Reducing Patient Care Delays in Radiation Oncology via Optimization of Insurance Pre-Authorization

PURPOSE/OBJECTIVE(S)

Difficulties and delays in insurance pre-authorization (pre-auth) can negatively impact patient care, resulting in postponing, modifying, or even cancelling radiation therapy for patients. Unfortunately, pre-auth delays are not uncommon. The purpose of our project was to perform a root cause analysis of reasons for pre-auth delays, and implement solutions to optimize our workflow to better serve our patients. Our primary objectives were to decrease the mean time for clinical treatment plan (CTP) completion, and for number of cases delayed/denied, by 50% each.

MATERIALS/METHODS

We performed a root cause analysis of reasons for pre-auth delays and used the PDSA & A3 quality improvement methods. We sampled ∼2 cases per disease site (total 19 cases from July - Aug 2022) to determine the "current state," pre-interventions. Countermeasures included: 1) customizing our CTP templates for each disease site to contain the specific clinical information required by each insurer, 2) formalizing earlier completion of CTPs through task automation at time of scheduling CT simulation in our Care Path, and 3) continuously refining our countermeasures based on monthly status updates and department meetings. We tracked various physician, authorization, and outcome-metrics between October 2022 and January 2023, including mean time for CTP completion, % usage of our Care Path, % usage of revised CTP templates, mean time until pre-auth initiated & completed, % of cases requiring peer-to-peer phone calls, and % of cases denied/delayed.

RESULTS

There were 417 patients from a variety of disease sites who had a CT simulation at our institution between October 1, 2022, and January 31, 2023. Mean time for CTP completion (from the time of CT simulation request) improved from 16 days at baseline to 7 days by the end of the project. In the beginning, only 5% of CTPs were completed within 2 days of scheduling the CT simulation, and this improved to 42-56% during the project period. Percent usage of the Care Path improved dramatically from 16% to 91%, as did % usage of our revised CTP templates, from 0% to 96%. Despite initial lag in pre-authorization team workflow changes, the % of pre-authorizations initiated by day 3 from CT request improved from 32% at baseline to 48% by month 4. Mean time to complete insurance pre-authorizations improved from 16 days at baseline to 10 days. The percent of cases requiring peer to peer or were denied was reduced significantly from 32% at baseline to 4-11%.

CONCLUSION

Improvingtimeliness and details of CTP documentation by using our Care Path and revising CTP templates improved efficiency of insurance pre-auth completion, and reduced the number of cases delayed/denied.

Emotional and informational social support from health visitors and breastfeeding outcomes in the UK

BACKGROUND

Shorter breastfeeding duration is associated with detrimental consequences for infant health/development and maternal health. Previous studies suggest social support is essential in maintaining breast/chest-feeding and helping to improve general infant feeding experiences. Public health bodies therefore work to support breastfeeding in the UK, yet UK breastfeeding rates continue to be one of the lowest globally. With this, a better understanding of the effectiveness and quality of infant feeding support is required. In the UK, health visitors (community public health nurses specialising in working with families with a child aged 0-5 years) have been positioned as one of the key providers of breast/chest-feeding support. Research evidence suggests that both inadequate informational support and poor/negative emotional support can lead to poor breastfeeding experiences and early breastfeeding cessation. Thus, this study tests the hypothesis that emotional support from health visitors moderates the relationship between informational support and breastfeeding duration/infant feeding experience among UK mothers.

METHODS

We ran cox and binary logistic regression models on data from 565 UK mothers, collected as part of a 2017-2018 retrospective online survey on social support and infant feeding.

RESULTS

Informational support, compared to emotional support, was a less important predictor of both breastfeeding duration and experience. Supportive emotional support with unhelpful or absent informational support was associated with the lowest hazard of breastfeeding cessation before 3 months. Results for breastfeeding experience followed similar trends, where positive experience was associated with supportive emotional and unhelpful informational support. Negative experiences were less consistent; however, a higher probability of negative experience was found when both types of support were reported as unsupportive.

CONCLUSIONS

Our findings point to the importance of health visitors providing emotional support to bolster the continuation of breastfeeding and encourage a positive subjective experience of infant feeding. The emphasis of emotional support in our results encourages increased allocation of resources and training opportunities to ensure health visitors are able to provide enhanced emotional support. Lowering health visitors caseloads to allow for personalised care is just one actionable example that may improve breastfeeding outcomes in the UK.

Two new frog species from the Litoria rubella species group from eastern Australia

The bleating tree frog (Litoria dentata) is one of the more prominent pelodryadid frogs of eastern Australia by virtue of its extremely loud, piercing, male advertisement call. A member of the Litoria rubella species group, L. dentata has a broad latitudinal distribution and is widespread from coastal and subcoastal lowlands through to montane areas. A recent mitochondrial DNA analysis showed a deep phylogeographic break between populations of L. dentata on the mid-north coast of New South Wales. Here we extended the mitochondrial survey with more geographically comprehensive sampling and tested the systematic implications of our findings with nuclear genome wide single-nucleotide polymorphism, morphological and male advertisement call datasets. While similar in appearance and in male advertisement call, our integrative analysis demonstrates the presence of three species which replace each other in a north-south series. We redescribe Litoria dentata, which is restricted to coastal north-eastern New South Wales, and formally describe Litoria balatus sp. nov., from south-eastern Queensland, and Litoria quiritatus sp. nov., from the mid-coast of New South Wales to north-eastern Victoria.

598 Burns Management at A UK Major Trauma Centre During The COVID-19 Lockdown

Aim

The COVID-19 pandemic forced huge changes in healthcare delivery in the UK within a matter of weeks. We report our experience of managing burns presenting to a UK Major Trauma Centre during the COVID-19 lockdown period.

Method

Retrospective patient data was collected on aetiology, severity and management of burns during the first six weeks of the government-enforced lockdown. Data was compared with patients presenting with burns during the same period in 2019 (control) and statistical analysis was performed.

Results

Fifteen patients were treated during the COVID-19 lockdown and fourteen in the control group. Adults treated during the COVID-19 lockdown had a greater total body surface area (TBSA) (9% vs. 2.9%, p 0.035) and were more likely to suffer full thickness burns (40% vs. 0%). In the COVID-19 group all patients that did not require resuscitation, seven of whom met criteria for referral to burns services, were managed locally by the plastic surgery department with good outcomes.

Conclusions

Despite the increase in severity of adult burns seen during the COVID-19 lockdown period, local plastic surgery units have been able to adapt their practice and successfully manage more complex burns. This adaptability will be key as we move through the pandemic.

The differential role of practical and emotional support in infant feeding experience in the UK

Social support is a known determinant of breastfeeding behaviour and is generally considered beneficial. However, social support encompasses a myriad of different supportive acts, providing scope for diverse infant feeding outcomes. Given the vulnerability of postpartum mental health, this paper aims to explore both how support prolongs breastfeeding and which forms of support promote the positive experience of all infant feeding. Using survey data collected online from 515 UK mothers with infants aged 0-108 weeks, Cox regression models assessed the relationship between receiving different types of support, support need and breastfeeding duration. Quasi-binomial logistic regression models assessed the relationship between receiving support, infant feeding mode and maternal experience of infant feeding. Rates of negative infant feeding experience indicate the widespread need for support: e.g. 38% of currently, 47% of no longer and 31% of never breastfeeding women found infant feeding stressful. Overall, practical support via infant feeding broadly predicted shorter breastfeeding durations and poorer feeding experience; results in relation to other forms of support were more complex. Our findings indicate different forms of support have different associations with infant feeding experience. They also highlight the wide range of individuals beyond the nuclear family on which postpartum mothers in the UK rely. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Craniomaxillofacial trauma management in austere and war zone environments - A role for composite tissue allotransplantation?

Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of extensive severe facial injury and tissue loss. Despite the risk of allograft rejection and the post-operative need for lifelong immunosuppression, facial CTA can be used to restore the normal structural appearance and function of the face. Areas of socioeconomic deprivation and armed conflict zones have a high preponderance of patients with facial burns and other severe injuries. However, these regions often also suffer from lack of resources, expert surgical care and limited facilities. The purpose of this manuscript is to provide a comprehensive review of key principles relevant to facial CTA and their potential applicability in such austere environments. We present a concise literature review of the surgical and immunological basis of facial CTA aimed at the plastic surgery readership, as well as issues surrounding organ transplantations in low- and middle- income countries. We then consider the particular challenges posed by austere settings and countries of active armed conflict and discuss how these may impact the suitability of facial CTA for treating severe facial injuries in these circumstances. Facial CTA is recognised as giving huge benefits for patients with severe facial defects with potentially superior results compared with conventional autograft techniques. Its performance in austere settings is limited by scarce resources and increased pre-, intra- and post- operative risks. However, a case can be made for its use even in these more challenging situations when general organ transplantation compliance and expertise input have been addressed.

Population structure of modern-day Italians reveals patterns of ancient and archaic ancestries in Southern Europe

European populations display low genetic differentiation as the result of long-term blending of their ancient founding ancestries. However, it is unclear how the combination of ancient ancestries related to early foragers, Neolithic farmers, and Bronze Age nomadic pastoralists can explain the distribution of genetic variation across Europe. Populations in natural crossroads like the Italian peninsula are expected to recapitulate the continental diversity, but have been systematically understudied. Here, we characterize the ancestry profiles of Italian populations using a genome-wide dataset representative of modern and ancient samples from across Italy, Europe, and the rest of the world. Italian genomes capture several ancient signatures, including a non-steppe contribution derived ultimately from the Caucasus. Differences in ancestry composition, as the result of migration and admixture, have generated in Italy the largest degree of population structure detected so far in the continent, as well as shaping the amount of Neanderthal DNA in modern-day populations.

Systematic Review: Efficacy and Safety of Accelerated Induction Regimes in Infliximab Rescue Therapy for Hospitalized Patients with Acute Severe Colitis

BACKGROUND

Pharmacokinetic data suggest that standard induction dosing schedules may not be sufficient in patients with acute severe colitis (ASUC). Hence, intensified induction regimes are increasingly used in the rescue treatment of hospitalized patients with ASUC to avoid the need for colectomy although the evidence for this is uncertain.

AIM

To conduct a systematic review of short- and long-term efficacy outcomes from accelerated infliximab induction studies.

METHODS

Systematic search of relevant databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) and relevant conference proceedings (Digestive Diseases Week, European Colitis and Crohn's Organisation Congress, United European Gastroenterology Week) was done.

RESULTS

We identified ten relevant studies with a total of 705 patients, of whom 308 received an intensified infliximab regime. Pooled analysis showed no difference in short-term or long-term colectomy rates in those receiving accelerated induction regimes when compared to standard induction. No significant differences in complication rates were identified.

CONCLUSIONS

The available uncontrolled studies so far do not suggest short-term or long-term benefit in using accelerated induction in hospitalized ASUC. The overall poor quality of available studies with confounding variables indicates the need for a randomized controlled trial with personalized risk stratification.

Identifying avoidable switchboard delays in England's NHS hospitals: phase one of the national SWITCH project

BACKGROUND

Inter-hospital communication frequently requires mediation via a switchboard. Identifying and eliminating switchboard inefficiencies may improve patient care.

METHODS

All 175 acute hospital switchboards in England were contacted six times. Call contents and duration were recorded. No clinician calls or bleeps were connected.

RESULTS

The mean delay before contacting a switchboard operative was 55±46 seconds. 115 hospitals (66%) used automated switchboards; 34 of these (30%) had infection control messages. Robot operators introduced an additional 40 second delay versus humans (mean 70.3±28 versus 29.8±23 seconds, p<0.0001). Multivariate analysis identified robot operators (HR 5.1, p<0.0001) and infection control messages (HR 2.9, p=0.003) as predictors of delays over 60 seconds.

CONCLUSIONS

There are significant avoidable delays in contacting switchboard operatives across England. Quality improvement is underway.

A possible biomedical facility at the European Organization for Nuclear Research (CERN)

A well-attended meeting, called "Brainstorming discussion for a possible biomedical facility at CERN", was held by the European Organization for Nuclear Research (CERN) at the European Laboratory for Particle Physics on 25 June 2012. This was concerned with adapting an existing, but little used, 78-m circumference CERN synchrotron to deliver a wide range of ion species, preferably from protons to at least neon ions, with beam specifications that match existing clinical facilities. The potential extensive research portfolio discussed included beam ballistics in humanoid phantoms, advanced dosimetry, remote imaging techniques and technical developments in beam delivery, including gantry design. In addition, a modern laboratory for biomedical characterisation of these beams would allow important radiobiological studies, such as relative biological effectiveness, in a dedicated facility with standardisation of experimental conditions and biological end points. A control photon and electron beam would be required nearby for relative biological effectiveness comparisons. Research beam time availability would far exceed that at other facilities throughout the world. This would allow more rapid progress in several biomedical areas, such as in charged hadron therapy of cancer, radioisotope production and radioprotection. The ethos of CERN, in terms of open access, peer-reviewed projects and governance has been so successful for High Energy Physics that application of the same to biomedicine would attract high-quality research, with possible contributions from Europe and beyond, along with potential new funding streams.

The use of Biobrane® as a delivery method for cultured epithelial autograft in burn patients

BACKGROUND

Cultured epithelial autografts (CEA) are well described in the literature and are advantageous when dealing with major burns. There have been many methods of CEA application described, however they all have their own difficulties. Here we describe a novel technique of culturing the keratinocytes in Biobrane(®).

METHODS

Skin samples were taken from three patients and cultured into pre-confluent keratinocytes. These were seeded in Biobrane(®) and applied directly to the patients' wounds.

RESULTS

Three patients had Biobrane(®) with seeded keratinocytes applied. The Biobrane was applied to both donor and burn wound sites, with healing times being similar to the keratinocyte sheets.

CONCLUSION

The experience of the authors shows that using Biobrane(®) seeded with keratinocytes was easier to handle and quicker to produce than confluent sheets of keratinocytes, with no perceived disadvantages to the patients.

Large Hadron Collider commissioning and first operation

A history of the commissioning and the very successful early operation of the Large Hadron Collider (LHC) is described. The accident that interrupted the first commissioning, its repair and the enhanced protection system put in place are fully described. The LHC beam commissioning and operational performance are reviewed for the period from 2010 to mid-2011. Preliminary plans for operation and future upgrades for the LHC are given for the short and medium term.

Systemic blood pressure, arterial stiffness and pulse waveform analysis at altitude

OBJECTIVES

Systemic arterial pressure rises on acute exposure to high altitude and changes in blood pressure (BP) and endothelial function may be important in the pathogenesis of clinical syndromes occurring at high altitude.

METHODS

Arterial BP, stiffness (SI) and tone (RI) were studied over 11 days in 17 subjects (three having mild hypertension) ascending to 3,450m and 4,770m using a non-invasive, finger photoplethysmography technique.

RESULTS

At 3,450m BP rose from mean 131/75 mmHg (SD 23/12) to 145/86 (23/12) and was maintained at this level (p < 0.001). SI did not change significantly from 8.5 m/sec (2.5) to 9.7 (3.2). RI fell during the first day at 3,450m from 74.4% (7.9) to 70.5% (13.8) (NS p > 0.05) and to 69.9% (12.0) (p < 0.02) at 4,770m but then reverted to baseline. Changes in SI and RI did not relate to changes in blood pressure. Changes in both arterial stiffness and tone were similar in those who developed AMS compared with those who did not. Baseline SI tended to be higher in the three subjects with hypertension 11.1m/sec (SD 2.7)) compared with the normotensives 8.3 m/sec (SD 2.7) (NS) and baseline RI lower 74.7% (7.0) compared with the normotensives 76.5% (8.5) (NS). Changes in SI and RI at altitude in the hypertensive subjects were similar to the non-hypertensive subjects.

CONCLUSIONS

We conclude that acute exposure temporarily affected endothelial function as measured by a change in vascular tone but this did not predict the development of AMS. The rise in arterial BP was not related to changes in arterial stiffness or tone.

Abstract P1-08-02: Short-Term Pregnancy Levels of Estradiol Delays Mammary Tumor Development by Altering PI3K/AKT Pathway in Her2/neu Mice

Approximately 20-30% of all breast cancers overexpress the human epithelial growth factor receptor 2 (Her2). Breast cancers that overexpress Her2 have been associated with a more aggressive phenotype and decreased survival. Currently, the FDA has only approved trastuzumab, a recombinant monoclonal antibody against the Her2 receptor, for treatment of Her2- overexpressing breast cancer. Even though trastuzumab has been effective, many breast cancers do not respond to treatment or they eventually progress to a resistant state. Hence, several research investigations are underway to identify therapies besides trastuzumab that could be used for the treatment of Her2-positive breast cancer. It has been earlier demonstrated that uniparous Her2/neu transgenic mice developed smaller mammary tumors and these tumors had significantly decreased metastatic potential. Also, we had earlier demonstrated that short-term treatment with pregnancy levels of estradiol was very effective in delaying tumor progression and decreasing tumor burden. In this present investigation, we have attempted to understand the molecular mechanisms underlying this anti-tumor effect of short-term pregnancy levels of estradiol treatment against Her2/neu driven mammary carcinogenesis. Seven week old activated Her2/neu (murine-mammary-tumor virus (MMTV)-c-neu) FVB transgenic mice were treated for 3 weeks with 100mg of estradiol in silastic capsules. We have shown that this dose of estradiol treatment mimics pregnancy levels of the hormone in circulation. Control animals received empty silastic capsules for the same duration. Mice were palpated once every week for nine months to monitor the development of mammary cancer. Histopathological examination was performed to confirm the carcinomatous nature of the palpable tumors. A group (n=3) of mice were terminated from control and estradiol treated groups immediately after three weeks of treatment, and also, at 6 and 12 weeks post withdrawal of the treatment. Mammary tumor and normal mammary tissue were excised, snap-frozen in liquid nitrogen and stored at −80°C. Protein and total RNA were extracted from these tissues. Pathway focused microarray analysis was done on the PI3K/AKT pathway. Results demonstrate that, in parous and estrogen treated mice, proteins and genes involved in tumor-suppression (Mtcp1,Rbl2,Srf and Ywhah) and immune response (Cd14,Tlr4) were upregulated; which have been shown to play a role in reducing tumors by induction of apoptosis. This trend in gene expression alteration is present in both normal and mammary tumor tissue in the estradiol treated and parous groups and demonstrates that short-term pregnancy levels estrogen is altering the PI3K/AKT pathway; which correlates with our previous findings that short-term estradiol treatment is effective in tumor delay.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-08-02.

Introduction of the chronic care model into an academic rheumatology clinic

BACKGROUND

While the chronic care model has been extensively used for the management of patients with diabetes in non-academic, primary care settings, it is not clear whether this model can be used effectively in academic, specialty clinics for other chronic disorders.

METHODS

Through the Academic Chronic Care Collaborative, the chronic care model was introduced to help manage patients with osteoarthritis in an academic rheumatology service with seven prespecified goals. These goals included measurements of Western Ontario MacMaster (WOMAC) osteoarthritis scores, self-efficacy scores and exercise time.

RESULTS

Five a priori goals were achieved in this study: average WOMAC scores less than 1000 mm as measured on a visual analogue scale, average self-efficacy score of less than 5 mm, average exercise time greater than 90 min, more than 40% of patients exercising at least 60&emsp14;min per week and a 20% improvement in self-efficacy scores. However, a 20% improvement in WOMAC scores and a 60% completion of documented self-management goals in our patients were not achieved. Our inability to achieve our self-management goal underscores the fact that we have not yet fully implemented the chronic care model into our practice. The inability to detect a 20% improvement in WOMAC scores in the context of having reached our absolute WOMAC goal at baseline suggests a probable ceiling effect for this measure.

CONCLUSIONS

The chronic care model can be effectively introduced into an academic specialty service and can be used effectively in the management of patients with non-diabetic disorders, in this case osteoarthritis.