Systematic application of oncology clinical pathways can reduce variation in cancer disease management and result in significant overall savings, said Jim Koeller, MS, at the Hematology/Oncology Pharmacy Association 9th Annual Conference.1
A pathway is a tool for standardizing a specific disease care plan, or “a method to control the application of resources.” The need for clinical pathways in oncology is evident when one considers that variations in cancer disease management can exceed 100%, said Koeller, a professor of pharmacy at the University of Texas at Austin and the Health Science Center, San Antonio.
Although criticism of clinical pathways as “cookbook” medicine has been levied, “if the pathway is created properly, it can build in variations for patients who don’t fit the mold, the outlier patient,” he said.
A Cochrane systematic review of 27 studies of pathway use within a hospital found that by employing a resource management tool, hospital length of stay declined significantly by more than 1 day and cost decreased significantly.2
To date, most active pathways have focused on the disease treatment phase of cancer care, in which a set of regimens to be used as the standard of care, including regimens for chemotherapy and supportive care, is established. “Once you have the regimens locked, a pathway is putting regimens in order by line of therapy,” said Koeller. In lung cancer, the main cost driver of cancer care is not chemotherapy but hospitalization, which accounts for about 60% of the costs.
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End-of-life care also is in need of standards, as 20% of patients with lung cancer receive chemotherapy in the last 14 days of life, and 40% receive it in the last 30 days. “That’s where a lot of the variations in treatment can come,” he said.
Oncology clinical pathways should combine evidence-based medicine, supported by nationally recognized guidelines, and practicing physician consensus to develop the best approach, he said. The pathways should be designed to narrow treatment options and guide physicians to preferred treatment strategies. “When managed properly, pathways should maintain or enhance health outcomes and bring down the cost,” said Koeller.
Stakeholders should consider a variety of inputs when selecting regimens for a specific pathway. At his institution in the past, physicians were insulated from the economics of selecting regimens for pathways. “In hindsight, it was a mistake,” he said. “Moving forward, it’s a necessity.”
The American Society of Clinical Oncology (ASCO) is expected to include value and quality as elements of cancer care, “which means you’ll be making value calculations for regimens and treatments coming up relatively quickly, so physicians can start to see what those numbers look like for care,” he said.
Pathways are currently available from the National Comprehensive Cancer Network (NCCN), McKesson/US Oncology, University of Pittsburgh Medical Center/Via Oncology (implemented by Horizon Blue Cross Blue Shield), and Cardinal Health/P4 Healthcare (utilized by CareFirst). The NCCN pathways include clinical judgment when the evidence is insufficient to answer a question, unlike ASCO guidelines, which only consider evidence and do not take cost into consideration.
A retrospective analysis of US Oncology’s Level 1 Pathway (the most restrictive pathway; see Table) for the management of non–small cell lung cancer in 1409 patients revealed that managing chemotherapy and supportive care drugs accounted for 22% and 23%, respectively, of a reduction in costs over 12 months compared with off-pathway management.3 Total cumulative costs were 35% lower with on-pathway care, with no detriment to survival. Chemotherapy cost savings came from a reduction in cost during the first line of on-pathway therapy (29% savings).
References
1. Koeller J. Oncology pathways: what’s the endgame? Presented at: Hematology/Oncology Pharmacy Association 9th Annual Conference; March 20, 2013; Los Angeles, CA.
2. Rotter T, Kinsman L, James EL, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;17(3):CD006632.
3. Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract. 2010;6(1):12-18.