Clin­i­cal path­ways face fork in the road

Modern Healthcare - - NEWS - —Sabriya Rice

On a typ­i­cal day, on­col­o­gist Dr. Linda Bosser­man spends hours por­ing over lists meant to guide clin­i­cians to­ward the op­ti­mal course of treat­ment. Th­ese “clin­i­cal path­ways” are based on a can­cer’s stage and lo­ca­tion in the body, and pa­tient-spe­cific fac­tors, such as co­mor­bidi­ties. Then, af­ter she and the pa­tient have cho­sen a plan, Bosser­man says she spends hours ex­plain­ing to pay­ers how and why the choice was made.

The path­ways have reached the point of be­ing an “un­sus­tain­able” ad­min­is­tra­tive bur­den, ac­cord­ing to the Amer­i­can So­ci­ety of Clin­i­cal On­col­ogy in a new pol­icy state­ment, of which Bosser­man was the se­nior au­thor. Also, the process of de­vel­op­ing them is laden with in­ad­e­qua­cies and con­flicts of in­ter­est. Clin­i­cal path­ways were cre­ated more than a decade ago when per­son­al­ized care be­gan to trend. But some ar­gue they have had the op­po­site ef­fect.

For each pa­tient and for each type of dis­ease, a provider faces count­less path­ways in­cen­tivized by dif­fer­ent in­ter­est groups such as pay­ers, who of­fer in­creased re­im­burse­ment or shared sav­ings for us­ing a path­way. Ben­e­fit man­agers, or in­ter­me­di­aries be­tween providers and pay­ers, cre­ate path­ways that fa­vor can­cer drugs. The pro­to­cols work on what might be de­scribed as an “if-then” for­mat. For ex­am­ple, if the pa­tient has breast can­cer that has metas­ta­sized, then X has been shown to have the best re­sults; or if the lung can­cer pa­tient also has di­a­betes, then Y would be bet­ter.

The Via On­col­ogy path­way pro­gram that was cre­ated at the Pitts­burgh-based UPMC sys­tem is used by many of the na­tion’s providers, in­clud­ing five aca­demic med­i­cal cen­ters. Dr. Peter El­lis of UPMC said the full list of path­ways is “more than 12,000 pages” long. He agrees it’s time to reg­u­late the process.

“The un­for­tu­nate truth is that peo­ple have bas­tardized what the name path­ways means, us­ing it to fur­ther other means,” he said, adding that they should re­sult in pa­tients get­ting the best ev­i­dence-based care.

ASCO sug­gests nine changes to the clin­i­cal path­way process, in­clud­ing bet­ter col­lab­o­ra­tion among pay­ers and on­col­o­gists to adopt flex­i­ble poli­cies; con­sis­tent and trans­par­ent method­olo­gies for de­vel­op­ment; changes that al­low real-time up­dates; and a greater fo­cus on the full spec­trum of care, from di­ag­no­sis to end of life.

ASCO has also been push­ing ef­forts to help physicians and pa­tients choose ap­pro­pri­ate ther­a­pies amid the sky­rock­et­ing cost of can­cer drugs. In June, the so­ci­ety re­leased a tool for on­col­o­gists to com­pare var­i­ous drug treat­ments for four com­mon can­cers based on sur­vival rates, side ef­fects and costs. They have also been work­ing on CancerLinQ, a not-for-profit sub­sidiary that gath­ers data from mil­lions of elec­tronic health records with the goal of pro­vid­ing real-time feed­back on can­cer trends and pa­tient out­comes.

The path­ways have reached the point of be­ing an “un­sus­tain­able” ad­min­is­tra­tive bur­den, ac­cord­ing to the Amer­i­can So­ci­ety of Clin­i­cal On­col­ogy.

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