Dr Derek Raghavan Explains How Use of Guidelines Can Address Issues of Cost and Variation

Guidelines can help address issues of cost and variation, especially in complex diseases, said Derek Raghavan, MD, PhD, FACP, FRACP, president, Carolinas HealthCare System's Levine Cancer Institute.

What is the importance of implementing evidence-based guidelines for complex diseases, such as hematological malignancies?
One of the big problems in managing hematological malignancies is the rapidly burgeoning costs. The costs are from the new diagnostic tests that are tremendously expensive, the new targeted therapies that are even more expensive, and the fact that diagnostic companies and pharmaceutical companies are increasingly looking to make profits and going to the bottom line. And there’s a tension between that and the payers, who are increasingly looking to reduce expenditure.

One of the ways of getting around this is to structure guidelines that will take into account the best evidence base of what we do, if, for example, there are 2 agents that are equally active against a particular malignancy, then obviously physicians and patients will want to use the one that is less toxic. If these agents are equiactive, in other words have the same success rate and the same level of toxicity, then we need to be moving to the agents that are less expensive. And pharmaceutics committees are increasingly looking at that algorithm.

In the design of clinical guidelines and clinical pathways, what we have to do is overcome unnecessary variation. At the Levine Cancer Institute, where I work, we’ve actually created a mechanism where we’ve developed a series of electronically accessible pathways. They can be modified electronically, they’re created by a series of tumor-specific teams based on level 1 evidence. And, so, for every type of disease, we have a structured approach of preferred treatments, acceptable treatments, and treatments that we will not use.

Now, the trick is trying to make sure that our physicians use those treatments. There are a number of ways of incentivizing physicians. One is just simply making them do the right thing. If they’re reluctant to do that, then you can actually put financial penalties in place. As a rule, physicians are competitive and want to get the best results. So, I would anticipate over the ensuing years, with increasing pressures of cost, increasing stringency of oversight, physicians will increasingly adopt guidelines. And the reality is, if that doesn’t happen, the payers will ensure that it goes in that direction.
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