An article titled, “A Description of Outcomes Experienced by Patients Whose Orders for Peripheral Artery Revascularization Were Reviewed by a Nondenial Prior Authorization Program” has been published by the journal Vascular and Endovascular Surgery. A poster based upon the analysis was previously presented at the 2021 New Cardiovascular Horizons Annual Conference. The study was produced by the ongoing outcomes research collaboration between HealthHelp and Humana.
Peripheral artery disease (PAD) is common in older individuals, and impacts more than 20% of people over the age of 80. PAD can limit physical activity and significantly reduce quality of life, as it can cause intermittent claudication (IC). There are multiple ways in which PAD can be addressed, including exercise, medication, and surgical revascularization.
Multiple organizations recommend that nonsurgical approaches to resolving PAD be attempted, as there are risks to surgery. Patients that have peripheral artery revascularization (PAR) may in some instances develop infections at the site of surgery. Consequently, a nondenial prior authorization program recommends that PAR orders be reconsidered when patients may be able to pursue other approaches to managing their peripheral artery disease.
Once a nondenial prior authorization program evaluates orders for PAR, ordering physicians in some cases opt to withdraw their orders based upon the recommendations made by the program. PAR orders are withdrawn when patients may be able to resolve their claudication through unsupervised or supervised exercise rather than PAR. Some patients with withdrawn orders ultimately receive PAR if their claudication does not resolve. In order to better understand the outcomes produced by the prior authorization program, the research team evaluated whether associations existed between the withdrawal of patients’ initial PAR orders and the presence of claims for PAR and claims mentioning IC in the 16 weeks following the order.
The study analyzed nondenial prior authorization program orders for PAR that were placed between January 1st 2019 and September 30th, 2019, and related to patients with commercial and Medicare Advantage health plans. Orders were excluded if they pertained to patients who had a prior PAR order during the period, were not aged 18-89, had acute limb ischemia, had no claudication, had a PAR claim in the prior sixteen weeks, were not continuously enrolled in their health plan for 16 weeks following their PAR order, or did not have angiography in the 16 weeks preceding or following their order. Claims data from 0-16 weeks following the order were reviewed to determine if patients had downstream PAR claims, or if they had emergency department or hospital claims mentioning IC. Chi-square tests were used to assess the association between order withdrawal and downstream receipt of PAR and claims mentioning IC. Multivariate logistic regressions were run to assess the above associations, after controlling for patient age, gender, urbanicity, local median income, state obesity rate, type of PAR ordered, specialty of the ordering physician, and whether PAR was ordered in a hospital setting.
The analysis found that of the 1,588 orders meeting inclusion criteria, 71.9% (1,038/1,444) of authorized orders and 61.1% (88/144) of withdrawn orders were followed by PAR within 16 weeks, a significant difference (P<0.01). Relatedly, 69.8% (1,008/1,444) of authorized orders and 70.8% (102/144) of withdrawn orders were followed by IC claims, an insignificant difference. Multivariate logistic regressions showed that patients with withdrawn PAR orders had significantly lower adjusted odds of PAR claims (odds ratio [OR]: 0.63; 95% CI: 0.44-0.91), but an insignificant difference in their adjusted odds of IC (OR: 1.10; CI: 0.76-1.64). From these findings, the research team concluded that although patients with withdrawn PAR orders were significantly less likely to receive PAR in the following 16 weeks, there was no statistical association between patients having withdrawn PAR orders and subsequent claims mentioning IC.
In response to the study’s findings, the study’s lead author, Adam C. Powell, Ph.D., remarked, “There are multiple organizations that recommend patients attempt nonsurgical approaches to addressing peripheral artery disease before pursuing peripheral artery revascularization. The nondenial prior authorization program implemented by HealthHelp and Humana encourages physicians to reconsider revascularization when appropriate. We found that patients whose initial revascularization orders were withdrawn were no more likely to experience intermittent claudication in the following sixteen weeks than patients whose initial orders were approved. By encouraging physicians to attempt a nonsurgical approach to care, the nondenial prior authorization program fosters guideline-concordant care, thus improving quality.”
To read the article, visit: https://journals.sagepub.com/doi/10.1177/15385744211055911