Clinical Pathways: Many Potential Benefits but 'More Work to Do'

Interview With Dr Robin Zon

Kathy D. Miller, MD; Robin Zon, MD


June 20, 2018

Kathy D. Miller, MD: Hi. I'm Dr Kathy Miller, professor of medicine and associate director of clinical research at the Indiana University Simon Cancer Center. Welcome to Medscape Oncology Insights. Today I'm joined by Dr Robin Zon, one of my longtime friends. Robin is an oncologist at the Michiana Hematology and Oncology Group and chair of the American Society of Clinical Oncology (ASCO) task force on clinical pathways.[1] Thank you, Robin.

Robin Zon, MD: Thank you for inviting me to talk about something near and dear to my heart—pathways.

Why Pathways?

Miller: Let's first talk about the genesis of pathways. Why were they developed? What problem were they trying to address?

Zon: Pathways go back as far as the 1980s, when staff at a hospital on the East Coast decided that they needed to do a better job managing their operations and their efficiencies. Oncology pathways were developed almost two decades ago to serve as care management tools so that institutions could reduce variability and become more efficient operationally in delivery of patient care. Many of the pathways initially were payer-facing so that they could help manage utilization of services.

Miller: Whenever care management is talked about, it sounds like code for "we want to reduce the cost and the amount we are paying for care."

Zon: You are exactly right. When we talk about cost management, we are talking not only about containing or reducing costs, but also care management. When we talk about care management, we are talking not only about containing or reducing costs, but also about managing the care of the patient to make certain that they are getting the best care available.

Miller: One of the challenges of pathways is that they talk about the ideal patient, the usual patient, the common scenario. But we have a lot of patients who are not common. They are not usual. As a specialist, when I look at the breast cancer pathways, what I see are all of the things that are missing, the nuances that are not there. How do you, as a general oncologist, see pathways?

Zon: Those are great points—you're exactly right. Pathways as they are developed should not be intended to have 100% adherence rates. Patients vary not only by their disease type, stage, and molecular markings, but also by what they are able to tolerate in terms of therapies because of their comorbidities and by what they are able to access because of their geographic location. That being said, I agree that pathways need to take into account all of those variables. In pathway development and analysis, we would never recommend 100% adherence. In fact, I would challenge you to think that as precision medicine goes forward and care for patients becomes more granular, that pathways will need to keep up with that and be able to account for those variances.

Keeping Pathways Relevant

Miller: That has me thinking about one way that pathways could be really helpful to the practicing oncologist. We used to talk about first-line treatment for metastatic colon cancer. Now you need to know whether it is RAS mutated or RAS wild-type. We don't have one disease anymore. We have a lot of different subsets; the numbers of molecular tests and therapies are growing, and growing at a quicker rate. How do you keep up with that in practice?

Zon: The explosion of new evidence is telling us and instructing us on how best to care for our patients. Keeping up with all of the precise information we need to know about our patients and applying that to their treatment care plans can be overwhelming. We advocate very strongly for pathways to be clinically up-to-date and take into account those nuances so that care plans can be developed that address those nuances, to help make sure that the right patient is getting the right drug at the right time. This is one potential benefit that pathways can give us.

Miller: Do you use pathways in your practice?

Zon: We have used a payer-facing pathway for 2 or 3 years now.

Miller: How is that integrated into your practice? My experience as a subspecialist at an academic center was very different. When we integrated pathways, at the end of a long clinic day I would go to a separate system which would pull up all of my patients, and I would put in what I did. It was not really something I used in real time to look for options. How does it get rolled out in your practice?

Zon: Many members have articulated their concern that pathways are not well integrated as decision support tools into existing electronic health records (EHRs). We will be talking a little bit later about the criteria ASCO has developed that advocates for that. But to answer your question, we use a separate system in our practice and it's very frustrating. As you mentioned, you have to leave the EHR system and go [to another system to go] through questions and answers to determine what therapy options you have. It is burdensome, and that is one of the [difficulties that] pathways have had—to optimize or reduce the administrative burden by integrating pathways more easily into the flow of the of the daily practice.

Do Pathways Improve Outcomes?

Miller: A goal and hope of pathways is that by reducing variability of care, quality of care would be improved, and more patients would get the best evidence-based care for their situation. Do we know if pathways do that? Do they have that effect?

Zon: Some small published studies[2,3] have been able to prove that. The key is trying to prove that to scale. I do believe that the answers are out there. Some large pathway vendors and payers are collecting this information and I hope they will be able to analyze their data to tell us whether pathways are delivering high-quality care in a cost-effective manner.

Miller: Cost becomes tricky in other ways. Ideally, pathways will look at evidence around therapy, toxicities of therapy, and cost. But cost could be [many things]. It could be the out-of-pocket cost to the patient, cost or profit to the practice, cost to the payer, or general cost to the healthcare system. Do we know what costs are looked at in those various pathways?

Zon: That is a great question. And in fact, that is one of the criteria that advocates for its transparency. How are you measuring and weighing efficacy, toxicity, and cost? Costs will be variable, not only from the healthcare standpoint, but to the provider, payer, and patient. It gets even more nuanced when you start looking at the fact that when there are different providers across the country, they are able to bring the drug into their practice with different contract rates. In addition to that, patients have different payer contracts with their insurers, so cost is going to be variable. That is very tricky, and I don't think that has been well defined yet.

What Are Disadvantages to Pathways?

Miller: Pathways clearly have advantages to them. Are there disadvantages to the increasing move to pathways?

Zon: We have not really addressed the administrative burden associated with pathway utilization, especially if a group has to use multiple pathways because of multiple payer requirements. One potential way to try to solve that problem is to develop a deeming system where you can "certify" pathways and then have the agreement that all payers would accept a deemed pathway. That would help reduce the administrative burden.

Another challenge is the continued integration of new scientific knowledge. What may happen in the next few years are point-of-care decision support tools because of big data. I think of CancerLinQ®. How are we going to integrate that information when we are looking at pathways and making decisions about our patients? Somehow that needs to be reconciled.

Furthermore, you have to look at what's going to happen as a multidisciplinary team, because cancer care is multidisciplinary. We need pathways that are comprehensive, that look at diagnosis, treatment, follow-up care, surveillance, and end-of-life care. Other providers [need to be] involved, [but] we have to make sure that we are not in conflict with them and that we are congruous in the care that we are advocating for in those pathway programs.

Miller: We have lots more work to do with pathways, but they are a good idea and they are definitely not going away.

Zon: That's correct. Pathways are not going away, and I think there is going to be some advocating for the continued use of pathways and increasing use when it comes to value-based reimbursement models. We do need to do more work. Pathway programs have evolved beautifully over the past 10-20 years. Do they need to be further improved? Yes, a lot of work needs to be done, but at all times we need to make certain that we keep pathways patient-centric, meaning that we need to develop the pathway to improve communication and help our patients understand the treatment that they are getting—and the reason why.

Miller: Thank you, Robin, for joining me for this fascinating discussion. We will get you back another time to talk about how we might evaluate pathways and make them better. And to our audience, thank you for joining us. This is Dr Kathy Miller for Medscape.


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