Are Oncology Pathways 'Achieving the Goals We Promised'?

Kathy D. Miller, MD: Hi. I'm Dr Kathy Miller, professor of medicine and associate director of clinical research at the Indiana University Simon Cancer Center. Welcome to Medscape Oncology Insights. Today I'm joined again by Dr Robin Zon. Dr Zon is an oncologist at the Michiana Hematology and Oncology Group and, important for this discussion, she is also chair of the American Society of Clinical Oncology (ASCO) Task Force on Clinical Pathways. Welcome back, Robin.

Robin Zon, MD: Thank you, Kathy.

ASCO Task Force on Clinical Pathways

Miller: We talked before about pathways, the good and the bad. Why did ASCO take this on as a special task force?

Zon: That's a great question. Oncology pathways have been around for almost two decades, but over the past decade or so especially, there has been a proliferation of pathways, both payer-facing and provider-facing. With that proliferation, our members started telling us that they had concerns. It actually came from our members at ground level through the SAC, the State Affiliate Counsel, as well as the Clinical Practice Committee to the Board of Directors. They were concerned that these oncology pathways might be affecting patient access and care. Taking that into consideration, the ASCO Board of Directors decided to develop this task force. We started convening in 2015 to examine the pathway landscape and better understand what the issues were, so that we could make recommendations back to the board about how to go forward.

Miller: It's fascinating. One of the major goals of pathways is to decrease the variability of care and improve quality, and improve compliance with evidence-based care. It's interesting that members were concerned that maybe pathways were having the opposite effect.

Zon: That is exactly right because some members were experiencing a requirement to use multiple pathways within their group for the same [type of] patient (eg, stage and disease). They were having to color-code their charts so that when they walked into the room they would know that they had to use this decision support tool but [use something else for other patients]. That was the beginning.

But there were also concerns about the pathways in general, even for groups like ours which is only using one payer-facing pathway. [The concern is] about transparency. Who is writing these pathways? Were they experts? And how did they make decisions about methodologies to use when selecting one treatment regimen over another?

There were these concerns as the proliferation went on, because what we realized is that there was no standard out there. There was no standard to guarantee that thresholds were being met to guarantee high-quality and cost-effective care in the pathway world.

Criteria for Pathway Evaluation

Miller: Many of our members are not able to pick which pathway they have to use; that will be decided by a payer, practice manager, or a large hospital system. But they will want to evaluate whether the pathway is a good one. What criteria did your task force think they should be looking at?

Zon: Great question. One of the [objectives] the task force made initially was to develop some criteria that members could use to evaluate pathways to make certain that they were high-quality and cost-effective. The criteria were developed in three general areas: development of pathways, implementation and usage, and analytics. In total there are 15 specific criteria that support those three different areas. They examine things such as transparency (ie, who are the experts that are making selections, and do they have any conflict of interest), whether they are they clinically up-to-date, the levels of evidence being used to make those decisions, and whether clinical trials are being promoted within those pathway programs.

In regard to development and use, there were great concerns about the ease of integration into electronic health record systems and concerns about lack of decision support tools to make that transition happen, as well as communication in adjudication when you are using pathways.

With the analytics piece there were great concerns about outcomes. Are pathways doing what they were intended to do? Are we delivering high-quality care for our patients and containing costs at the same time? And, of course, we think the pathway program should be evaluating itself and determining whether we are achieving the goals that we promised our patients. If they are payer-facing, are they achieving the goals that their target audience needs? If they are provider-facing, are they achieving the goals that that target audience needs?

Pathway Evaluation

Miller: Once you enumerated these criteria, how many pathways did you evaluate?

Zon: That is a great question because pathways are developed in many levels. You have national pathways so you have national vendors. You have decision support tools like Eviti, for example, that refer to pathways. You have regional pathways like Seattle and Fred Hutchinson [Cancer Research Center], and then you have individual pathways that are within practices.

In the decision to evaluate the pathways, we consciously decided just to do those from national vendors, and we based this on the State of Cancer Care Report,^[1] which was a survey of members in 2016. One of the questions it asks is, what pathways are you using? We, along with a consultant from DK Pierce & Associates out of Zionsville, Indiana, took that information to find out what major pathway vendors and pathway programs the members were using. We selected six for evaluation and our results have since been published in the Journal of Oncology Practice.^[2]

Miller: How did they do?

Zon: Overall, we looked at all 15 criteria [and considered whether] they fully met, partially met, or did not meet the criteria. Then a unanimous decision was made among all of the task force members.

Miller: That sounds impossible. Trying to get a group of people to be unanimous about anything is a challenge.

Zon: But we did it. And overall, I was quite impressed. The pathways generally were consistent with the criteria. But at no time did I ever expect that all of the criteria would be met because many of the criteria were developed for guidance, for evolving the pathways so they could be optimized for quality, cost containment, and analysis. If you go through the appendixes in the analysis, you will see that some [pathways] fall out in some of those higher-level criteria that we hope pathways will eventually get to.

I want to mention something about the criteria and the recommendations. I want to call out the fact that all of the stakeholders were very involved in developing these criteria. In fact, we had face-to-face meetings with the patient advocates, payers, vendors, and providers to get criticism when we first rolled out our criteria so we could better understand what was and was not realistic. We got buy-in. So when the criteria came out and we went to the vendors, they were very helpful. We would come out with our analysis and give them a chance to respond to our critiques and why they did not fully meet or only partially met the criteria. Then we did re-analysis. We took their comments very seriously and adjusted things appropriately.

What you are seeing is not just a siloed analysis; it's a team effort. I'm very proud of the fact that we were able to get all of the stakeholders involved. In fact, we even noticed that in the generation of the work over the past two and a half years that the initial recommendations about transparency, for example, were taken to heart by some of the vendors and they changed their policies.

We moved the needle without even having to publish anything, so I'm very proud of the stakeholders and the team effort that everybody made. Because what are we trying to do? Ultimately, we are trying to enhance or promote optimal patient care. We understand the problem we have right now: containing soaring costs. How are we going to make things affordable? Not only for the healthcare system and the provider, but at the end of the day, for the patient and their family?

Which Criteria Were Usually Met? Why Did Some Fail?

Miller: What were some of the criteria that pathways generally met, where they generally were already doing a really good job?

Zon: I would say the development bucket. Most of those criteria were fully met by all of the vendors. Transparency increased, although there may be some that were partially meeting. They were up-to-date as best as they could be. They were evidence-based, definitely, and basically all promoted clinical trial participation. So in the development bucket, their criteria were very well met.

Miller: Where are the areas that they struggle with, either because they are just more difficult or they had not considered them until this ASCO effort?

Zon: It likely would be in the area of implementation and usage and the analytics. Implementation is how they can seamlessly integrate the pathway program into daily activities and practice flow so we are not having to go out of the system and take away valuable time from our patients. That has improved. Also, there was consideration about using the pathways to reduce administrative burden by getting prior authorization. That is a whole other problem because pathways are not meant to do prior authorization, but it's working with payers.

Miller: You would have a whole bunch of fans if you could make that work.

Zon: Exactly. Interestingly, when those criteria came out, some local payers said to their providers that if they used that pathway, they would get prior authorization. If you followed that pathway, the backroom staff did not have to call 15 times a day to make sure that you can give the therapy. The other area where improvement can be gained is in the analysis. Again, not only analysis for outcomes, because mostly they are based on adherence, but about the patient. If they are on the pathway, how did they do? What was their survival like? What kind of toxicities did they have?

Miller: If they are on the pathway, we would want to know whether they did better than similar patients who were not on the pathway. I think that is the most important question.

Zon: That's exactly right. If you are delivering care based on the pathway, you would want to know whether you are exceeding the standard or just breaking even. Then, of course, there is the cost issue as well that helps balance that.

What Comes Next?

Miller: What's next for the ASCO Task Force? This was a huge body of work, and it's really exciting to hear that it's already led to some changes in pathway policies and improvements in methodology and in transparency. What comes next?

Zon: Stay tuned. In the town hall tomorrow [at ASCO 2018] we are going to be talking about utilization management strategies. It is my belief, as well as for many others, that as opposed to us as providers having to succumb to the utilization management policies as governed by payers—and there is a great article and policy statement that ASCO put out about that^[3]—that pathways may be a great answer. Pathways empower providers to make sure that they are delivering the best care for our patients as opposed to being told to use step therapy or a number of other utilization management strategies. That is a work in progress.

Miller: We'll get you back another time to talk about the work from that, Robin. Thank you for joining us again today. To our listeners, thank you for joining us as well. This is Dr Kathy Miller for Medscape.

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