The ongoing outcomes research collaboration between HealthHelp and Humana has presented two conference abstracts examining the association between patient race and prior authorization program determinations in the context of radiation therapy. At the Academy of Oncology Nurse & Patient Navigators (AONN+) conference, held virtually from November 7th through 21st, 2021, a poster titled, “Ensuring equal access to guideline-based radiation therapy for prostate cancer through prior authorization” was presented. Likewise, at the National Comprehensive Cancer Network (NCCN) conference, held virtually from March 31st through April 2nd, 2022, a poster titled, “An assessment of the association between patient race and prior authorization program determinations in the context of radiation therapy for breast cancer” was presented. Both studies were written in the context of a larger initiative to examine the association between race and prior authorization program determinations.
When a physician determines that a patient needs radiation therapy (RT), they submit an RT order to a prior authorization program which assesses guideline-concordance. An up-to-date, evidence-informed, rule-based clinical decision support system (CDSS) evaluates whether the order is appropriate or potentially non-indicated. If potentially non-indicated, a board-certified oncologist discusses the order with the ordering physician. After discussion, the order is authorized, modified, withdrawn, or recommended for denial. Although the patient’s race is not captured by the program, bias prior to and during ordering, or during the discussion, may influence outcomes. Racial disparities have been documented in access to insurance, access to primary care, access to oncology care, and access to high-quality radiation therapy. The abstracts evaluated the association between patient race and order determination by both the CDSS and the overall prior authorization program in the context of breast cancer (NCCN) and prostate cancer (AONN+).
The research team assessed orders pertaining to patients who were enrolled in a Medicare Advantage plan from one national organization and had their RT order placed in calendar year 2019. Centers for Medicare & Medicaid Services patient race data was appended to the order data, as the orders did not include race. The team used multivariate logistic regression to examine the association between patient race (Black, White, Other) and order determination, controlling for age, the urbanicity and median income of the patient’s ZIP code, and whether the patient had breast magnetic resonance imaging (MRI) prior to the RT order. Multivariate logistic regress was conducted using both unmatched samples and samples matched on patient race.
Both the breast cancer and the prostate cancer analysis had the same overall conclusions. Prior authorization was found to produce outcomes that, when combined with retrospective race determination, revealed similar clinical appropriateness of orders for Black and non-Black populations. Rule-based CDSSs may be a means of ensuring that patients equally receive guideline-based care considering the latest scientific evidence, and that guidelines are enforced without racial bias. No evidence was found suggesting that combining CDSS with physician review increased bias.
In interpreting the findings, several limitations to the analyses should be considered. The analyses were not designed to examine racial disparities that may exist in cancer care outside of the ordering process. As all patients included in the study had a Medicare Advantage health plan from the same organization, the findings may not be generalizable to other populations
Due to the reliance upon order data, this study was not able to fully characterize the presentation of the patients, their comorbidities, or their social determinants of health. The patients significantly differed by race on all the characteristics considered in the descriptive statistics, and may have differed on other unobserved characteristics as well.
In response to the study’s findings, the study’s lead author, Adam C. Powell, Ph.D., remarked, “The HealthHelp / Humana research team is committed to identifying and addressing racial disparities in healthcare. We looked carefully at the prior authorization outcomes that patients experienced when seeking radiation therapy for the treatment of multiple cancers, including breast and prostate cancers. We consistently found that among the patients we examined – who were all insured and received orders for radiation therapy – there was no evidence of racial disparities.”
To learn more about AONN’s annual conference, visit: https://aonnonline.org/conferences/annual-conference
To learn more about NCCN’s annual conference, visit: https://www.nccn.org/education-research/educational-events-and-programs/annual-conference