Clinical Decision Support Helps Compliance with Evidence-Based Pathways

TOP - September 2020 Vol 13, No 5 - Value-Based Care
Charlie Dawson

As the complexity of cancer care continues to evolve, adhering to evidence-based treatment guidelines is a growing challenge for oncologists. The use of clinical decision support tools within the electronic health record (EHR) system can boost provider compliance and drive quality improvement, according to data presented at the ASCO 2020 virtual annual meeting.

This retrospective cohort study showed that adherence to evidence-based pathways increased from 58% to 72% across 9 statewide oncology practices after implementing a clinical decision support tool, and adherence increased over time. Physicians reaching the established benchmark of 75th percentile of compliance improved significantly, according to Debra A. Patt, MD, MBA, PhD, FASCO, Executive Vice President, Policy and Strategic Initiatives, Texas Oncology, Austin.

“Clinical decision support has been shown to be effective at facilitating compliance broadly, at the practice, and at the individual clinician level,” said Dr Patt. “In addition to improved guideline adherence, variance reporting and accessible structured data improved significantly after implementation of the system, making this a useful tool for further investigation.”

Cancer care is changing rapidly, requiring detailed understanding of the disease in the face of increasing therapeutic choices. Clinical pathways have been key to improving compliance with evidence-based treatment. For more than a decade, Dr Patt said, Texas Oncology and the many practices within that network have adopted a system of pathways that was developed as a subset of the National Comprehensive Cancer Network guidelines.

The therapeutic choices are developed by a Pathways Task Force of physicians that attempts to balance efficacy, toxicity, and cost. This study was a collaborative effort among Texas Oncology, the US Oncology Network, and the University of Texas School of Public Health.

Clinical Decision Support

For this analysis, Dr Patt and colleagues conducted a retrospective cohort study from January 2014 to May 2016. They evaluated the impact of a clinical decision support system on compliance with evidence-based pathways across 9 statewide community-based oncology practices. Evidence-based pathways were incorporated into the clinical decision support system within the EHR at the point of care to “alter the choice architecture a clinician sees when prescribing therapy,” Dr Patt explained.

The study spanned a 4-month preimplementation period and a 4-month postimplementation period after 1-month washout. Qualifying diseases were common cancers, but cancers with available oral oncolytics were excluded from the study.

A total of 560 doctors and 29,926 patients were included in the study. Preimplementation, of the 14,009 eligible patients, 10,623 received initial therapy following the guideline recommendations. Postimplementation, of 15,917 eligible patients, 13,090 received initial therapy with a recommended treatment pathway.

“Of the 560 physicians included in the analysis, 58% were at least 75% concordant before this clinical decision support system implementation, and 72% were at least 75% concordant after the implementation,” said Dr Patt, noting this was a significant difference. “In addition, we saw adherence improved over time.”

In addition, completeness of accessible structured data improved over time. This is important, according to Dr Patt, because for each cancer there can be anywhere between 8 and 20 structured data elements that need to be satisfied.

“You can think of them [data elements] as nodes on the decision tree that guide care delivery. Without satisfaction of those nodes, you can’t proceed forward and prescribe treatment. Having this system integrated within the structured data greatly improved accessible data quality,” Dr Patt added.

Implementation of the clinical decision support tool also gave researchers insight into the variance in physician reporting.

“There is a lot of information out there today about how it’s important to have learning healthcare systems,” said Dr Patt. “Understanding variance from guideline-based behavior is an important way to continue to improve the process.”

Although alterations in treatment choices or nudges are an effective way to guide clinical practice, other factors could influence cancer care, including culture, pay for performance, or financial incentives, Dr Patt acknowledged.

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Last modified: September 14, 2020