and diabetic eye care. A secondary outcome was the percentage of practitioner-patient encounters at which appropriate eye care was received.

RESULTS

A median of 20 records (range 9 to 63) per practice were reviewed. Data collection time ranged from 3 to 5.5 hours (median 3.5). The most effective sampling strategy involved random letter generation followed by sequential sampling. The appropriateness of care was 69% (95% CI 67% to 70%) for preventative eye care, 60% (95% CI 56% to 58%) for glaucoma and 63% (95% CI 57% to 69%) for diabetic eye care.

CONCLUSIONS

Appropriateness of eye care can be measured effectively using retrospective record review of eye care practices and consensus-based care indicators.

Association between lay perception of morbidity and appropriateness of specialized health care use in adolescent idiopathic scoliosis

In absence of school scoliosis screening programs (SSSP) in Canada, this study examined the relationships between the lay person's perception of morbidity and the appropriateness of referral in orthopedics. A cross-sectional study was conducted with all children consecutively referred in orthopedics for suspected scoliosis. The 831 participants were classified as Appropriate, Late, or Inappropriate referrals for the orthopedic setting. Perceived morbidity was operationalized by: the scoliosis detection originator, the perceptions of the seriousness of the condition and urgency to consult a physician, the perception of the general health, as well as Visible Back Deformity, Self-image, and Pain. Direct associations between the perceived morbidity and the appropriateness of referral were found in all scoliosis-specific measures; the most discriminant variable was Visible Back Deformity. Lay perceived morbidity is a good indicator of the objective morbidity, and thus reflects in the appropriateness of referral status. The important role of the lay persons in symptoms appraisal does not however insure appropriate referral. Searching for alternatives to SSSP would wisely include a health promotion and medical management program. Statement of Clinical Significance: Perceived morbidity by the lay persons is strongly associated with the objectively evaluated severity of scoliosis deformity. Therefore, in absence of SSSP, lay person awareness plays an important role in symptom recognition and search for care. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

A spotlight on chronic patients' hospitalization: Some exploratory insights

All over the world, health care systems are experiencing the challenges raised by the epidemiological transition from the prevalence of acute diseases to the preponderance of chronic illnesses. However, the traditional design for acute conditions of most of health care systems – which triggers a hospital-centric culture – is not consistent with the special health needs of people suffering from long-term conditions. In fact, the access of chronic patients to hospital services has been variously contested to be inappropriate and ineffective to meet their demand for care. Sticking to these considerations, this study investigates the factors that influence the occurrence of hospitalization and the length of hospital stays of a representative sample of Italian chronic patients. Secondary data were collected from the European Health Interview Survey. The sample consisted of 8,127 people. A probit model and a multiple regression analysis were performed to obtain some evidence on the regressors of Italian patients’ access to hospital care. Among others, gender, work condition, health services’ use and health status were found to have a role in influencing chronic patients’ behaviors. The study findings prompted the formulation of several avenues for future developments, which provide some food for thought to policy makers and inspire an agenda for further research.

Choosing wisely in cancer control across Canada-a set of baseline indicators

Value-based care, which balances high-quality care with the most efficient use of resources, has been considered the next frontier in cancer care and a means to maintain health system sustainability. Created to promote value-based care, Choosing Wisely Canada-modelled after Choosing Wisely in the United States-is a national clinician-driven campaign to identify unnecessary or harmful services that are frequently used in Canada. As part of the campaign, national medical societies have developed recommendations for tests and treatments that clinicians and patients should question. Here, we present baseline indicator findings about current practice patterns associated with 7 cancer-related recommendations from Choosing Wisely Canada and about the effects of those practices on patients and the health care system. Indicator findings point to substantial variations in cancer system performance between Canadian jurisdictions, most notably for breast cancer screening practices, treatment practices for men with low-risk localized prostate cancer, and radiation therapy practices for early-stage breast cancer and bone metastases. Extrapolating indicator findings to the entire country, it was estimated that 740,000 breast and cervical cancer screening tests were performed outside of the recommended age ranges, and within 1 year of diagnosis, 17,000 patients received treatments that could be low-value. A 15% reduction in the use of the 7 screening and treatment practices examined could lead to multiple benefits for patients and the health care system: 9000 false-positive results and 3000 treatments and related side effects could be avoided, and 4500 hours of linear accelerator capacity could be freed up each year. Interjurisdictional performance variations suggest potential differences in clinical practice patterns in the planning and delivery of cancer control services, and in some cases, in disease management outcomes. Although the cancer screening and treatment practices described might be unnecessary for some patients, it is important to realize that they could, in fact, be necessary for other patients. Further research into appropriate rates of use could help to determine how much cancer care represents overuse of practices that are not supported by evidence or underuse of practices that are supported by evidence.

The balance of care approach to health and social care planning: lessons from a systematic literature review

The strategic allocation of resources is one the most difficult tasks facing health and social care decision makers, with multiple organisations delivering complex services to heterogeneous populations. The enduring appeal of the balance of care approach, a systematic framework for exploring the potential costs and consequences of changing the mix of community and institutional services in a defined geographical area, is thus unsurprising. However, no attempt has previously been made to synthesise or appraise the methodological approaches employed and lessons to inform future applications may go unheard. This paper seeks to address those concerns by reporting the findings of a systematic literature review that identified 33 examples of the model's use spanning 40 years. The majority of studies were undertaken in the UK and explored the services needed by frail older people. There is, however, nothing in the model to restrict it to this context. The paper also details the different ways key elements of the model (information about clients, resources, the appraisal of settings, costs and outcomes) have been operationalised, and considers their strengths and weaknesses. Whilst several studies identified a potential to reduce costs via the use of less institutional care, not all applications predicted cost savings.

Use of the World Wide Web to implement clinical practice guidelines: a feasibility study

BACKGROUND

Important efforts have been invested in the past few years in the development of quality clinical guidelines. However, the means for the effective dissemination of guidelines to practicing physicians have not been determined. Several studies have examined the possibilities offered by the World Wide Web (the Web), but studies examining the implementation of clinical guidelines in actual practice are clearly lacking.

OBJECTIVE

This study assessed the potential of the Web to implement clinical practice guidelines in actual clinical settings. It also documents the obstacles perceived by the physicians in their use of guidelines on the Internet to determine the role that the Web can play in the implementation of guidelines in practice.

METHODS

Two guidelines were developed using a standardized panel method and made available via the Web. One concerned indications for low-back surgery and the other dealt with indications for upper and lower digestive endoscopies. To identify obstacles to their use in clinical practice, 20 physicians were asked to consult the guidelines during consultations with patients. Answers were collected using 3 different questionnaires.

RESULTS

Questionnaires were completed for consultations involving 213 patients. Less than 50% of the physicians have direct access to the Internet in their examination room. For 75%, the use of the guidelines was easy and the time required to consult them acceptable (3.4 minutes on average, or 12% of the time spent with the patient). The fear that use of such guidelines might interfere with the physician-patient relationship was mentioned as a reason for not consulting the guidelines for 27 consultations. Taking into account their experience with the Web, 75% of the physicians considered that the Web has a great or very-great potential for the dissemination of guidelines and 78% indicated that they would use such guidelines if they became generally available for clinical questions that concerned them. Only 3 physicians had consulted guidelines on the Web prior to this study.

CONCLUSIONS

The acceptance of use of clinical practice guidelines via the Web is high. The main limits to further use of such Web-based guidelines seem to be the lack of a computer connection in the physician's office or examining room and the fear that use of such guidelines might interfere with the physician-patient relationship. Though most participants appreciate the considerable potential of the Web for disseminating guidelines, only a small handful regularly use guidelines available on the Web. There are still numerous obstacles to the regular use of guidelines in clinical practice, some related to the physicians, others to the guidelines themselves.