Improving Oncology Patient Care Through the Use of Clinical Pathways

What are clinical pathways and how are they related to improving patient care?

As a concept initiated by oncologists, clinical pathways are a patient management tool utilized by a managed care organization's network of physicians that standardizes and outlines a patient's clinical course of care based on best practices which are specific to his or her diagnosis. Typically, clinical pathways tend to be more focused on the specific course of patient care, rather than on more broad-based clinical guidelines or other clinical parameters.^1,2 As one physician describes in a report, "When I think of guidelines, whether they come from the NCCN, ASCO, or ASH, I think of many different approaches to treatment. When I think of pathways, I think of active management of those guidelines, which allows you to narrow the number of approaches in a given clinical scenario."¹

Targeted at standardizing patient care, clinical pathways are also intended to streamline related patient care processes, limit the inappropriate use of drugs, improve patient safety, provide a basis for practices to be able to assess the cost of care, as well as, result in potential cost savings. Together, these elements are ultimately designed to improve patient care by limiting variability in treatment protocols, while at the same time remaining focused on providing the optimal course of care for a patient's specific diagnosis.²

In an environment of federal healthcare legislation that is increasingly focused on value-based outcomes and coordinated quality care, treatment standardization will most likely play an even more important role in the delivery of oncology patient care.^1,3 Specifically, with the implementation of healthcare reform and its provisions that are grounded on integrated delivery care systems, such as accountable care organizations, patient-centered medical organizations, and the use of bundled payments, having clinical pathways in place can be integral to providing this level of coordinated quality care.⁴

In addition, as the field of healthcare moves towards personalized medicine, clinical pathways are expected to work in parallel to this trend. For instance, with the growing use of molecular diagnostics, some payers and healthcare providers are starting to partner on clinical pathway programs in order to provide effective treatment and care while also managing limited financial resources.¹

What makes clinical pathways effective and what do its components look like?

For a clinical pathway program to be effective in improving the quality of patient care, the following characteristics should be present as part of its development and ongoing implementation processes:²

• Designed by physicians
• Evidence-based
• Updated regularly
• Informed through a formal physician feedback mechanism
• Evaluated for key data points on an ongoing basis
• Monitored for minimum compliance

In general, successful clinical pathway programs are those in which the actual clinical pathways are developed by physicians, supported through evidence-based medicine, and updated on a regular schedule. Within this model, programs may also contain a reporting mechanism through which physicians who use the clinical pathways can provide feedback. Throughout the process, to ensure an effective clinical pathway program, the collection of key data points is also critical, including elements such as cancer staging, line of therapy, tumor characteristics, performance status, and the reasoning behind any alterations to the course of treatment, such as disease progression and toxicity. As part of setting up compliance requirements, clinical pathway programs should include clear guidelines that outline how to identify and treat patients for whom the clinical pathways are not the most appropriate route of treatment. Specifically, as a component of compliance requirements, a formal tracking system is often recommended so that any exceptions to the use of a clinical pathway – including either patient or physician factors – is approved. By developing this tracking system, useful data can be generated that shows the adherence to clinical pathways as well as if and under what circumstances adjustments were needed to improve the clinical pathway.²

What is the relationship between clinical pathway programs and payers?

With the high cost of oncology patient care, payers have become increasingly focused on effective strategies to manage medication and services utilization while maintaining consistent quality patient care. In turn, over the past several years, payers have been pushing oncology practices to look for ways to cut costs. One oncology practice, which has been conducting a clinical pathway program for almost two years now, acknowledges that the payer market was influential in its decision to start the program – however, its payers did not actually specify what approach should be used towards the implementation of the clinical pathway program. A senior executive of this oncology practice is cited in a recent report saying, "Over the past 5 years, oncology reimbursement has changed more than in the past 20, and the combined forces push us to look at pathways as one of the top strategies to address these changes."⁴

Recently, data has been surfacing in oncology literature that demonstrates significant cost savings for practices that implement pathway-adherent treatment. For instance, a recent study was published that focused on assessing the relationship between measureable cost savings and clinical pathways for patients with non-small-cell lung cancer who were treated in an outpatient setting during a 12-month period. Patients who received care on a clinical pathway had a total treatment cost of $18,042 compared to patients who did not received care on a clinical pathway who had a total treatment cost of $27,737. In another report, the collaboration among Highmark Blue Cross Blue Shield (BCBS), CareFirst BCBS, and the University of Pittsburgh Medical Center resulted in savings of more than $1 million in just six months of limiting the use of an oncology product through the implementation of clinical pathways.²

Are there opposing views on the implementation of clinical pathways in oncology?

Some healthcare providers, including oncologists, contend however that limiting variability in providing patient treatment may prove to be counterproductive and can lead to poor care and higher costs. As one physician described in a recent report, "The narrowness of clinical trials further makes it difficult to generalize some standards to a broader patient population." In particular, some oncologists claim that several of the major trends in medicine are seemingly in conflict with one another, including physician autonomy, clinical guidelines/pathways, and personalized medicine.⁵

Others disagree with this stance and claim that current clinical pathways include provisions that allow for patient variation. One physician who supports clinical pathways is cited in a report saying, "The development and use of evidence-based medicine by physicians allows for physician autonomy and continues to apply the logic of understanding treatments, which allows for there to be even more personalized care."⁵

How does the uptake of clinical pathways impact oncology practices?

As with the implementation of any new program or process, consensus-building among physicians, other healthcare providers, and staff is crucial – especially in a setting such as a multi-specialty oncology practice.³ Once the decision has been made to implement a clinical pathway program, a review of current resources, staffing, communication tools, and infrastructure may need to be evaluated for any adjustments. In one oncology practice's experience, a senior executive recently said, "We did not have to build a lot of infrastructure for pathways. We did have to identify the individuals responsible for rolling out the pathways, but we did not have to upgrade computers. We wanted the pathway system to interface with our medical records, so that when the physician picked the pathway, the order set associated with that pathway would go directly into the EMR. We have not had to reduce or increase staffing because of pathways."⁴

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While clinical pathways have become a frontline topic in the oncology community over the past several years, organizations considering the development of a clinical pathway program should fully review and understand the information available to evaluate implementation of such a program.

For more information on clinical pathway programs, please review the following resources: