Feature article

Addressing Cost and Quality with Clinical Pathways in Oncology

The trend toward value-based care in the past few years has boosted the use of oncology clinical pathways (OCPs), a care delivery strategy to improve coordination among multidisciplinary teams, streamline treatment, and reduce costs.According to the American Society of Clinical Oncology (ASCO), there was a 42 percent increase in the number of pathway programs implemented by oncology practices from 2014 to 2016.1 A McKinsey analysis found that breast and lung cancer pathways are the most common OCPs, with 68 percent of surveyed payers using them as of 2014, followed by prostate and colorectal cancer pathways at 57 percent, multiple myeloma at 43 percent, and chronic leukemias at about 40 percent.15 Other pathways include renal cell, non-Hodgkin lymphoma, melanoma, and ovarian cancer.15

Currently, OCP pilot programs are documenting their ability to lower cancer treatment costs while maintaining or improving outcomes.1

Useful pathways

OCPs are implemented as critical components for reducing variability in outcomes.8 They offer a reliable method for delivering treatment that is more measurable, predictable, and accountable than current standard practices.8 Many pathways, such as those developed by the National Institute for Health and Care Excellence (NICE) and the National Comprehensive Cancer Network (NCCN), are already accepted by providers to support decision-making.18

Oncologists are developing OCPs and additional standardized treatment pathways that integrate into existing OCPs to improve the quality of patient care, capture data, support clinical trial enrollment, manage health status, and minimize emergency room (ER) visits and admissions. 

One community-based oncology practice improved outcomes and reduced costs by decreasing ER visits and hospitalizations after a patient health-status monitoring and intervention program were integrated into an existing OCP.4 Oncology-certified nurses performed care over the phone that supported patients before, during and after chemotherapy. Frequency of treatment, patient comorbidities, risk of adverse events and symptoms are taken into account throughout the treatment process in order to determine when an intervention is needed.4

Optimizing clinical outcomes is a primary driver of OCP implementation because these standardized treatment protocols can incorporate the latest and most effective therapeutic options for patients, such as new immunotherapy drugs, new combinations of existing drugs, new types of radiation therapy, or available clinical trials.17

In one institution and vendor partnership example, a comprehensive collection of evolving cancer data was built from the input of hundreds of oncologists across the nation that allowed physicians to create a curated list of protocols.3 Doctors were able to seamlessly access the latest research, treatment regimens, and complementary therapies to inform the treatment selection process because the clinical decision support tool was designed to access the electronic health record system and eliminate any interruption to clinician workflows.3

Other ways OCPs are being used to improve treatment include prioritizing pathways with lower toxicity or reduced costs with similar outcomes to therapeutic options known to have increased side effects or more expensive treatments.17 Clinical pathways can also reduce the financial burden for patients by noting when a treatment is likely to be ineffective, which can also save time and reduce stress.17

Issues and concerns

A significant concern for many oncologists regarding OCPs is the increasing importance of personalized medicine in treating cancer versus the one-size-fits-all design of clinical pathways, which are generally developed based on the broader population.8,11

Increasing evidence suggests that a tumor is a heterogeneous mix of cells whose genetic variation plays a key role in determining what works or does not work; therefore by its nature, each tumor requires treatment tailored to an individual patient’s diagnostic information and lifestyle choices.5,8,11

When the implications of genetic variation in tumor cells are considered together with the view that personalized medicine is the future of oncology care and emerging trends like precision medicine, many feel the expansion of OCPs will be challenged to keep pace.5,10  In one survey, when patients were asked for their input, 83 percent responded that they consider personalized care to be extremely important and 96 percent said they would choose personalized care over standard care.10

Patient advocacy leaders are another group voicing concerns about OCPs because patient preferences and feedback are seldom part of the pathway development process. In addition, few cancer patients are informed when they are put on a clinical pathway.12 When asked in a survey, 95 percent of patients didn’t understand the concept of a clinical pathway.12  Once explained, patients expressed concerns such as if the pathway prevented them from getting better treatment and if their physician was incentivized to keep them on the pathway.12

Still others in the healthcare industry are concerned that evidence-based, standardized clinical pathways may have a negative impact on innovation and experimentation for patients who fall outside payer-approved protocols.9

New uses for forgotten drugs, unexpected benefits of off-label applications, and hard-to-treat diseases that may only respond to therapies too expensive to be included on a payer’s optimal treatment list are a few results of the medical discovery process that medical experts believe OCPs could impact.9  Concerns over payer-driven programs are that off-pathway options may not be communicated, may be more stringently controlled, and/or require jumping through extra hoops for approvals that cause treatment delays.5

OCPs improving outcomes

Despite concerns, OCPs are demonstrating their ability to improve outcomes. For just one metastatic non-small cell lung cancer (NSCLC) care pathway pilot program that recommended a single standardized chemotherapeutic protocol, the Cleveland Clinic demonstrated how institutions can implement and assess pathways with resources already available to them.2 By documenting improved physician adherence to the standardized protocol and patient outcomes, they were able to reduce per patient costs by $98,000.2 Manual identification of patients combined with additional review of pre-existing data sources (e.g., a tumor registry) allowed for near-real-time analysis of OCPs while providing valuable information about impact.2

The Dana Farber Cancer Institute (DFCI) documented a savings of more than $15,000 in one year with no survival rate compromise after introducing OCPs for non–small cell lung cancer (NSCLC).13 The protocol used a new web-based platform for real-time decision support and post-treatment data aggregation that allowed them to observe and credit the largest source of cost savings to cancer drug management.13

Community-based practice Texas Oncology implemented OCP programs across breast, colorectal and lung cancers.4 Total combined documented cost reduction was substantial at more than $506,000. Reductions were attributed to decreases in hospital admissions by 34 percent, hospital days by 44 percent, ER visits by 48 percent as well as a reduction in cancer-related use costs and an increase in on-pathway adherence.4 Significant changes were made in order to standardize procedures, including implementing committees to report and promote collaboration, a patient health status management strategy, and regimen-specific patient education.4

A suburban Philadelphia oncology practice, Consultants in Medical Oncology and Hematology, has embraced value-based care models.16 They developed customized symptom management protocols for dehydration, diarrhea, insomnia, and delayed chemotherapy-induced nausea and vomiting (CINV).16 After five years, the percentage of patients directed to the ER as a result of a clinical call decreased by almost 60 percent.16 Standardized prevention of delayed CINV decreased post-treatment nausea and lowered prescriptions for drugs to control it.16

The University of Alabama at Birmingham (UAB) demonstrated the power of overcoming barriers to treatment and improving patient engagement with the integration of a patient navigation program into existing OCPs to reduce total estimated costs by more than $18 million, or $952 per beneficiary, over the first five quarters after implementation.18 UAB designed a program to help patients overcome transportation issues, scheduling challenges, and other barriers by pairing patients with a lay navigator.18 When researchers compared utilization before and after implementation, they saw decreases in hospitalizations by 18 percent, ER visits by 12 percent, and ICU admissions 14 percent.18

The use of OCPs has demonstrated their value and advantages when all stakeholders, including oncology researchers, providers, payers, patients and vendors, are involved. When pathways are developed and implemented with appropriate involvement they have the power to support high-value care delivery, allow doctors to quickly identify and manage at-risk patients, empower care teams to implement and track care plans, engage patients in care management, and provide improved outcomes at reduced costs.1,18

References.

  1. Oncology Clinical Pathways: Charting the Landscape of Pathway Providers. Journal of Oncology Practice. http://ascopubs.org/doi/full/10.1200/JOP.17.00033 Accessed 5/10/2018
  2. Data collection for care pathways in the Cleveland Clinic Health System. Journal of Clinical Oncology. http://ascopubs.org/doi/abs/10.1200/jco.2016.34.7_suppl.115 Accessed 5/10/2018
  3. Want to save hundreds of lives and millions of dollars? Integrate clinical pathway tools with your EHR. Healthcare IT News. http://www.healthcareitnews.com/news/want-save-hundreds-lives-and-millions-dollars-integrate-clinical-pathway-tools-your-ehr Accessed 5/10/2018
  4. Opening the Black Box: The Impact of an Oncology Management Program Consisting of Level I Pathways and an Outbound Nurse Call System. Journal of Oncology Practice. http://ascopubs.org/doi/10.1200/JOP.2013.001210 Accessed 5/10/2018
  5. New Study Examines Clinical Pathways: An Overview of Current Practices and Potential Implications for Patients, Payers, and Providers. PhRMA The Catalyst. https://catalyst.phrma.org/new-study-examines-clinical-pathways-an-overview-of-current-practices-and-potential-implications-for-patients-payers-and-providers Accessed 5/10/2018
  6. Oncology Clinical Pathways: A Form of Governance?. Journal of Oncology Practice. http://ascopubs.org/doi/full/10.1200/JOP.17.00084 5/13/2018
  7. PAYING FOR PERSONALIZED MEDICINE How Alternative Payment Models Could Help Or Hinder The Field. Personalized Medicine Coalition. http://www.personalizedmedicinecoalition.org/Userfiles/PMC-Corporate/file/paying_for_personalized_medicine.pdf Accessed 5/10/2018
  8. Oncology Pathways—Preventing a Good Idea From Going Bad. JAMA Oncology. https://jamanetwork.com/journals/jamaoncology/fullarticle/2485187 Accessed 5/10/2018
  9. Are Standardized Clinical Pathways Stymying Drug Innovation? Health IT Analytics. https://healthitanalytics.com/news/are-standardized-clinical-pathways-stymying-drug-innovation Accessed 5/10/2018
  10. Can Clinical Pathways Support Person-Centered Care and Improve Outcomes? Journal of Clinical Pathways. https://www.journalofclinicalpathways.com/article/clinical-pathways-congress-1 Accessed 5/10/2018
  11. The Healthcare System's Struggle With Oncology Care Pathways. AJMC. http://www.ajmc.com/journals/evidence-based-oncology/2016/april-2016/the-healthcare-systems-struggle-with-oncology-care-pathways- Accessed 5/10/2018
  12. What’s Missing from Clinical Pathways in Cancer Care. Institute/Alliance for Patient Access. http://allianceforpatientaccess.org/whats-missing-from-clinical-pathways-in-cancer-care/ Accessed 5/10/2018
  13. Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non–Small-Cell Lung Cancer. Journal of Oncology Practice. http://ascopubs.org/doi/abs/10.1200/jop.2017.021741 Accessed 5/10/2018
  14. Oncologists Say Clinical Pathways Are Too Confining. ONCLIVE https://www.onclive.com/publications/oncology-business-news/2015/september-2015/oncologists-say-clinical-pathways-are-too-confining Accessed 5/10/2018
  15. Strategies in oncology: Spotlight on clinical pathways. McKinsey Oncology Knowledge Report.
    https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/pharma%20and%20medical%20products/pmp%20new/pdfs/786594_strategies_in_oncology.ashx Accessed 5/10/2018
  16. New Strategies Emerge for Urgent Care in Oncology. OncLIVE. https://www.onclive.com/publications/oncology-live/2018/vol-19-no-8/new-strategies-emerge-for-urgent-care-in-oncology Accessed 5/14/2018
  17. How Oncology Practices Can Use Clinical Pathways for Value-Based Care Success. McKesson blog. http://www.mckesson.com/blog/oncology-practices-use-clinical-pathways-for-value-based-care-success/ Accessed 5/14/2018
  18. Clinical Pathways: Paving the Way to Improve Patient-Centered and Cohesive Cancer Care. Oncology Nurse Advisor. https://www.oncologynurseadvisor.com/navigator-notes/clinical-care-pathways-improve-patient-centered-cancer-care/article/667692/ Accessed 5/14/2018
  19. Mock Clinical Pathways: A Method for Exploring the Oncology Clinical Pathway Development Process. Journal of Clinical Pathways. https://www.journalofclinicalpathways.com/article/mock-clinical-pathways-method-exploring-oncology-clinical-pathway-development-process 5/14/2018
  20. Cancer Facts & Figures. American Cancer Society. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2018.html  Accessed 5/14/2018