Dr Robert Dubois Outlines the Creation, Utilization of Clinical Pathways

A survey of groups using and developing clinical pathways revealed 7 distinct themes that highlight how these pathways are created and used, and the challenges and barriers to creating new pathways, explained Robert Dubois, MD, PhD, chief science officer and executive vice president of the National Pharmaceutical Council.

Transcript (slightly modified for readability)
We've been interested in clinical pathways and there's been very, very little written or researched around the breadth of them. Who is developing? How are they being developed? What are the topics? What are the challenges? Are they working?

So we set about to try and bring some data to the table and worked with the Analysis Group and the folks there to do a landscape assessment. And we did that by doing internet surveys and telephone surveys with about 25 folks representing different groups. And these represented payers and providers and patient groups and vendors and the like. And we observed 7 themes that are worth considering.

The first is there are many players involved in pathways. Typically, payers are the ones initiating it, but providers are critical to the development of those pathways. And sometimes there are outside vendors that are developing the pathway because that gives some independence from the payer.

The second observation that we made was that the topics that the pathways are focusing on are really no surprise. These are areas that are expensive, where there's multiple ways to handle the patient, and when there's variability.

The third is there really are very few best practices. The Institute of Medicine came out with guidelines for developing guidelines. Well, there's no corresponding one for pathways. Most groups are using literature reviews and focusing on randomized trials, but there's really no consensus or really best practice about “How do I bring that evidence together? What do I do if there's a lack of evidence?”

The fourth is, there are many measures of success. For some people it's: how many patients were ending up using the pathway and how often did the doctor comply. But there's very little evidence around: how did the patients do? What were their clinical outcomes? What was the impact on cost of care?

The fifth area is really about disclosure. By and large, a patient comes to see their doctor, they have no idea that the physician might be incented to comply with guidelines that might impact the type of care they either do or don't receive. And that's an area where we believe more transparency is needed.

The sixth issue is we're likely to see more of these in more areas than just oncology. We're likely to see them in rheumatoid arthritis and multiple sclerosis and even hypertension. That's what our survey indicated.

And then the last, the seventh observation, is that there are a bunch of barriers for this moving forward, for pathways to be more ubiquitous. Everything from physicians don't necessarily want to buy into this; there are information technology issues of how do you do this in the day-to-day moments of care; and is it cost effective? Is it actually improving care and doing it in a way that is reasonable for the investments to make them happen.

So these are the types of things that we observed as we've spoken to 25 different groups around the country and how they're doing it and what they're doing and what the problems are.
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