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.

RADT-39. STAGED GAMMA KNIFE STEREOTACTIC RADIOSURGERY FOR LARGE INTACT AND RESECTED BRAIN TUMORS; THE MUSC EXPERIENCE

Stereotactic radiosurgery (SRS) is a well-established treatment modality for management of both benign and malignant central nervous tumors. One limiting factor in the use of SRS is tumor size. Staged radiosurgery treatment is an option to utilize this treatment modality while still limiting associated toxicity. This involves treating each target in 2 separate sessions, spaced apart by approximately 30 days. We describe a series of 17 patients with 20 unique lesions treated using this technique in our department from January of 2019 through December of 2021. 18 treated lesions were malignant brain metastases and 2 were meningiomas. For 13 lesions, SRS was the primary treatment, and for 7 lesions, SRS was adjuvant treatment after surgery. The median target size for fraction 1 was 18.40 cm^3 with a median dose of 12.65 Gy. The median target size for fraction 2 was 14.50 cm^3 with a median dose of 12.08 Gy. All but one target was prescribed to the 50% isodose line. Median follow up was 7.12 months. Local control at the site of treated lesions was 90%. 3 patients with local control at the site of the fractionated treatment were noted to have additional progression within the CNS. There were 2 patient deaths within 30 days of treatment. One death was due to respiratory failure. The other cause of death was unknown. Treatment was well tolerated with no grade 3 or higher acute toxicity. 50% of patients went on to receive additional systemic therapy. 55% of patients are known to have died at the time of latest follow up. Overall, staged gamma knife radiosurgery appears to be an effective option for treating both intact and resected tumors with an acceptable toxicity profile.

RADT-01. GAMMA KNIFE STEREOTACTIC RADIOSURGERY FOR PATIENTS WITH 10 OR MORE BRAIN METASTASES AT INITIAL CNS PRESENTATION

Stereotactic radiosurgery (SRS) is an established treatment modality for patients with up to 10 brain metastases. Previous guidelines have recommended whole brain radiation therapy (WBRT) for patients with > 10 brain metastases, but many providers and patients have opted for SRS in an attempt to minimize neurocognitive toxicity. There is growing literature supporting SRS in patients with ≥ 10 brain metastases in both the up-front and salvage settings. Data remains limited in how to best manage patients with ≥ 10 brain metastases at their first central nervous system (CNS) presentation. A retrospective review was performed on all patients with ≥ 10 brain metastases at their first CNS presentation treated with Gamma Knife SRS since 2010 at our institution. Patients with prior surgery for neurological symptoms were included, but patients who had received prior CNS radiation were excluded. Patients could be treated in a single stage or as many stages necessary to treat all metastases. Demographics and clinical data were collected. Descriptive statistics were used to summarize variables. 91 patients were identified with a median age of 64 years old. The median brain metastases treated was 13 with a range of 10-57. Local failure was 11% and occurred at a median 10.8 months. Distant failure was 51.6% and occurred at a median 2.7 months. 30.8% of patients required repeat SRS and 18.7% of patients required salvage WBRT. Median survival was 7.2 months. 1-year and 2-year overall survival were 34.8% and 16.5%, respectively. Radiation necrosis occurred in 4.4%. Grade 2 toxicity occurred in 36.3% and Grade 3+ toxicity occurred in 7.7%. There were no grade 5 toxicities and only 5.5% of patients died from clear neurological causes. Upfront SRS provides acceptable local control, survival, and toxicity in patients with ≥ 10 metastases at CNS presentation and can be considered for first-line treatment.

Validation of the Pediatric Infectious Diseases Society-Infectious Diseases Society of America Severity Criteria in Children With Community-Acquired Pneumonia

Background

The Pediatric Infectious Diseases Society (PIDS)-Infectious Diseases Society of America (IDSA) guideline for community-acquired pneumonia (CAP) recommends intensive care unit (ICU) admission or continuous monitoring for children meeting severity criteria. Our objective was to validate these criteria.

Methods

This was a retrospective cohort study of children aged 3 months-18 years diagnosed with CAP in a pediatric emergency department (ED) from September 2014 through August 2015. Children with chronic conditions and recent ED visits were excluded. The primary predictor was the PIDS-IDSA severity criteria. Outcomes included disposition, and interventions and diagnoses that necessitated hospitalization (ie, need for hospitalization [NFH]).

Results

Of 518 children, 56.6% were discharged; 54.3% of discharged patients and 80.8% of those hospitalized for less than 24 hours were classified as severe. Of those admitted, 10.7% did not meet severity criteria; 69.5% met PIDS-IDSA severity criteria. Of those children, 73.1% did not demonstrate NFH. The areas under the receiver operator characteristic curves (AUC) for PIDS-IDSA major criteria were 0.63 and 0.51 for predicting disposition and NFH, respectively. For PIDS-IDSA minor criteria, the AUC was 0.81 and 0.56 for predicting disposition and NFH, respectively. The sensitivity, specificity, and likelihood ratios (LR)+ and LR- of the PIDS-IDSA criteria were 89%, 46%, 1.65, and 0.23 for disposition and 95%, 16%, 1.13, and 0.31 for NFH.

Conclusions

More than half of children classified as severe by PIDS-IDSA criteria were not hospitalized. The PIDS-IDSA CAP severity criteria have only fair ability to predict the need for hospitalization. New predictive tools specifically for children are required to improve clinical decision making.

Kidney Support in Children using an Ultrafiltration Device: A Multicenter, Retrospective Study

BACKGROUND AND OBJECTIVES

Provision of kidney replacement therapy (KRT) to manage kidney injury and volume overload in critically ill neonates and small children is technically challenging. The use of machines designed for adult-sized patients, necessitates large catheters, a high extracorporeal volume relative to patient size, and need for blood priming. The Aquadex FlexFlow System (CHF Solutions Inc., Eden Prairie, MN) is an ultrafiltration device designed for fluid removal in adults with diuretic resistant heart failure. It has an extracorporeal volume of 33 ml, which can potentially mitigate some complications seen at onset of KRT in smaller infants.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this multicenter, retrospective case series of children who received KRT with an ultrafiltration device (n=119 admissions, 884 circuits), we report demographics, circuit characteristics, complications, and short- and long-term outcomes. Patients were grouped according to weight (<10, 10-20, and >20 kg), and received one of three modalities: slow continuous ultrafiltration, continuous venovenous hemofiltration (CVVH), or prolonged intermittent KRT. Our primary outcome was survival to end of KRT.

RESULTS

Treatment patterns and outcomes varied between the groups. In patients who weighed <10 kg, the primary indication was AKI in 40%, volume overload in 46%, and ESKD in 14%. These patients primarily received CVVH (66%, n=48) and prolonged intermittent KRT (21%, n=15). In the group weighing >20 kg, volume overload was the primary indication in 91% and slow continuous ultrafiltration was the most common modality. Patients <10 kg had lower KRT survival than those >20 kg (60% versus 97%), more volume overload at onset, and received KRT for a longer duration. Cardiovascular complications at initiation were seen in 3% of treatments and none were severe. Complications during therapy were seen in 15% treatments and most were vascular access-related.

CONCLUSIONS

We report the first pediatric experience using an ultrafiltration device to provide a range of therapies, including CVVH, prolonged intermittent KRT, and slow continuous ultrafiltration. We were able to initiate KRT with minimal complications, particularly in critically ill neonates. There is an unmet need for devices specifically designed for younger patients. Having size-appropriate machines will improve the care of smaller children who require kidney support.