Clinical assessment for obstructive sleep apnea and national health insurance criteria for polysomnography

Sleep apnea is a sleep disorder that includes symptoms such as snoring and apnea during sleep and daytime drowsiness. This disorder reduces a person’s quality of life and can also cause serious problems that interfere with one’s social life. Both non-surgical, such as positive pressure treatment, and surgical treatments can be performed to improve sleep apnea. Polysomnography is first needed to confirm the degree of sleep apnea before surgery and should be conducted in certified facilities according to strict regulations. While appropriate treatment for sleep apnea can be implemented based on polysomnography results, it is burdensome for patients to obtain a polysomnography examination because of the high cost. To increase the accessibility of polysomnography to patients, the government has implemented an insurance program for patients who meet certain criteria. Recently, these criteria have been revised. The purpose of this paper is to provide information on the latest health insurance criteria for polysomnography.

FEMOROACETABULAR IMPINGEMENT INSURANCE COVERAGE TRENDS IN RECENT YEARS: A COHORT BASED ANALYSIS

Background: The diagnostic criteria for surgical indication of femoroacetabular impingement (FAI) remain controversial. With a growing body of literature investigating the quality of these criteria, little is known about the direction that these have had on changes of third-party policies. The purpose of this study was to measure how these changes in policy would affect the exclusion of a cohort of previously identified FAI patients who were treated operatively. Methods: Four insurance companies’ coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points, 2012 and 2018, to determine whether these third-party payer criteria for FAI surgery were met. The insurance criteria were assessed in a prospective multicenter cohort of 712 patients undergoing primary FAI surgery. The policies listed various combinations of age, symptom duration, positive impingement test, radiographic osteoarthritis, radiographic sign of CAM and/or pincer impingement, and physical exam findings. Results: The cohort of 712 hips included 324 men [45.5%] and 388 females [54.5] with a mean age of 28.7 years. Overall, insurance criteria were not met in: Insurance #1 old 30.1%, new 25.7%; Insurance #2 old and new 17.8%, Insurance #3 old 21.9%, new 21.1%; and Insurance #4 old 17.8%, new 14.9%-20.6%. In 2012, the average percent exclusion of the four companies was 21.9%, this number decreased slightly to 20.6% overall in 2018. The most likely reason to be excluded was found to be failure to meet imaging criteria. The second most likely failed characteristic was a negative impingement test (65 patients excluded). Several insurance companies continue to utilize Outerbridge criteria for cartilage lesions which cannot be assessed preoperatively. Discussion and Conclusion: The diagnosis of FAI and its surgical indications have no definitive set criteria. Our study shows that with a six-year span of growing literature and updated policies, nearly 1 in 5 patients deemed to need surgical intervention by experienced hip preservation surgeons would still be denied coverage. There is a need for continued improvement of consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention based on the available literature.

Questions Frequently Asked of Healthcare Professionals: A 2-Year Data Survey Conducted at a Medical Center

In this descriptive, retrospective study, we analyzed the types of questions posed by healthcare professionals to drug counselors at a medical center and the types of provision of pharmaceutical advice solicited to improve pharmaceutical care quality and establish clear directions for clinical pharmacist training. We collected 8,558 questions posed by healthcare professionals (physicians, 38%; pharmacists, 39%; nurses, 23%) from the electronic drug information record system from May 2013 to April 2015 in one medical center. Overall, 52% and 45% of calls came from outpatient and inpatient departments, respectively. Telephone was the main route of provision of pharmaceutical advice (total, 6,035 questions; 72%), and hospital/electronic formulary was the main reference type (43%). The top 10 topics were dosage, alternatives, drug name, usage, adverse drug reactions, medication suggestion, drug compatibility, national health insurance criteria, mechanism, and indications. Pharmacological classification inquiries most frequently addressed antimicrobial agents (20%), and vancomycin was the top single drug. Finally, 67% of calls were completed in 5 minutes. Our results suggest that the systematic organization of issues into a searchable database would reduce inquiry durations and improve work efficiency. Furthermore, the availability of various search tools and methods would quickly provide healthcare professionals with provision of drug information needed to improve patient medication safety.

ID: 15: ELIGIBILITY FOR PCSK9 THERAPY IN CHOLESTEROL CENTER PATIENTS WITH INITIAL LDL CHOLESTEROL ≥130 BUT <160 MG/DL

BackgroundBy lowering LDL cholesterol (LDLC) ∼60% beyond statins, PCSK9s have the potential to profoundly improve primary and secondary prevention of atherosclerotic coronary artery (CAD), peripheral (PAD), and carotid artery disease.PurposeIn 189 patients referred to a regional Cholesterol Center for diagnosis and treatment of hypercholesterolemia, who had initial LDL cholesterol (LDLC) ≥130 but <160 mg/dl, our specific aim was to determine how many would be eligible for PCSK9 therapy by extant preferred commercial insurance criteria.MethodsCurrent preferred commercial insurance criterion for PCSK9 therapy consisted of ≥1 of the following 3 conditions:Heterozygous familial hypercholesterolemia (previous LDLC >190 mg/dl and Tendon Xanthomas),Atherosclerotic cerebral-cardio-peripheral vascular disease.Failure to tolerate 2 or more statins.ResultsAt entry, in the 189 patients, mean±SD and median LDLC were 144±9 mg/dl and 143 mg/dl respectively. Of the 189 patients (96 female and 93 male with median age 53) 16 (8%) were diagnosed as having heterozygous FH, with median LDLC of 139 mg/dl, and 32 (17%) had sustained a cerebral-cardio- peripheral vascular event with median LDLC on treatment of 146 mg/dl. Of the 189 patients, in 44 (23%) the maximum tolerated statin dose was zero (complete statin intolerant), with median LDLC of 145 mg/dl. Of the 44 statin intolerant patients, 18 (41%) had either HeFH or an atherosclerotic event, and 26 (59%) had neither positive. Altogether 73 of 189 (39% of patients with entry LDLC ≥130 but <160 were eligible for PCSK9 therapy from commercial carriers.ConclusionOf 189 patients referred to a regional Cholesterol diagnosis and treatment center with initial LDLC ≥130 but <160 mg/dl, 73 (39%) met current commercial insurance carrier preferred criteria for PCSK9 drug coverage.

ID: 19: ELIGIBILITY FOR PCSK9 TREATMENT IN 734 HYPERCHOLESTEROLEMIC PATIENTS REFERRED TO A REGIONAL CHOLESTEROL TREATMENT CENTER WITH LDL CHOLESTEROL ≥70 MG/DL DESPITE MAXIMAL TOLERATED CHOLESTEROL LOWERING THERAPY

BackgroundLDL cholesterol (LDLC) lowering has been revolutionized by PCSK9 inhibitors, Alirocumab (Praluent) and Evolocumab (Repatha), which have approved indications as an adjunct to diet-maximally tolerated cholesterol lowering therapy in heterozygous (HeFH) or homozygous (HoFH) familial hypercholesterolemia, and/or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient despite maximal tolerated therapy.MethodsWe applied FDA approved and commercial insurance eligibility criteria for PCSK9 inhibitor use in 734 patients serially referred over 3 years who then received ≥2 months maximally tolerated LDLC lowering diet-drug therapy with follow up LDLC ≥70 mg/dl, as well as in 37 patients approved by commercial insurance for PCSK9 inhibitors. We obtained estimates of the percentage of patients with HeFH and/or CVD who meet FDA and commercial insurance eligibility for PCSK9 inhibitors using LDLC goal-based guidelines.ResultsOf the 734 patients with LDLC ≥70 mg/dl after ≥2 months maximally tolerated LDLC lowering therapy, 220 (30%) had HeFH and/or CVD events with LDLC >100 mg/dl, meeting both FDA and commercial insurance criteria for PCSK9 inhibitor therapy. Sixty-six (9%) patients were statin intolerant, without HeFH or CVD events. Of the 37 patients whose PCSK9 inhibitor therapy was approved for coverage by medical insurance carriers, 34 (92%) had LDLC>100 mg/dl after ≥2 months on maximally tolerated LDLC lowering therapy. Sixteen (43%) of these 37 patients had HeFH without CVD (LDLC on maximally tolerated conventional treatment 181±48 mg/dl), 11 (30%) had CVD without HeFH (LDLC on maximally tolerated conventional treatment 122±22 mg/dl), and 8 (22%) had both HeFH and CVD (LDLC on maximally tolerated conventional treatment 204±56 mg/dl).ConclusionOf the 734 patients referred for high LDLC treatment, with LDLC ≥70 mg/dl after ≥2 months on maximally tolerated therapy, 220 (30%) had HeFH and/or CVD with LDLC >100 mg/dl, meeting both FDA and insurance criteria for PCSK9 inhibitor therapy. If 30% of patients with high LDLC and HeFH-CVD are eligible for PCSK9 inhibitors, then specialty pharmaceutical pricing models (∼$14,300/year) will collide with an estimated 16–21 million HeFH-CVD patients. Although the costs for PCSK9 inhibitors given to an estimated 16 to 21 million patients are extraordinary ($228–300 billion), we speculate that, when weighed against direct and indirect costs of CVD, on balance, the cost to society might be either none, or that society would, in fact, save money by an anticipated 50% reduction of CVD events with PCSK9 inhibitors. Whether the health care savings arising from the anticipated reduction of CVD on the PCSK9 inhibitors justify the broad population use of these agents remains to be determined.