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The American Journal of Managed Care January 2016
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Care Pathways in US Healthcare Settings: Current Successes and Limitations, and Future Challenges
Anita Chawla, PhD; Kimberly Westrich, MA; Susanna Matter, MBA, MA; Anna Kaltenboeck, MA; and Robert Dubois, MD, PhD
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Care Pathways in US Healthcare Settings: Current Successes and Limitations, and Future Challenges

Anita Chawla, PhD; Kimberly Westrich, MA; Susanna Matter, MBA, MA; Anna Kaltenboeck, MA; and Robert Dubois, MD, PhD
Care pathways influence quality of care and outcomes. Despite positive trends in development and implementation, further efforts in process transparency and evaluation are required.
In our review of the literature on care pathways, we observed variation in the characterization of care pathways. Evaluations of care pathways were more frequently focused on resource use and cost, and some concerns about transparency were expressed. The extent to which care pathway development, implementation, and evaluation were documented varied, and descriptions were not standardized, although some studies described these activities in detail.10,13,24-29 Furthermore, roles and responsibilities of key stakeholder groups in these activities were documented in some cases,12,25 but were not always clear. Evidence documenting the impact of care pathways on quality of care, patient outcomes, and healthcare resource use is beginning to emerge; a few studies have been published, and others have been presented in conference abstracts or posters. Some studies documented pathway adherence or compliance,12,25,28,30-36 or patient outcomes.31,33,37-39 Most studies we identified assessed the ability of care pathways to control resource use or costs.25,28,31,33,34,38-49 In addition to concerns about transparency in methodology associated with pathway development, concerns about lack of patient awareness of use of pathways, and implications for clinical decision making in delivery of their care, have also been noted.50,51

Phase II: Primary Research

Twenty-six participants completed the online survey. Ten were from payer organizations: 8 medical directors and 2 pharmacy directors representing managed care organizations, integrated delivery systems, and pharmacy benefit managers that covered a total of approximately 60 million lives. Nine were providers (1 solo/group practice, 7 hospital/clinic-based, and 1 indicated both) representing a range of specialties and practice sizes. Seven were from pathway vendors—of which 6 had experience with oncology care pathways. Nearly all payers and providers personally had a role in the development, implementation, evaluation, or use of at least 2 care pathways (17 of 19); nearly all respondents from pathway vendor organizations had experience with more than 5 care pathways (6 of 7). Seven payers, 5 providers, 3 pathway vendors, and 3 opinion leaders completed telephone interviews. Interviewees were selected based on their depth of knowledge of care pathways, willingness to participate in a follow-up interview, and, in the case of opinion leaders, their speaking or publication record on the topic of care pathways. Detailed characteristics of primary research participants are presented in the Table.

Selection of Therapeutic Areas and Treatment Settings

The majority of survey respondents that answered questions about selection of therapeutic areas and treatment settings (67%; 14 of 21 respondents that filled out this section) indicated that selection of therapeutic areas for care pathway development is often the result of an internal selection process. Attractive candidates for care pathway development are disease states associated with a high cost of treatment or high prevalence rates, availability of multiple branded therapies, and heterogeneity in treatment patterns; high cost of care and high utilization or disease prevalence were the most commonly cited triggers for the development of a new care pathway. Over half of respondents reported that disease areas were selected based on cost of care (62%; 13 of 21) and variation in treatment patterns (57%; 12 of 21); only 33% (7 of 21) reported selection based on clinical outcomes. Heterogeneity of case mix was considered a factor in selection by 19% (4 of 21) of the respondents. In follow-up interviews, suitable features mentioned for future care pathway development included opportunities for standardization and integration of multiple treatment modalities.

Most survey respondents expected that use of care pathways would expand in the next 5 years, in both oncology (85%; 22 of 26) and other therapeutic areas (65%; 17 of 26). Beyond oncology, rheumatology, cardiology, diabetes, and multiple sclerosis were identified as therapeutic areas with the greatest expectations for uptake. When asked to rate practice settings in which care pathways are most likely to be developed (no expected increase [0] to significant increase [5]), the highest ratings were ascribed to ACOs, IDSs, and specialty practices (Figure 1).

Providers as Key Stakeholders

Respondents consistently identified providers as the critical group involved in activities associated with care pathway development and implementation. Providers were viewed as taking increasingly prominent roles in care pathway development initiatives, in addition to acting as gatekeepers to successful adoption. Physician resistance was the most commonly cited barrier to care pathway expansion and uptake, and nearly all respondents reported that physicians could choose whether a patient is treated on-pathway.

Evidence Considerations in Care Pathway Development

Most respondents that answered questions about evidence considerations—86% (18 of 21) and 81% (17 of 21)—reported that treatment guidelines and randomized clinical trials, respectively, are key data sources for care pathway development (Figure 2). Peer-reviewed publications and consensus guidelines, compendia, and medical societies were the most frequently mentioned sources of evidence during interviews. Interview respondents identified the quality of efficacy-reporting studies as the most important consideration for inclusion in care pathway development, followed by data on safety or tolerability, with costs considered only after evaluating efficacy. Nevertheless, in survey responses, 81% (17 of 21), 71% (15 of 21), and 57% (12 of 21) identified medical (nonpharmaceutical) costs, pharmaceutical costs, and healthcare resource use, respectively, as measures that are considered in care pathway development. In interviews, some respondents noted that lower-cost options are likely to be placed on the pathway if there are therapeutic alternatives available and there is little to no perceived clinical differentiation among them. Some participants noted the importance of assessing the overall value of treatment, taking into account outcomes and health resource utilization, especially in the context of safety and tolerability assessment.

Processes or practices in pathway development are not commonly reported, codified, or documented, and the reported degree of methodological rigor applied to care pathway development varies greatly. In survey responses, 81% (17 of 21) reported grading evidence quality when evaluating studies used to inform development of a care pathway. Meta-analysis, adjustments for patient characteristics, and indirect comparison of interventions were reported by 62% (13 of 21), 48% (10 of 21), and 43% (9 of 21), respectively; however, many noted that the approach is not typically systematic or applied consistently. In the absence of high-quality data, respondents reported widely varying approaches and levels of rigor in pathway development. Decision making, without direct comparative studies, relies on consensus, best practices, clinical judgment, or indirect comparisons.

Implementation of Care Pathways

Electronic medical record systems were reported to be the most commonly identified mechanism for implementing care pathways. Web portals or websites are also common, particularly for health plan care pathways. Meetings and seminars, e-mail communication, and paper publications also effectively disseminate information and serve in physician education.

Most survey respondents (92%; 23 of 25 respondents who rated ≥3 as their level of experience and knowledge regarding pathway implementation) reported that physicians had multiple treatment options on care pathways for a given diagnosis. Deviating from these options is possible but often requires prior authorization. Interviewees reported that some deviation is expected, primarily due to patient heterogeneity, but deviation was associated with financial disincentives. Failing to meet compliance targets may also result in administrative hassle, potential exposure of performance statistics to other practices, and follow-up inquiry or monitoring. Provider responses regarding pathway effect on treatment decisions were mixed: some viewed them as altering their treatment decisions, while others felt validated.

Once implemented, reimbursement for care pathways is typically fee-for-service or fee-per-patient. Over half of the survey respondents who answered questions about financial incentives in the context of care pathway implementation (68%; 13 of 19 respondents who rated ≥3 as their level of experience and knowledge regarding financial incentives [or penalties] tied to physician use of care pathways to make treatment decision) reported that qualifications for reimbursement are most commonly tied to compliance, with target rates reported to be 75% to 80%. The proportion of eligible patients maintained on-pathway was considered the key measure of compliance (92%; 12 of 13), and therefore, that of reimbursement. Nevertheless, reimbursement policies may also consider quality of care (77%; 10 of 13), cost savings (38%; 5 of 13), physician satisfaction (23%; 3 of 13), and hospital length of stay (23%; 3 of 13).

Evaluation of the Impact of Care Pathways

Systems or processes for evaluating performance of care pathways were reported by nearly all survey respondents who answered questions about evaluation of care pathways. Most respondents (95%; 18 of 19 respondents who responded to questions in the survey section on “evaluation”) indicated that compliance rate was the most commonly used metric; 68% (13 of 19) reported the use of quality metrics (Figure 3). Physicians generally receive data on their compliance with care pathways through periodic (quarterly) reports that detail their performance metrics. Provider feedback on care pathways may be included in the evaluation of care pathway performance on an ad hoc basis. During interviews, a few respondents noted that a significant amount of negative feedback on a pathway, pushback, or widespread deviation from a pathway could trigger further investigation and potentially lead to modification of a pathway.

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