Developing Cancer Care Pathways for the New Environment

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We are in a changing practice environment, and effective pathway programs drive standardization across multiple sites for numerous physicians, increasing adherence to increasingly complex evidence-based medicine.

—Peter G. Ellis, MD

As community practices and the insurance industry seek cost-effective ways to adapt to the Patient Protection and Affordable Care Act, the evolving concept of cancer care pathways is emerging as a strategy that may help control oncology costs and add value to care. At ASCO’s recent Quality Care Symposium in San Diego, Peter G. Ellis, MD, Director of Medical Oncology Network for the University of Pittsburgh Medical Center (UPMC) Cancer Center, discussed his institution’s experience with cancer care pathways.

Dr. Ellis explained that UPMC Cancer Center is a distinct product line of UPMC, which is a not-for-profit health system that provides health services and insurance coverage in Western Pennsylvania. “After developing a cancer care delivery system across a large network of academic and community sites, we wondered what kind of quality we have. So we sent out surveys of five case studies to all of our providers, asking them how they would handle each clinical issue, and we got back 25 different answers,” said Dr. Ellis. He added, “we sought to assess the quality of our delivery system and develop cancer care pathways to drive standardized care, lower costs, and increase trial accrual. It was a forward-thinking idea for 2004, almost a decade ago.”

Why Pathways Now?

Pathways made sense then, Dr. Ellis noted, but “why do we need them now?” he asked. He continued, “We still need the benefits of standardized care, but now we also have to prepare for health-care reform that will usher in the new era of medical homes and accountable care organizations. We also need to have the ability for reporting our outcomes to our value-conscious consumers and to facilitate practice-hospital comanagement relationships. Moreover, pathways may also be used to aggregate large networks of physicians under clinically integrated systems and make sure that they have the latest clinical information at point of service,” said Dr. Ellis.

The Pathway Process

“To begin our pathways development process, we set up disease-specific committees, in which we asked for volunteer co-chairs to lead each committee. On each committee, one chair was an academician and one was community based—the chairs were selected for their expertise in the treatment of that specific disease,” commented Dr. Ellis.

The initial goal of the committees was to define the states and stages of disease for which a treatment is needed, and to define common comorbidities that would commonly occur and be likely to demand alternative therapies. “The overriding goal was to define therapies for 80% of our patients. We are not going to have pathways that apply to all the patients who walk in our doors. There is art to what we do, and although not all patients will fit into the pathways, we feel that the 80% who do will benefit from reductions in unwarranted variation in care that we see,” said Dr. Ellis.

The committees collect and review all relevant published clinical literature and determine a single best recommendation for each state, stage, and presentation of disease including common comorbidities, based on a three-tier process of efficacy, toxicity, and cost. “These are living documents that need to be maintained, so the committees meet quarterly via webinar. We first review any conflict of interest disclosures that may influence decisions. Then we review new evidence and debate that evidence until consensus is established for possible changes to the pathway,” he said.

Dr. Ellis stressed that there are significant challenges to developing and initiating clinical pathways. “It seems like a pretty straightforward process, but it isn’t. For instance, there is a lack of head-to-head data for many of the regimens, and assigning worth to very expensive new drugs that have marginally improved outcomes becomes a difficult task. Also, the need to drive standardization via consensus where there are no clear data can be a challenge create an obstacle to the pathways,” said Dr. Ellis.

Getting Doctors on Board

According to Dr. Ellis, the benefits of clinical pathways outweigh the challenges of implementation. “The best way to get practices on board with pathways is to be honest and emphasize their proven value in reducing medical errors, improving patient outcomes, driving practice efficiencies, and measuring success,” said Dr. Ellis. He added that it’s important to mention the emergence of accountable care organizations and medical homes as key drivers of patient referrals. “And of course, make sure they know it’s okay to go ‘off pathway,’” said Dr. Ellis.

“Finally,” he emphasized, “you need to make this tool easy to use! You cannot expect doctors to adopt a system that is burdensome on their already overtaxed practice. Imbed the pathways in a convenient point-of-care decision support tool that helps physicians select treatments. Hopefully, practices will be able to integrate the pathways into their current flow, either as a stand-alone tool or with their electronic medical records,” said Dr. Ellis.

“Challenges aside, we are in a changing practice environment, and effective pathway programs drive standardization across multiple sites for numerous physicians, increasing adherence to increasingly complex evidence-based medicine. Properly implemented, pathways improve practice efficiency and conserve health-care resources, which is a vital component for today’s oncology practices,” concluded Dr. Ellis. ■

Disclosure: Dr. Ellis is Chief Medical Officer for Via Oncology and owns stock in D3 Oncology Solutions.