Clinical pathways in MDS treatment are explored by Amer Zeidan, MBBS, MHS, and Jay Weaver, PharmD, MPH.
Ryan Haumschild, PharmD, MS, MBA: Dr Zeidan, what are your thoughts on clinical pathways? Because clinical pathways are getting used more and more. Dr Weaver brought that up. But for a unique patient population that’s smaller in MDS [myelodysplastic syndrome], not everyone has them. Does your institution utilize clinical pathways or order sets? How do we make sure we’re providing high-quality care for such a small, unique patient population?
Amer Zeidan, MBBS, MHS: Those are very important tools, especially as the care of patients gets very complex and different people are involved in it. The way to treat patients with MDS is a team effort. It isn’t only the physician. We have a pharmacist who meets with any patient who’s about to start any kind of new treatment, whether it’s IV [intravenous] azacitidine or decitabine or oral decitabine. Whichever treatment you’re giving, they would meet with the patient in addition to the physician or after the physician. They would go over the potential adverse effects and logistical aspects of the treatment that the physician might not necessarily go into a lot of detail about, along with drug interactions and when to take the drug. What do you do if you miss a dose? There are all these practical aspects of using it.
In addition to that, our practice nurse would print some of the information material about the drug, the adverse effects, and what to do in different situations that the patient might have questions about. It’s a team approach. Having orders can also help make sure people are applying a uniform way to treat patients. For any kind of treatment for patients with cancer, we use order sets. Those order sets are going to have requests to do a CBC [compete blood count] every 1 or 2 weeks. They’re going to have type and screen, because many of those patients are going to potentially need transfusions. You mentioned luspatercept, which is a good example, where you have step-up dosing. When do you do that? All of these are included in the order sets.
The pathways are a little more complicated. Pathways—at least currently—are more applicable to diseases where you have many alternatives. There could be differences in what you want to use for different reasons, whether it’s efficacy, institutional access, or other reasons. In high-risk MDS, we have only 2 agents, including the oral version of decitabine, which is a third agent. We use our discretion many times. What’s the patient’s goal? How far do they live from the institution? Sometimes their insurance coverage can affect the drug choice. All of those factors could be built in regarding which drug we use.
Ryan Haumschild, PharmD, MS, MBA: That’s helpful context. As you said, it’s more of a niche patient population and niche treatments. We brought up that payers could utilize pathways. How do we stratify patients by treatment? Or if a patient is in a large IDN [integrated delivery network], how do we make sure that the community oncologist who might be treating the patient provides the same great level of care as the subspecialist, who sees only these types of patients? That’s helpful guidance, with order sets driving appropriate prescribing, right dosing, dose escalation, de-escalation, as well as laboratory values that we evaluate.
We talked a lot about pathways from a clinical standpoint, but I want to get some thoughts on benefit design around these patients. Dr Weaver, you talked about utilizing pathways before, but what’s your experience with benefit design in myelodysplastic syndromes? What are some of the challenges in managing interventions that we see across the medical benefit with IV and the oral benefit with pharmacy? Lastly, when we consider patient access, is it reasonable to provide a preference for an oral therapy? Do you look at patients and see if they have good proportion of days covered and create that as a preferred therapy? How do you look at that?
Jay Weaver, PharmD, MPH: I appreciate the question. There are a lot of dilemmas. There’s some fragmentation of the benefit and the experience around those benefits depending on how your benefits were built. For instance, let’s say you have a health plan that manages your medical benefit and a standalone PBM [pharmacy benefit manager] that manages your pharmacy benefit. There can be lack of coordination between those organizations around what’s covered and when it was covered. Those organizations could be at odds with who they believe should cover the cost of that therapy, and folks are pointing at one another. That sometimes creates challenges to receiving access.
Sometimes an equalizer in those things can be clinical pathways, where the order sets are guiding the physician along the line of the products. Maybe there’s some curation of benefit that those third parties can have some oversight and say, “We know that this is covered in this benefit, and we know that isn’t covered, so we can steer you along the path.”
Other challenges that we see include the differences in cost share between the benefits, especially in fee-for-service. Medicare is a good example. Someone might have 20% coinsurance for injectable drugs in Part B, and they might have a 30%-plus coinsurance in Part D. That could set up a different experience for the member in terms of affordability for the therapy, even more so than the clinical piece. It’s great that something might perform differently clinically. But if they can’t access the product because they can’t afford it, then what have we achieved?
All those considerations come under the guise of managing and coordinating the benefit. Sometimes it’s done best through case- and care-management personnel that should understand the clinicals, the business, and the benefit, and can help steer someone to a pathway that might work best for them. When I say pathway, I’m not saying specifically clinical pathway. I mean overall pathway through the health care ecosystem and navigating benefits.
As someone who works in this space, when I’m trying to help my family or friends who are trying to navigate the system, I often realize how complex it is. I’m an expert in it. I work in it. I’ve designed programs. I see how hard it is when I’m a learned person in it. I can only imagine how difficult it can be for people who don’t have an advocate for them to help steer that. Some of these experiences in a more curated fashion certainly serve to help patients.
Transcript edited for clarity.