3.4 Transcranial Doppler Ultrasonography

Adjustment of PHP contracts to cover RBC molecular antigen testing is a short-term investment. NC Medicaid can look to Blue Cross NC’s medical policy for language regarding the scope of coverage. Blue Cross NC recommends two FDA-approved panel test systems— BLOODchip® ID CORE XT™ by Grifols Diagnostic Solutions Inc. and PreciseType® HEA Test by Immuncor, Inc.—that are appropriate for patients with SCD who require frequent transfusions.265

NC Medicaid should facilitate annual transcranial doppler ultrasonography (TCD) screening for children with SCD aged 2 to 16.

Implementation: • NC Medicaid should remove prior authorization requirements for TCD.

• NC Medicaid should reimburse PHPs to coordinate care between radiologists and

SCD clinics and training of SCD clinical staff to perform TCD screening.

Background

Annual TCD screening is standard for children with SCD aged 2 to 16. TCD identifies those individuals who need transfusions, which in turn reduces their risk of stroke.266 If left untreated, approximately 11 percent of children with SCD will experience a stroke by age 20, a rate 250 times higher than the child population at large.267 Nationally, TCD screening rates among Medicaid patients are under 40 percent.268 Patient-related barriers to annual TCD screenings include inadequate transportation, duration of clinic visits, missed appointments, lack of awareness of the need for annual screenings, and mistrust of the procedure.269 Provider-related barriers include lack of awareness that TCD should begin at age 2, expectations that children will be uncooperative, lack of motivation, and poor coordination.270

North Carolina Context

As of February 2021, NC Medicaid covers TCD screening, however, the screening requires prior authorization, even for children.271 This prior authorization requirement results in an unnecessary barrier and burden to care. In many clinics, TCD screenings are managed

by radiology departments rather than SCD centers. Many radiology departments refuse to perform TCDs when patients are already at the clinic with their SCD provider, necessitating follow-up visits which make successful TCD completion less likely.272 This additional complexity means that patients may have to manage scheduling across multiple clinical departments, which often do not coordinate their appointments. NC Medicaid does not have a policy regarding TCD screening coordination and provider reimbursement.

Evidence

In a seminal study, TCD-based identification of children at risk of stroke, followed by appropriate transfusions, led to a reduction in stroke risk by 92 percent.273 In a United Kingdom systematic review and economic evaluation, the clinical- and cost-effectiveness of TCD scans combined with appropriate blood transfusions was demonstrated, with an incremental costeffectiveness ratio of £24,075 (about $38,422) per quality-adjusted life-year gain and avoidance of 68 strokes over the lifetime of a population of 1000 patients.274 The lives saved and stroke care avoided justified the treatment cost.

Patient education and coordination of TCD and SCD care can cost-effectively improve TCD adherence and reduce stroke incidence. Education and coordination of TCD within SCD care consists of a variety of activities. For example, coordinating radiology and SCD clinic appointments so that parents can obtain TCD screening in conjunction with a SCD clinic visit, improves TCD screening rates.275 Phone outreach by providers to parents explaining the purpose of TCD, sharing videos illustrating a typical procedure, and reminding them to bring children for annual screenings improves both TCD and SCD clinic appointment adherence.276

Example: Transcranial Doppler Ultrasonography

At St. Jude Children’s Research Hospital in Tennessee, a SCD clinic nurse was trained to perform TCDs, obviating the need for separate appointments with an unfamiliar radiology department.277 The St. Jude program, which also involved patient education and communication of abnormal TCD results and recommendations for transfusion, reduced initial stroke incidence among patients by 80 to 85 percent.

Additional Considerations

NC Medicaid should remove prior authorization requirements to facilitate access to this lifesaving procedure. Adjustment of PHP contracts as such would be a short-term investment. NC Medicaid should also reimburse providers for coordination between radiology and SCD departments and training nurses or other SCD clinical staff to perform TCDs. Developing TCD screening programs which PHPs would be required to implement is a medium-term investment. NC Medicaid can look to St. Jude and the Cincinnati Comprehensive Sickle Cell Clinic’s TCD program, which had 100 percent of eligible patients—most of whom were Medicaid enrollees—complete an initial TCD screen, with the average patient receiving an initial screen at 25 months old.278