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Evidence-Based Oncology April 2016
ASCO Policy Statement on Clinical Pathways in Oncology: Why Now?
Robin Zon, MD, FACP, FASCO
The Oncology Medical Home - Beyond Clinical Pathways
Daniel P. McKellar, MD, FACS; Charles Bane, MD; M. Asa Carter, MBA, CTR; Allison Knutson, CCRP; Vicki Chiappetta, RHIA, CTR; Bo Gamble
Recommendations for the Role of Clinical Pathways in an Era of Personalized Medicine
Alan J. Balch, PhD; Charles M. Balch, MD; Al Benson III, MD; Deborah Morosini, MD; Robert M. Rifkin, MD; Loretta A. Williams, PhD
Cancer Care Pathways: Hopes, Facts, and Concerns
Bernardo Haddock Lobo Goulart, MD, MS
Developing an Oncology Clinical Pathways Program - the UPMC Case Study
Peter G. Ellis, MD
Clinical Pathways: A Systems Approach Toward More Patient-Centric Cancer Care Delivery
Joseph Alvarnas, MD
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Are Oncology Clinical Pathways a Value Framework in the Making?
Surabhi Dangi-Garimella, PhD
Conference Coverage: ACCC
Surabhi Dangi-Garimella, PhD

Are Oncology Clinical Pathways a Value Framework in the Making?

Surabhi Dangi-Garimella, PhD
Evidence-Based Oncology invited a panel of experts who are experienced in the creation of oncology care pathways, use them in their practice, and have researched the development and implementation of care pathways, to exchange ideas on the topic.
Clinical pathways remain ambiguous for much of oncology and its stakeholders. Adoption has been slow, and it is fraught with negotiations and push-back from providers. This could be due to a lack of understanding of how a treatment regimen was developed and who participated in the process, or it could be the result of reservations about the recommendations, which may clash with the oncologist’s clinical experience or opinion.
 
To gain an understanding of this gray area, Evidence-Based Oncology invited a panel of experts who are experienced in the creation of oncology care pathways, use them in their practice, and have researched the development and implementation of care pathways. The discussion included Robert Dubois, MD, PhD, chief science officer and executive vice president, National Pharmaceutical Council, and Blase N. Polite, MD, MPP, associate professor of medicine, chief quality officer, Section of Hematology/Oncology, University of Chicago. Polite also serves on the American Society of Clinical Oncology’s Value Task Force and their Payment Reform Working Group. The panel also included 2 experts from organizations that develop clinical pathways: Michael Fisch, MD, MPH, medical director, Medical Oncology, AIM Specialty Health (a division of Anthem), and Kathy Lokay, president and CEO, Via Oncology.
 
The discussion began with each panelist providing his or her perspective on what is an oncology care pathway. According to Fisch, pathways are created to provide optimal care choices from among a large pool of evidence-based choices that oncologists are faced with on a daily basis, although he said they may not be as comprehensive as the guidelines developed by the National Comprehensive Cancer Network. “I think our focus, at least with the pathways that we’re doing with AIM Specialty Health and Anthem, is on drug regimen treatment choices,” said Fisch, where the emphasis is on efficacy and safety, with cost considered only when the first 2 features overlap for the treatments being compared.
 
Via Oncology takes a slightly different approach, according to Lokay, but that’s only because of their customer base, she pointed out: cancer centers that are open to a more specific, case-by-case method. According to Lokay, the pathway development committee leans toward a more stratified pathway driven by a specific case presentation. In her opinion, care pathways extend beyond medical oncology and can be mirrored in all aspects of cancer care, including radiation oncology and symptom management, as long as the highest standards of evidence are used.
 
“If you want to be a purist, in my way of thinking about it, the element that’s unique about pathways is a longitudinal characteristic,” said Dubois, unlike guidelines that work off of a single node. The practicing oncologist in the group, Polite considers pathways a clinical decision tool that ensures care providers avoid unnecessary variability in care while also being armed with necessary flexibility. “This is a way to ensure some consistency in how we see patients, such that if a patient comes into my office or comes into one of my satellite’s offices with the same diagnosis, they’re not being treated in several different ways,” he said. “It’s not whose door [patients] choose to open on that day and what appointment they get, but much more a consensus driven opinion by experts using evidence-based medicine.”
 
AIM Specialty Health and Via Oncology have somewhat distinct approaches to their pathway development process, in terms of the evidence used. AIM uses published clinical data, updated in a quarterly fashion, which is then implemented based on the specific cancer type, and the outcome being evaluated (progression-free survival, overall survival, response rate, etc) may vary, according to Fisch. He added that safety and quality-of-life outcomes are also curated in the pathway development process, along with costs.
 
Via Oncology, on the other hand, defragments individual case presentations to identify the subpopulations of patients for which a specific treatment can be defined. Then, this is corroborated with published literature and included as a pathway recommendation, Lokay said. Their committee also considers alternate scenarios for patients that might warrant a different approach, although she agreed with Fisch in that efficacy, toxicity, and cost are considered, in that order, when comparing treatments. “So for us, really if we look across all the end branches, the primary end branches of our medical oncology pathways at least, the cost decision really only comes into account about 5% of the time.”
 
Dubois referenced a recent analysis that was published by the National Pharmaceutical Council (NPC) in The American Journal of Managed Care that stemmed out of a survey conducted by NPC among the various stakeholders—developers to end users.1 “What we found was extremely variable approaches to both the development and the implementation of the pathway,” said Dubois. As of yet, there are no stringent guidelines for developing these pathways, he added, saying that the variability is multifactorial and may lend itself in the form of evidence used, outcomes evaluated, or whether expert assessment versus consensus is used. Dubois believes there needs to be more consideration for heterogeneity of patient response, and the granularity of guidance should be driven by the extent of compliance that is expected.
 
Polite responded, saying that from a policy standpoint, clinical pathways—whether used to ensure quality or for preauthorization—“should have some sort of deeming process where we essentially bless pathways and say if you’re using a blessed pathway, then that pathway should be considered by all payers.” This process would also blend with healthcare’s movement to value-based pricing. Polite, however, does not believe that clinical pathways have matured enough to be a useful tool for a shared decision-making process. Fisch and Lokay agreed that pathways are a general guide and that the final decision should be made by the physician in discussions with the patient.
 


 
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