Results Presented at NCCN Conference Highlight Value of Clinical Decision Support in Pathway Adherence

Evidence-Based OncologyJune 2023
Volume 29
Issue 5
Pages: SP352

Clinical decision support tools helped physicians stick with regimens on oncology clinical pathways, including those based on National Comprehensive Cancer Network (NCCN) guidelines, according to abstracts presented during the NCCN Annual Conference held March 31 to April 2, 2023.

Use of Flatiron Assist to Reduce Variation

Findings from Flatiron Health and Hematology-Oncology Associates (HOA) of CNY showed that adopting the Flatiron Assist clinical decision support tool helped the practice dramatically reduce the number of unique cancer regimens its clinicians prescribed. Flatiron’s Rebecca Maniago, PharmD, BCOP, associate director for clinical oncology, presented the abstract, which was listed among the top 5 at the conference.1

The Flatiron tool, which is embedded in the electronic health record (EHR), can be customized to coordinate and document treatment regimens that align with NCCN guidelines. To measure the effectiveness of Flatiron Assist in helping 57 prescribers stay on guideline-concordant pathways, researchers examined data from November 2017 through September 2022, which covered the period before and after HOA adopted Flatiron Assist in May 2020.

Maniago said the study examined orders in breast, colon, rectal, and prostate cancer, as well as non–small cell lung cancer and small cell lung cancer. “For our statistical analysis,” she said, “we calculated the proportion reduction in the number of [unique] regimens ordered,” with Wald (normal approximation) 95% confidence intervals, “to describe the relationship between the regimen variation seen before and after implementation.”

Results showed the following:

  • The team analyzed 9530 oncology therapy orders made after HOA implemented Flatiron Assist.
  • Overall, the number of unique regimens to reach 100% of ordered placed was reduced by 44% after implementation of Flatiron Assist.
  • The analysis showed that 75% of the orders prior to use of Flatiron Assist involved only 20% of the total number of unique regimens.

“This tells us that most of the variety we see across regimen ordering in general is done for a much smaller proportion of the total orders being placed,” Maniago said. “Regardless of that finding, the unique number of regimens ordered to reach the total number of orders placed was significantly reduced in both cohorts.”

More research may shed additional light on prescribing distribution patterns, she said.

Limitations include the team’s inability to isolate other factors that may have contributed to the drop in regimen variation. However, Maniago said, the key finding remains: implementing a clinical decision support tool within the EHR greatly reduces care variation “by standardizing unique regimens ordered at a multisite community cancer clinic.”

Partnership With Payer in Breast Cancer

A poster presented by New Century Health in partnership with Neighborhood Health Plan of Rhode Island examined the impact of a program to promote adoption of hypofractionation in breast cancer through the use of clinical pathways and peer review.

Investigators noted that clinical guidelines recommend use of hypofractionated whole breast irradiation (HF-WBI) for certain patients with early-stage breast cancer, but despite the evidence from clinical trials, uptake has been slow. New Century Health, a specialty care management company, partnered with Neighborhood for the intervention to increase hypofractionation. In a risk-based engagement between the health plan and New Century Health, clinical pathways were implemented that included mandatory use of hypofractionation for breast irradiation in eligible patients.

The 2-part system featured electronic prior authorization and a portal that delivered clinical decision support; when a clinician accepted hypofractionation, the request was automatically approved. Deviation from this request—or clinical exceptions to its use—led to a real-time peer review by a radiation oncologist prior to approval.

Sang Chau, PharmD, BCOP, senior oncology pharmacist for New Century Health, presented the resulting retrospective observational study that used radiation oncology prior authorization data from the health plan in a New Century Health database.2

All practices in the Neighborhood Health Plan were included, resulting in 190 patients eligible for HF-WBI being tracked from September 2020 to July 2022. According to Chau, the use of HF-WBI was defined as a provider indicating intent to treat the patient with 16 to 21 fractions. Results showed the following:

  • 190 patients with breast cancer were eligible for HF-WBI for the period from September 2020 through July 2022.
  • At the start of the program, baseline HF-WBI use was 40% (17/43). At the end of 2021, HF-WBI use had meaningfully improved to 54% (50/93), and performance continued to rise to 61% (33/54) from January to July 2022.

“[Results from] prior studies have shown that clinical pathways mandating the use of hypofractionated whole breast irradiation and prospective peer review can improve compliance with guidelines,” Chau said. “Neighborhood and New Century have combined both interventions with success, accelerating and sustaining adherence to evidence-based guidelines on hypofractionation.” 


  1. Congelli JM, Lewin H, Calip, JS, et al. Do EHR-embedded clinical decision support tools reduce variation in care? Poster presented at: NCCN 2023 Annual Conference; March 31-April 2, 2023; Orlando, FL.
  2. Soni SM, Hertler A, Chau S, et al. Accelerating adoption of hypofractionation in breast cancer through clinical pathways and peer review. Poster presented at: NCCN 2023 Annual Conference; March 31-April 2, 2023; Orlando, FL.
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