Fann Jessica, Kozlicki Miranda, Whelchel Kristen
J Am Pharm Assoc (2003). 2025 Jan-Feb;65(1):102262. doi: 10.1016/j.japh.2024.102262. Epub 2024 Oct 5.
Prior authorizations (PAs) for biologic medications, used to treat inflammatory bowel disease (IBD), are often denied by pharmacy benefits managers and can require a complex appeal process for patients to gain access to medication.
This quality improvement project evaluated the impact of implementing a standardized appeal letter template and customizable clinical rationale letter content on specialty pharmacist workflow and workload in an integrated hospital health system specialty pharmacy (HSSP) IBD clinic.
This initiative was conducted in an IBD outpatient clinic at a tertiary academic medical center with an integrated HSSP whose specialty pharmacists work collaboratively with providers to manage specialty medications.
A letter template was created in the electronic health record (EHR) for pharmacists to use when submitting appeal letters. The template automatically populates patient results from recent labs, imaging, and clinic visit notes as part of the appeal documentation. Clinical rationale letter content was developed for the most common appeal reasons using EHR functionality that allows the creation of standardized notes that can be shared among team members and customized at time of use.
An analysis of 2 months of data preimplementation/postimplementation was conducted using descriptive statistics to report the number of appeals submitted, time from PA denial to appeal submission, and appeal approval rate. A pharmacist postimplementation satisfaction score was also collected.
The number of appeals submitted preimplementation (n = 73) and postimplementation (n = 73) was the same. Postimplementation, 89% of appeals were submitted within 3 days of PA denial compared to 29% preimplementation. PA approval rate was high (93%) preimplementation and postimplementation. Overall pharmacist satisfaction was 9.7 out of 10.
Implementation of an appeal letter template and standardized clinical rationale letter content in the EHR led to decreased time to appeal submission and high specialty pharmacist satisfaction.
用于治疗炎症性肠病（IBD）的生物制剂药物的预先授权（PA）常常被药房福利管理人员拒绝，患者需要通过复杂的上诉程序才能获得药物。
本质量改进项目评估了在综合医院健康系统专科药房（HSSP）的IBD诊所中，实施标准化上诉信模板和可定制临床理由信内容对专科药剂师工作流程和工作量的影响。
该项目在一家三级学术医疗中心的IBD门诊诊所开展，该诊所设有综合HSSP，其专科药剂师与医疗服务提供者合作管理专科药物。
在电子健康记录（EHR）中创建了一个信模板，供药剂师在提交上诉信时使用。该模板会自动填充患者近期实验室检查、影像学检查结果以及门诊记录，作为上诉文件的一部分。利用EHR功能为最常见的上诉原因制定了临床理由信内容，该功能允许创建标准化记录，可供团队成员共享并在使用时进行定制。
使用描述性统计对实施前/实施后两个月的数据进行分析，报告提交的上诉数量、从PA被拒到上诉提交的时间以及上诉批准率。还收集了药剂师实施后的满意度评分。
实施前（n = 73）和实施后（n = 73）提交的上诉数量相同。实施后，89%的上诉在PA被拒后的3天内提交，而实施前这一比例为29%。实施前和实施后的PA批准率都很高（93%）。药剂师总体满意度为9.7分（满分10分）。
在EHR中实施上诉信模板和标准化临床理由信内容可减少上诉提交时间，并提高专科药剂师的满意度。
