Now in its fourth year, the Oncology Clinical Pathways Congress (OCPC) serves as a forum for oncology care professionals interested in utilizing clinical pathways as a tool to facilitate more value-based care delivery in their facilities. OCPC is the official annual meeting of the Journal of Clinical Pathways (JCP).
This year’s meeting featured a variety of roundtables and presentations, including how technology is advancing pathways guidance and point-of-care decision support; integrating more patient preferences in pathways; and the role of the payer in the use, design, and leverage of value-based contracting.
Full conference coverage will appear in an upcoming supplement issue featuring full results of and insights on the 2019 JCP Benchmarking Survey.
Additional presentation coverage and interviews can be found online here.
Benchmarking Survey Shows Increased Pathway Comprehensiveness
To kick off OCPC, JCP Editor-in-Chief Winston Wong, PharmD, highlighted the most notable findings from the 2019 JCP Benchmarking Survey.
Clinical pathways continue to be an integral part of oncology care, he began, especially as care evolves to support alternative care models and reflect value-based care. The benchmarking survey was distributed and responded to by 75 individuals from across the pathway stakeholder landscape, including direct care providers (84%), physician assistant and nurse practitioners (16%), and cancer center pathway administrators (4%), among others. Dr Wong noted that there has been a shift from community to institutional settings responding to the survey year-over-year.
The distribution of financial model participation did not change much from 2018, with the predominant reimbursement model being fee-for-service (64.9%), he stated. Similarly, the level of oncology pathway utilization has not changed significantly since 2018. Sixty-six percent of respondents currently have pathways in place, and 14% plan to implement pathways within the next year.
Among the most noted drivers to implement clinical pathways include payer request/reimbursement, physician request, patient organization request, and alternative financial reimbursement models, Dr Wong listed. These are similar to the results reported in the inaugural JCP Benchmarking Survey from 2018.
One of the most significant changes to pathway utilization and development in this year’s survey was a greater percentage of respondents creating pathways internally (23.7%) at the expense of utilizing third-party programs (10.5%). As a result of this trend, oncology clinical pathways appear to be trending toward more comprehensive options and guidance; there has been a significant increase in surgical, radiation, supportive care, and genomic profiling inclusion in pathways, according to the survey results.
In regard to pathway application, Dr Wong reported that 55% of respondents utilize pathways to track individual prescribing patterns, which corresponds to 47% of respondents being able to select off-pathway choices without some type of peer-review. The remaining 49% of respondents are unable to prescribe off-pathway decisions without prior approval. Furthermore, he noted that there appears to be improvement in the ability to access pathways through the electronic medical record.
Moffitt Pathways and Value Pathways in Practice
In the second session of the 2019 OCPC meeting, three panelists discussed two mock patient cases and explained how the pathways at their institution would clinically guide decision-making in that disease setting as well as how the physicians interact in a practical sense with each institution’s pathways.
Stephen B Edge, MD, FACS, FASCO, Roswell Park Comprehensive Cancer, moderated this session, which included Karen K Fields, MD, Moffitt Cancer Center, representing Moffitt’s in-house pathways, and Neelima Denduluri, MD, Virginia Cancer Specialists, representing US Oncology Network’s Value Pathways powered by NCCNTM.
Dr Edge began by going over the first patient details: a woman diagnosed with left breast cancer at age 40. Seventeen months following initial diagnosis, she presented to her family physician with new onset of shortness of breath/fatigue. Computed tomography showed left-sided pleural effusion; two masses left lung (1 cm and 2 cm) and single 1.5 cm suspicious liver lesion. Thoracentesis showed exudative effusion; malignant cells; cell block showed ER+; PR-; consistent with breast primary.
Dr Fields showed attendees how the Moffitt pathways would guide treatment for this patient and showed a slide of a few parts of the actual pathway algorithm. She stressed that all treatment pathways begin with a note that hyperlinks to all the available clinical trials at Moffitt in that disease state, which is updated regularly. She also highlighted the push at Moffitt to have therapy driven by genomic testing. Treatment options and guidance are directed by National Comprehensive Cancer Network (NCCN) guidelines as well as current research and trial data. When next steps in care are less straight-forward, the pathways have active links to studies and other data sources to help physicians weigh the evidence to determine the appropriate course.
Dr Edge said he is impressed by Moffitt’s work to integrate other service lines into their pathways and predicted that “the next generation of pathways from any vendors will have to reflect multidisciplinary care—the continuum of care that the patient moves through—and not stay within just one discipline or service line.”
Dr Denduluri displayed a screenshot of the pathways platform US Oncology Network practices use to interface with their Value Pathways. All NCCN guideline options for the stage of treatment are displayed, along with pathway-prescribed options, which have been narrowed down by efficacy, toxicity, and cost. The evolution of their Level 1 Pathways into the Value Pathways powered by NCCN has strengthened the content of the pathways guidance—many NCCN committee members, experts in their specialty, also serve on the pathways committees to assist in optimizing the pathways options. This partnership also benefits US Oncology Network in their conversations with payers.
Dr Edge posed questions about hard stops in pathways—can clinicians ignore a pathway? What measures are in place if physicians decide to go off pathway? Do they need to input the reasons into the electronic platform, and how often are reasons reviewed?
Both Dr Denduluri and Dr Fields noted that physicians are never restrained by the pathways; rather, it is hoped that they treat patients according to what they feel is the best course and those options are ideally reflected in the pathways. If physicians do not believe the pathway options reflect the best course of treatment, they are encouraged to document why that is and choose the better option. These checks are in place so that pathways committees can see physicans’ rationale, not for punitive reasons, but to determine how they may improve the pathway, whether there is new data that should be reflected in the choices, or if it was simply a case of having a unique patient/patient circumstance.
Dr Denduluri summarized the patient details in the second case and displayed on the screen how the Value Pathways dashboard for multiple myeloma appears. She noted that, as a breast cancer specialist, this is a perfect example of how helpful a pathway can be for physicians who may not always treat patients in other disease states. The pathways not only provide the NCCN guideline therapy possibilities and more specific pathways guidance but also prompts/reminders for when supportive care and palliative care should be considered.
Input from the audience was solicited as far as questions on prescribed treatment; Blaise N Polite, MD, MPP, FASCO, stepped up to the microphone. He asked: How do we get providers to think more about value when making treatment choices, especially in multiple myeloma? He noted that multiple myeloma costs approximately $70,000 a year for first-line therapy alone.
Dr Denduluri responded that, in the Value Pathways, prompts show the price of the regimens, but providers will not be told that they cannot use a therapy due to cost. However, she agreed that we do need to change how we do things in terms of considering value at these junctures and how to proceed with that information in mind, or at least consistently display how much regimens cost.
Dr Fields also responded, saying that we should always first ask clinicians about evidence and consensus on best therapy options. After that priority, integrating cost is a challenge. It is difficult to even present costs in a meaningful way in a pathway, as those presentations may not line up with acquisition costs or total cost of care for a patient. We still need to figure out the best way to determine costs. She said they are currently trying to price out an entire pathway to let clinicians know what a line of therapy or section of a pathway would end up costing cumulatively.
Advancing Technology and Clinical Pathways
On the second day of OCPC, Rick Peters, MD, UT Austin Dell Medical School, and Mahek Shah, MD, Harvard Business School, gave a joint presentation on how technology can be used to enhance clinical pathways.
Drs Peters and Shah discussed a few areas in which technology could enhance pathways, including diagnostics, phenotyping, therapeutics, patient tracking, education, and communication.
Technologic innovation is needed in the diagnostics space because analytics and artificial intelligence/machine learning are accelerating faster than anticipated. This acceleration is due to “little data,” or quality data, rather than the often-heralded “big data,” Dr Peters explained. He provided multiple examples of how, in recent years, the medical field as a whole has been disregarding evidence. Published studies have attempted to disparage or rewrite the evidence or ignore the evidence altogether.
Dr Shah then posed the argument that non-clinical data and interventions should be harnessed and combined with clinical data and conventional therapy to improve patient care. An example he gave is that a diet of fresh food should be promoted alongside therapy options to improve the patient experience. There are a variety of missing components to support algorithmic diagnostics and therapeutic decision support, including environmental exposure (ie, workplace and travel), economic and financial profiles, family support and infrastructure, diet and nutrition, fitness and pre/post-habilitation, and transportation, Dr Shah added. He noted that tracking will be critical to support research and measures of outcomes and quality.
Dr Peters rounded out the list of areas in which technology should be built to enhance clinical pathways by stating that the biggest breakdown in clinical care, outcomes, and quality is a failure to communicate. The most important use of technology (ie, mobile, web, messaging, and video), he posited, should be to communicate, in detail, at every stage of the patient experience with clinicians and their family’s journey with their cancer.
In their concluding remarks, Drs Peters and Shah asked the audience to consider where we should be going in clinical pathways, decision-support, advanced intelligence, analytics, and machine learning. Importantly, Dr Peters stressed that we have to shift the pathways focus from a diagnostic/therapeutic retrospective view to a real-time predictive, prospective view, all while keeping the diagnostic/therapeutics record available at every point of care.
They finished with reference to a 1914 quotation from pioneering Boston surgeon Ernest Codman that simplified the theme of the session: “Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.”
Additional presentation coverage and interviews can be found online here.
