Oncology Pathways May Lead Patient Care Astray, Warns ASCO

Neil Osterweil

January 12, 2016

Clinical pathways are intended to improve the quality of clinical care in specific situations, but insurers' demands for rigid adherence to inadequate, prespecified oncology protocols may have the opposite effect and may cause administrative nightmares for many practices, an American Society of Clinical Oncology (ASCO) task force cautions.

"We think pathways do have a potential to make a significant difference in ensuring high-quality care that's cost-effective for all folks across the country ― we get that," said Robin T. Zon, MD, a task force member and lead author of an ASCO policy statement on clinical pathways in oncology.

"But what we're also saying is that while there needs to be quality, transparency, and consistency, there should never be a 100% requirement for pathway compliance. That would be dangerous," Dr Zon said in an interview with Medscape Medical News. She is a practicing oncologist at Michiana Hematology-Oncology PC, in South Bend, Indiana.

In the policy statement, published online in the Journal of Clinical Oncology, the task force recommends specific steps to help reform the clinical pathway development process and ease administrative burdens on oncology practices, with the ultimate goal of developing more consistent, uniform, and comprehensive pathways that meet the simultaneous goals of improving care and lowering costs.

Caring for the Pathway, Not the Patient

Approximately 60 individual health insurance plans, covering more than 170 million people in the United States, currently use oncology pathways, according to an ASCO press release.

Although they are well intentioned, oncology pathways tend to focus on therapeutics and often do not take into account the full spectrum of cancer care or individual patient characteristics and comorbidities, Dr Zon explained. In some clinical situations, blind adherence to a protocol mandated by a specific pathway (and by the insurer that uses that pathway) could actually harm the patient, she said.

In addition, the multiple and sometimes conflicting demands of different pathways used by different insurers can give even the most well-organized practices logistical migraines. In some areas of the United States, oncologists must cope with eight or more different pathways, and some have taken to using a system of color coding of patient records with cross-referencing to keep track of each company's oncology pathway requirements.

Dr Zon told Medscape Medical News that she recently had a patient for whom a pathway called for a drug that in her clinical judgment was wrong on the basis of that patient's age, comorbidities, and other characteristics.

"Depending on what insurance company she had, the pathway may be different, and I would have to be cognizant to care for the pathway as opposed to caring for her," she said.

Instead of following the pathway, she prescribed a different agent that was acceptable but not on the pathway. She and her staff had to spend several days documenting and justifying the reasons for the substitution, which led to a delay of a week in the patient's care, she said.

"Consistent and Transparent"

The task force's recommendations call for easing administrative burdens on providers, development of future pathways through processes that are "consistent and transparent to all stakeholders," and the expansion or modification of pathways to cover the full spectrum of cancer care, from diagnosis, multidisciplinary treatments, imaging, laboratory testing, and palliative services to end- of-life care.

Additionally, the authors say, pathways should

  • Be flexible, ready to respond to evidence-based changes in medical knowledge and practice,

  • Reflect awareness of patient variability and autonomy, and

  • Be implemented with an eye toward efficiency for both practitioners and payers.

In their final two recommendations, the task force calls for establishing a certification program for oncology pathways, with payers agreeing to accept all pathway programs that are certified through such a program, and for publicly and privately funded research into the effects of oncology pathways on care and outcomes.

The authors also offer guiding principles for developing clinical pathways across oncology.

What's Next?

Dr Zon said that the recommendations are just the first step in a lengthy process that must ultimately involve a coalition of all stakeholders ― providers, payers, regulators, and patients ― who can work together to implement comprehensive and adaptable oncology pathways that can benefit patients with many different types of cancer.

"There is great potential for pathways to really make a difference and to help the entire cancer-care continuum and the healthcare system, and we support that. But we're already seeing great challenges, and we have concerns, and this is just the beginning of our story. We plan to continue to do additional work to start examining these recommendations, implementing them, and helping the process so that providers and patients can feel secure in their treatment," she said.

The task force and its recommendations are supported by ASCO. Dr Zon has disclosed no relevant financial relationships.

J Oncol Pract. Published online January 12, 2016. Full text

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