Recognizing Excellence in Home and Specialty Infusion Research:
The NHIF Outstanding Abstract Achievement Award
The National Home Infusion Foundation (NHIF) is proud to announce the finalists for the 2025 Outstanding Abstract Achievement Award, a recognition of groundbreaking research that advances best practices in home and specialty infusion. Each year, this award highlights innovative approaches, quality improvements, and solutions to critical challenges within the field.
In a special clinical webinar, the 5 finalists presented their research abstracts, showcasing key findings, methodologies, and real-world impact. A distinguished panel of judges will evaluate the presentations, and the award recipient will be announced during the NHIA Annual Conference in Washington, D.C. If you attend the conference, please make a point of reviewing these finalists and all of the poster abstracts.
NHIF’s commitment to investigator-initiated research is reflected in the Poster Session at the NHIA Annual Conference, where innovative studies that identify best practices, address industry challenges, and demonstrate effective study designs are showcased. By fostering research and recognizing excellence, NHIF continues to support the advancement of home and alternate site infusion therapy.
Implementation of a Pharmacist Intervention Tool to Optimize Subcutaneous Immune Globulin Administration for Home Infusion Patients
Katie Laskin, PharmD
Jill Yusko, RPh
Jennifer Bunk, PharmD
Organization: Yale New Haven Health Home Infusion
Abstract
Background
Immune globulin (Ig) is used for the treatment of complex disease states, including primary immunodeficiency and immune-mediated disorders. The most common Ig administration methods include intravenous (IVIG) and subcutaneous (SCIG).
While the labeling of many SCIG products have more conservative volume and rate recommendations for the initial infusion(s), subsequent infusions can be customized according to patient tolerance and preference by adjusting the number of infusion sites and/or infusion rates within established parameters.
An opportunity exists to develop a standardized method and timeline for home infusion pharmacists to assess SCIG regimens and perform interventions to optimize infusions based on patient tolerance and preference, anticipating increased patient satisfaction and compliance.
Purpose
Develop a tool within the electronic patient management platform to standardize home infusion pharmacist SCIG infusion assessments and interventions.
Test the tool over a period of 2 months.
Methods
Build tasks within the patient management platform that automatically trigger for new SCIG patients.
Tasks prompt:
1. Pharmacist assessment of SCIG infusions
2. Pharmacist re-assessment of SCIG infusions after intervention
Create standardized patient questionnaires embedded in the patient management platform to assess compliance, tolerance, and infusion optimization preferences.
Review current census and new SCIG patients to identify patients whose infusions may be optimized and test the tool.
Assign tasks to the patient’s identified, administer questionnaires and perform interventions to optimize infusions.
Monitor patients after interventions to assess compliance, side effects, and satisfaction.
Results
Tasks and associated questionnaires built:
1. Pharmacist assessment 30 days from SCIG initiation
a. Assess tolerance and compliance with current regimen
b. Determine opportunity for infusion optimization
c. Identify patient infusion preferences
d. Recommend and implement infusion adjustments in coordination with the prescriber
2. Pharmacist re-assessment 30 days after implementation of any adjustments
a. Identify any new systemic or local site reactions
b. Identify changes in compliance
c. Determine satisfaction with updated infusions
3. On-going pharmacist assessments every 90 days
a. Monitor for continued tolerance and compliance
b. Assess satisfaction with infusions
During the 2-month period from November 2024 to January 2025, 35 patients were contacted and assessed using the tool. Baseline demographics of the patients were a mean age of 55.7 years, including 2 pediatric patients. 80% (n=28) of the population was female. The mean days since SCIG initiation for the study group was 377.34. The predominant diagnosis was primary immunodeficiency (80%, n=28).
Of the patients contacted, 29 (83%) were interested in pharmacistled interventions to optimize their SCIG infusions. Patient infusion preference breakdown was: 38% preferred reducing the number of needles, 21% preferred reducing infusion time, and 41% were interested in reducing both the number of needles and infusion time.
Interventions resulted in:
– For patients preferring a reduction in the number of needles, a mean reduction of 1.46 needles per infusion (37.3% reduction) in needles used
– For patients preferring to reduce infusion time, a mean reduction of 27 minutes was seen (33.3% reduction) in infusion time
– For patients who wanted to reduce both the number of needles and infusion time, a mean reduction of 1.09 needles per infusion (29.7% reduction) in needles used and a reduction of 13.2 minutes (18.3% reduction) in infusion time.
Nineteen patients were contacted within the study period for follow-up assessment after changes were implemented. Eighteen patients (94.7%) reported no new systemic or local reactions and were satisfied with the changes made. No patients reported a change in compliance. One patient reported new local site reactions and wanted to return to the previous regimen.
Discussion
The use of automated tasks and questionnaires embedded in the electronic medical record (EMR) assisted in identification of patients who were likely to benefit from SCIG infusion optimizations. Tasks within the patient management platform standardized on-going pharmacist management of SCIG patients. The majority of patients contacted were interested in implementing changes to optimize their SCIG infusions. Patient interviews allowed the pharmacists to make customized infusion recommendations based on patient history and preference. Patient’s preference for optimization were divided between reduction of needles, reduction in infusion time, or reduction of both. After pharmacist interventions to optimize infusions, an overwhelming majority of SCIG patients reported no new drug-related reactions and expressed satisfaction with the changes.
Conclusions
Testing of this tool demonstrated the substantial opportunity for home infusion pharmacist-led interventions to optimize SCIG infusions according to patient preferences, resulting in high patient satisfaction rates. Embedding this tool in the patient management platform ensures each patient receiving SCIG will be assessed by a pharmacist and receive on-going management to continuously evaluate infusion tolerance and adherence.
Utilization and Tolerability of Crizanlizumab in the Home and Alternate Infusion Settings
Kascha Brown, PharmD, MS
Annemarie Hocking, PharmD
Maria Giannakos, PharmD, MBA, BCPS, BCSCP, FNHIA
Christopher Roy, PharmD, BCSCP
Organization: Option Care Health
Abstract
Background
Sickle cell disease (SCD) is an inheritable hemoglobinopathy that affects an estimated 100,000 people in the United States of America. Vaso-occlusive crises (VOCs) are a hallmark of sickle cell disease that often result in hospitalizations and can result in organ damage and complications such as acute chest syndrome, splenic sequestration crisis, venous thromboembolism, and priapism. The major clinical manifestation of VOCs are acute painful crises. Over three-fourths of SCD-related hospitalizations in 2016 involved a pain crisis. The number of hospital admissions for sickle cell pain crises increased from 2016 through 2020. Several new therapies have come to market in recent years to prevent the sickling of red blood cells, reduce VOCs, correct mutations in the gene encoding hemoglobin A, or induce expression of fetal hemoglobin.
Crizanlizumab was FDA approved in 2019 to reduce frequency of VOCs in patients with SCD. Crizanlizumab is a humanized monoclonal antibody that inhibits P-selectin activity that works by binding to activated P-selectin on the surface of endothelial cells and platelets. This binding facilitates the inhibition of platelets, red blood cells, and leukocytes interactions thereby resulting in decreased platelet aggregation, increased blood flow and decreased vaso-occlusion.
Despite extensive health care needs, many patients with SCD have difficulty accessing appropriate care. Home infusion provides a level of convenience and can minimize geographic barriers to accessing treatment. While crizanlizumab has been shown to significantly reduce the rate of sickle cell-related pain crises with a low incidence of adverse events, limited data exists pertaining to the usage and tolerability of crizanlizumab in home and alternate infusion site settings.
Purpose
This research provides evidence of the clinical utility and positive impact on patient access to SCD treatment in home and alternate infusion site setting. The primary objective of this study was to assess usage of crizanlizumab in home and alternate infusion site patients. A secondary objective of this research was to assess patient tolerability of crizanlizumab in this patient population.
Methods
This retrospective, multi-center chart review evaluates 52 months of data on patients receiving crizanlizumab. Baseline characteristics, demographics, and adverse drug reactions will be reviewed. This study was determined to be exempt by the IRB. Patients aged 18 and older with a confirmed diagnosis of SCD and at least 1 dispense of crizanlizumab (since its FDA approval) were included. The following data, if available, was also reviewed:
- Number of patients that discontinued therapy (and reason)
- Frequency and types of adverse drug events (ADEs)
- Adherence to FDA approved labeling (dose and schedule)
- Missed doses
- Payer type
- Characteristics of referral sources (physician specialty, local disease burden)
- Site of administration (home or alternate infusion setting)
- Use of other medications approved for SCD
- Frequency of VOC-related hospitalizations
Results
This study evaluated the utilization and tolerability of crizanlizumab in 25 patients with sickle cell disease (SCD) across various infusion settings. Of these, 9 patients (36%) received their infusions in a provider clinic setting, while the remaining 16 patients (64%) received their infusions at home or in an alternate infusion site (AIS). Among the 16 patients treated outside of a clinic, 10 (62.5%) received crizanlizumab at home, and 6 (37.5%) were treated in an AIS.
The patient sample consisted of 17 males (68.8%) and 8 females (31.2%), with an average age of 27.81 years (± 7.32) and a median age of 25.5 years at the first dispense. The majority of patients were in the 18–34-year age range, with 7 patients (43.75%) aged 18–24 years and another 7 patients (43.75%) aged 25–34 years. Regarding payor types, 10 patients (62.5%) had commercial insurance, and 6 patients (37.5%) were covered by Medicaid. The predominant genotype amongst patients included in this study was HbSS (68.8%) whereas only 12.5% of patients presented with the HbSC genotype.
Patients were on service for pharmacy services for an average of 416 days and a median of 343 days, indicating a positive skewed distribution. This might be attributed to the high discontinuation rate observed in the dataset. A dispense ratio was calculated in order to better quantify adherence. The number of days on service was divided by the number for dispenses. This ratio was calculated for each patient. The data of 3 patients can be perceived as outliers since their dispense ratios were 107, 178, and 290. Interestingly, 2 of these patients were discharged for noncompliance and the third switched infusion providers due to issues with insurance authorizations. The outliers skew the dispense ratio to 63. Omitting the outliers reveals a mean ratio of 33.85 (SD 6.7) and a median of 32.44, values more in line with the FDA approved dosing schedule of once every 28 days.
Geographically, the 16 patients receiving home or AIS treatments were distributed throughout the United States as follows: 10 patients (62.5%) were from the South region, 2 patients (12.5%) from the West region, and 2 patients (12.5%) from the Midwest region and 2 patients were from the Northeast region. Of the 16 patients treated outside a clinic, 9 (56.3%) discontinued therapy during the study period. The reasons for discontinuation were varied: 2 patients (12.5%) discontinued due to medication non-adherence, 5 patients (31.3%) switched to another infusion provider, 1 patient (6.3%) discontinued at their own choice, and 1 patient (6.3%) discontinued based on the provider’s discretion.
In terms of co-treatment for sickle cell disease, most patients were taking additional therapies alongside crizanlizumab. Hydroxyurea was the most commonly coprescribed medication, with 13 patients (81.3%) receiving it. Patients were also co-treated with folic acid (56.3%), voxelotor (25%), and L-glutamine (6.3%). Notably, no adverse drug events (ADEs) or use of anaphylaxis kits were reported during the study. The study also found that eight patients (50%) had reported hospitalizations due to sickle cell crises during the study period.
Discussion
This study aimed to evaluate the clinical utility of crizanlizumab in home and alternate infusion settings for patients with sickle cell disease. The findings suggest that crizanlizumab can be effectively utilized outside traditional clinic settings, with a substantial proportion of patients (64%) receiving their infusions at home or in alternative infusion suites. However, the results also reveal a relatively high discontinuation rate, with 56.3% of patients in the home or alternate settings discontinuing therapy during the study period. Notably, 5 of these 9 patients switched to a different infusion provider. Two of the remaining 4 patients were discontinued due to medication non-adherence. One patient discontinued therapy at the prescriber’s discretion. The findings are consistent with previous studies that have explored factors contributing to the discontinuation of crizanlizumab. Non-adherence to scheduled infusion appointments was a significant reason for discontinuation in a previous report, a factor that was also evident in this study where 2 patients discontinued due to medication non-adherence. A perceived lack of efficacy has also been reported as a reason for discontinuation and was also identified as a factor for some patients in this cohort. Each of the 8 patients receiving infusions in non-clinic settings that reported hospitalizations were co-prescribed hydroxyurea. Two patients were co-prescribed voxelotor, 1 patient was prescribed L-glutamine, and 5 patients were co-prescribed folic acid.
These factors highlight the ongoing challenges in maintaining adherence to crizanlizumab therapy, which may require further investigation into the reasons behind patients’ choices to discontinue treatment, miss appointments, or switch providers.
This study’s retrospective nature and small sample size are significant limitations. A broader, prospective study would provide more robust data, particularly concerning the reasons for discontinuation and the long-term effectiveness of crizanlizumab in home and alternate settings. Furthermore, variations in statespecific regulations and different pharmacy practices complicate the interpretation of results, as demonstrated by the incomplete data for some patients.
Nevertheless, the study provides valuable insights into the utilization of crizanlizumab in real-world settings and underscores the potential benefits of expanding access to infusion therapy outside the clinic.
Conclusions
This study demonstrates that crizanlizumab can be utilized in home and alternate infusion settings for patients with sickle cell disease. However, the high discontinuation rate highlights the need for further research to identify barriers to treatment adherence and optimize care delivery in non-traditional settings. These findings contribute to the growing body of evidence supporting the use of home infusion therapies for chronic conditions like sickle cell disease, offering a potential model for improving patient access to care. Future studies with larger sample sizes and a prospective design are needed to confirm these findings and explore strategies to improve patient adherence and long-term outcomes.
Social Determinants of Health Impact on Participant Perception with Intravenous Immunoglobulin Therapy
Leslie Myers,1 PharmD, IgCP
Elizabeth Neal,1 RN, IgCN
Edward O’Bryan,1 MD, MBA, CPE
Michele Way, PharmD,1 IgCP, BCSCP
Janie Cole2
Zipporah Williams2
Marin Vander Schaaf2
Hailie Grant2
Organization: 1CSI Pharmacy, 2Medical University of South Carolina College of Pharmacy
Abstract
Background
Home infusion involves the administration of a medication through a needle or catheter in a setting other than a hospital or other medical facility. These therapies are supported by pharmacists, nurses, and other professionals with special training. Infusing medications at home or outside of an institutional setting reduces the time spent away from normal activities, such as work and school and is a safe and effective alternative to inpatient care for a variety of therapies and disease states. The number of treatments offered at home continue to grow as quality-of-life benefits and improved clinical outcomes are demonstrated for individuals who receive home infusion.
Purpose
Home infusion therapy is an alternative for participants requiring long-term treatment, potentially improving their quality of life by reducing hospital or infusion center visits. This study aims to analyze participant demographics, accessibility, safety perceptions, financial benefits, cultural understanding, and overall satisfaction with home infusion therapy across various diseases and geographies.
Methods
Data was collected from a survey of 207 participants receiving home infusion therapy for conditions including Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Myasthenia Gravis (MG), and various antibody deficiencies and conditions. The survey assessed accessibility, awareness, safety, financial impact, cultural understanding, mood improvement, and overall impression of intravenous immunoglobulin therapy (IVIG). Responses were collected through patient surveys consisting of “yes or no” or scaled (1-10) questions. Statistical analysis was conducted to summarize key findings and differences by disease.Results The study included 128 women (61.8%) and 79 men (38.2%) with a mean age of 60 (23-92) receiving immunoglobulin therapy for the treatment of conditions such as CIDP (27%), MG (18.4%), and other antibody deficiencies. Regarding accessibility and awareness, over twothirds of respondents (68%) reported having reliable transportation to an infusion center however only 47% were aware of the location of the nearest infusion center. Comparisons of perceived safety and cleanliness between home infusion and hospital infusions showed a mean response of 9/10 versus 5/10 respectively, 1 being not sure of safety and cleanliness, 10 being very sure. When assessing financial impact, 86% of respondents agreed that they believe home infusion saved them time and money, and 75.3% found it helped balance their work schedule. Cultural understanding was rated “very important” (10/10) by 42% of participants, with 58.9% responding that they felt home infusion improved other’s understanding of their cultural identity. A majority of participants (82%) agreed that in home treatment helped with mood improvement as opposed to traveling to an infusion center or hospital. Finally, 63.0% of respondents reported a positive change in their impression of home infusion therapy, with an average rank change of 7.8 out of 10.
Discussion
Based on the survey of patients, perception of home infusion therapy is that it offers great benefits. Including benefits in safety, cost savings, work-life balance, and mental health across various participant groups. These findings support the continued use and growth of home infusion services aimed to improve participant experience. Future research may benefit from evaluation within individual disease states and larger sample size.
Conclusions
Participant perception of home infusion therapy is that it offers substantial benefits in safety, cost savings, work-life balance, and mental health across various participant groups. These findings support the continued use and expansion of home infusion services to improve participant perception and satisfaction.
Utilization of Alternative Dosing Strategies for Infliximab and Infliximab Biosimilars in the Home Infusion Setting
Natalie D. Garcia, PharmD
Christopher Roy, PharmD, BCSCP
Maria Giannakos, PharmD, MBA, BCPS, BCSCP, FNHIA
Andrew Chinn, PharmD, BCSCP
Michelle Sahlani, PharmD
David Shepherd, PharmD
Cara Bivona, PharmD, BCSCP
Organization: Option Care Health
Abstract
Background
Presently, there are many biosimilars of infliximab available for various diagnoses compared to when the infliximab reference product, Remicade® (Johnson & Johnson), was released in 1998. These medications are approved for the treatment of ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, plaque psoriasis, psoriatic arthritis, and Crohn’s disease. The standard dose for infliximab is 5mg/kg infused over 2 hours at 0, 2, and 6 weeks for induction, followed by every 8 weeks for maintenance. Shortened infusion durations of 1 hour have been well studied and found to be safe and effective if patients have tolerated 4 standard sessions. The loss of response (LOR) to these agents has been well established, with 46% of patients requiring dose escalation within the first year of therapy. Previous studies have established the use of different dosing strategies, including a shortened dosing interval (4 weeks), and doubled-dose (10mg/ kg) and found that shortened interval was not superior to doubled-dose in terms of LOR. Potential disadvantages of these alternative dosing strategies include an increased risk of serious infections at higher doses and decreased quality of life due to more frequent dosing.
Treatment is typically stopped if there is no response by week 14 or if significant infusion reactions have occurred. Acute infusion reactions that are mild to moderate include pruritus, flushing, dyspnea, chest discomfort, hypertension, myalgia, nausea, urticaria, headache, skin rash, and dizziness during the infusion or within 1 to 2 hours of completion. More severe infusion reactions including bronchospasm, angioedema, hypotension, and related cardiovascular, cerebrovascular, and temporary vision loss have also been reported during and following infusion. Delayed infusion reactions, including serum-sickness-like reaction (SSLR) or maculopapular rash, can develop after more than 24 hours, or occur up to 1 to 3 weeks post infusion.
Purpose
Purpose The purpose of this study is to compare shortened dosing intervals and doubled-dose with standard dosing of infliximab reference product [Remicade® (Infliximab, REM), and infliximab biosimilars Organon’s Renflexis® (Infliximab-abda, REN), Amgen’s Avsola® (Infliximab-axxq, AVS), and Pfizer’s Inflectra® (Infliximabdyyb, IFX)] in order to evaluate the utilization of alternative dosing strategies and compare the tolerability of alternative dosing strategies.
Methods
This was a retrospective, non-randomized, multi-site observational study. Patient data spanning two years were included. Baseline demographics, medication history, dosing strategy, and adverse drug reactions were reviewed. Data was obtained through electronic medical records (EMR). Patients 18 years or older who have previously received or are actively receiving treatment with REM, REN, AVS, and IFX were assessed for shortened interval or doubled-dose strategies. Dose escalation is defined as dose increase or shortened interval, among the dose increase group, the doubled-dose population was assessed. Patients who have been switched between biologics for LOR or treatment failure were also recorded. LOR was measured by worsening symptoms, urgent medical intervention, and discontinuation of the biologic due to infusion symptoms. Patients receiving subcutaneous Zymfentra (infliximab-dyyb) were excluded from this study. As stated previously, studies have shown the safety and efficacy of rapid infusion. These patients were included whether a patient receives a rapid infusion or standard infusion, but this metric was not assessed in this study. This study was determined to be exempt by IRB.
Results
A total of 202 patients were included from 92 sites in the United States. In this patient population, ages 18-27 (25.2%) had the most reported adverse drug reactions. Between the 2 dosing strategies, a total of 59 (29.2%) patients received an increased dose of 7, 8, and 10 mg/kg per dose and 51 (25.2%) patients had shortened interval dosing every 4, 5, and 6 weeks. IFX had both the highest percentage of patients experiencing adverse drug events in doubled-dose 19 (9.4%) patients and shortened interval dosing 9 (4.4%) patients receiving 4-week dosing intervals. The most common adverse reactions were flushing, dyspnea, and chest discomfort. Out of 224 reported adverse drug reactions 171 (76.3%) were managed in the home. Twenty-one (10.4%) patients had previously attempted a different infliximab biosimilar. There were 170 (84.1%) patients who experienced an adverse drug reaction and discontinued infliximab, the 32 patients (15.8%) remaining continued the same therapy. Of patients who discontinued treatment, 91 patients (45%) switched to a different biologic class.
A total of 292 patients were included for frequency change from 8-week to 4-week intervals. From 2022 to 2023, IFX showed the highest percent increase (50%) of patients started on 8-week intervals and converted to 4-week intervals. Sixty percent of total patients in the IFX group were on 4-week intervals in 2023, increasing to 63% of total patients in 2024. The REN group in 2023 had no patients on shortened interval dosing. In 2024, no patients were actively receiving REN. AVS had a gradual shift from 66% of total patients in 2022 to 73% in 2024.
Discussion
Currently, infliximab biosimilars are utilized for several indications related to autoimmune diseases with standardized dosing strategies, however there is minimal data on the guidelines for patients with increased tolerance. After induction, 2 LOR mitigation strategies were utilized: patients who had doubled dosing utilized (10mg/kg) or patients who had decreased intervals shortened to 4 weeks. Doses were recorded from the time the adverse drug reaction was reported. Reported events occurred in the home or in an infusion center under observation of a nurse. Premedication (corticosteroids, antihistamines, and/or antipyretics) was determined at the ordering provider’s discretion and the patient was given the option to decline prior to each infusion. Patient weights (kg) were rounded to the nearest whole number and doses were grouped to the nearest 100 mg per prescriber orders. Unrelated to dosing, some patients discontinued an effective agent without any tolerability issues due to insurance coverage.
Conclusions
This study demonstrates the tolerability of the dose escalation group when adjusting for an increased tolerance of the medication. Of 202 patients, 46 (22.8%) patients received double dosing of 10mg/kg. A total of 18 (8.9%) patients received reduced frequency dosing every 4 weeks. The difference in patients who had adverse drug reactions reported was higher in the increase dose population (7, 8, and 10mg/kg) compared to the shortened interval (6, 5, 4 weeks) was 3.8%. The doubled-dose population (10mg/ kg) compared to the shortened interval (every 4 weeks) had a difference of 13.9% adverse drug reactions reported. The severity of adverse drug reactions was variable across the patient population. However, the definitive reasoning for prescribing practices has yet to be determined. This analysis of dose increase and shortened interval provides a baseline trend of how infliximab biosimilars are prescribed. Further studies are needed to provide background on prescriber initiation of therapy related to tolerability risk assessment for indications to determine what patients can receive dose escalation after therapy induction.
Home Parenteral Nutrition Diagnosis and Payor Trends: 2020-2023
Amy Braglia-Tarpey, MS, RD, CNSC
Gus Gear
Organization: Amerita
Abstract
Background
Reimbursement and primary diagnosis for home parenteral nutrition (HPN) are intertwined due to payor policies that employ diagnostic and clinical criteria for coverage of therapy. Although CMS criteria for coverage through traditional Medicare Part B (MCB) became less rigid with the recent retirement of the National Coverage Determination (NCD) and implementation of the new local coverage determinations (LCD), commercial payors (COM) including Medicare Advantage Plans (MAP) may employ different and more stringent standards. Further, HPN reimbursement rates vary broadly across payor types. Changing trends in payor mix and most common primary diagnoses may be predictive of future challenges to HPN coverage access.
Purpose
The purpose of this study was to identify payor and diagnosis trends upon admission to a home infusion pharmacy for HPN therapy from January 2020 – December 2023.
Methods
A query was completed to identify all unique new admissions to a home infusion pharmacy with multiple locations nationwide for HPN therapy between January 2020 – December 2023. A new admission was included if the patient had not previously received service from this pharmacy for any infusion therapy. Resumption of care admissions were excluded.
Data was analyzed to identify trends in payor mix and primary diagnosis between years. Admits were quantified by payor group and diagnosis category. Percent change in admits in each payer group category and diagnosis category were calculated between years and comparing year 2020 to year 2023.
Results
From January 1, 2020 to December 31, 2023 Medicare HPN admissions with a MAP increased from 34 to 50%, while traditional Medicare Part B (MCB) admissions decreased by 16%. During the same time period, admits with other non-Medicaid, non- Medicare COM rose 7%. Traditional and managed Medicaid plans, government, and other payor types remained relatively stable across the time period.
Admits with diagnoses in the Disease of the Digestive System (K00-K95) category ranged from 52% of all HPN diagnoses in 2020 to 58% in 2023, a 6% increase. MCB as payor declined by 6% in this group, MAP increased by 6%, and non-Medicaid non-Medicare COM climbed by 6%.
K90.821 and K90.829, short bowel syndrome with colon in continuity and unspecified, respectively, rose from 0.5% to 2.7% of all PN diagnoses, representing a 440% increase.
There was a 2% increase in category R00-R99, symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. MCB admissions rose and MAP declined by 3% each in R00-R99 admissions.
Discussion
The rise in HPN admissions associated with a MAP is consistent with statistics in the overall Medicare population demonstrating a growing election of MAP versus MCB. This is concerning for several reasons: variation in clinical criteria for coverage by plan, which may be more stringent than traditional Medicare Part B, (2) MAP’s lower HPN reimbursement rates, and (3) home infusion providers ending contracts with lower HPN reimbursement rates, thus limiting choice for HPN consumers.
Increases in diagnoses of the category K00-K99 Diseases of the Digestive System suggests improvement in appropriate use of HPN and access to care for those with primary impairment of the intestines. Although a small percentage overall, short bowel syndrome (SBS) diagnoses increased by 440%, which is of interest as this group tends to have long-term to lifetime dependence HPN and access to coverage is imperative for survival.
The increase in MCB admissions for category R00-R99 may be due to retirement of CMS NCD and issuance of less restrictive LCD in 2021. However, some of the top diagnoses in this category include R10.9 unspecified abdominal pain; R11.2 nausea with vomiting, unspecified; R13.10 dysphagia; and R62.7 adult failure to thrive—all of which may be non-covered diagnoses for HPN without accompanying documentation to demonstrate tube feeding failure or inability to trial tube feeding.
Improvements in nutrition support decision making may be producing positive impacts on appropriate HPN use, but changes in payor mix may ultimately result in declining access to HPN.
Conclusions
A growing number of HPN patients are admitted for HPN with Medicare Advantage Plans versus traditional Medicare Part B, and primary diagnoses in the category K00-K99 are increasing among HPN patients. Future work should analyze HPN payor and diagnosis trends across all infusion providers, as well as evaluation of impact of these trends on home infusion provider financial viability and consumer access to HPN care.
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