Executive Spotlight: Provide high-quality cancer care with clinical pathways

In a world where medical knowledge doubles every 73 days, how can oncologists keep up and still deliver personalized, high-quality care? 

This executive spotlight brings together leading voices in oncology to examine how clinical pathways—evidence-based treatment guides—are transforming cancer care. From enhancing patient outcomes and streamlining access to clinical trials, to strengthening payer relationships and maintaining physician autonomy, this comprehensive overview provides a forward-looking perspective on the future of oncology. 

 What you’ll gain from this report: 

• How can pathways help track quality of care? 

• How do you have conversations with patients about pathways? 

• Does clinical pathway integration take away provider autonomy? 

• How do oncologists participate in the development of pathways? 

• How do clinical pathways help providers track clinical trials? 

• How can pathways assist with payers and reimbursement? 

Whether you're a healthcare leader, clinician, or policymaker, this paper offers actionable insights and expert perspectives to help you optimize cancer care delivery in a fast-changing environment. 

Introduction

Clinical pathways enable providers to deliver evidence-based healthcare to patients. They provide treatment guidance based on the latest research and support standardization of care. Oncology practices implement pathways to ensure care is at the highest standard of quality, access, affordability and health outcome. Executives for Health Innovation (EHI) convened a group of oncologists and pathway experts at an executive roundtable, followed by a public webinar. The group discussed the appropriate use of clinical pathways in oncology, and answered relevant questions around the topic from other oncology leaders. This report highlights key takeaways from those discussions.

Background

With medical knowledge growing exponentially, it’s challenging for providers to keep up to date on oncology treatments. Using tools like clinical pathways can assist with navigating the vast amount of evolving information by providing clinicians with the latest evidence, treatments and clinical trial availability for patients. This helps providers find the drugs, treatments and clinical trials that work best for their patients.

Clinical pathways used in oncology often integrate research, guidelines and criteria developed by leading oncology organizations, such as the American Society of Clinical Oncology (ASCO). ASCO develops robust criteria for pathway programs.i This criterion is then used by vendors nationwide to develop clinical pathway products.

Many valuable discussion points were made during the EHI session. Highlights from the experts are included in this report.

It is estimated that the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years… [it’s now] projected to be 0.2 years — just 73 days. Students who graduated in 2020 will experience four doublings in knowledge. What was learned in the first 3 years of medical school will be just 6% of what is known at the end of the decade from 2010 to 2020.*2

Enhancing outcomes and patient experience

How can pathways help track quality of care?

Linda Bosserman, MD (LB), City of Hope: Having the system tied into your electronic [health] record really empowers these greater decisions and our ability to look at value-based care, contracting outcomes, hospitalizations and emergency room use. We’ve also done Goals of Care; we have the template for a ‘goals of care’ discussion.

Natalie Dickson, MD (ND), Tennessee Oncology: In addition to pathways driving appropriate decision making, almost equally important is the ability to use data from pathways to track treatment choices for our physicians to understand any inappropriate variance in treatments.

How do you have conversations with patients about pathways?

Stephen Edge, MD (SE), Roswell Park Comprehensive Cancer Care: We have established patient education tools based on the pathways and a graphic. [The graphic] is actually framed and hanging in the examination rooms in most of our medical oncology clinics that are using the pathways. We let patients know we’re doing this... We encourage [them] to ask questions about [their] treatment, clinical trials, and pathways… We try to make this apparent to patients rather than keep them behind closed doors.

ND: We provide [our] patients with the care plan so that they [can] see that there has been some organized thought through [their care].

Supporting providers

Does clinical pathway integration take away provider autonomy?

RZ: We don’t lose our autonomy in the sense that if we as a physician do not agree with the pathway option, we ‘go off’ pathway. We want and are obliged to do what’s best for the patient. The only time our autonomy, or the patient’s preference, is jeopardized is when insurance coverage or organizational mandates force our choices to comply and do not support our preferred recommendation.

SE: This doesn’t jeopardize autonomy, and it’s not ‘cookbook medicine’. Every time [leadership] talks to doctors we make it clear that going off pathway, [when appropriate], is also good care, and there is no such thing as a ‘ding’.

We have worked very hard with our payers to get them to understand that off pathway care is appropriate when it’s done in good care.

– Dr. Stephen Edge

How do oncologists participate in the development of pathways?

Ed Rodgers (ER), Elsevier: With Elsevier’s ClinicalPath, certified oncologists are the ones that participate in the committees with support by pharmacists… We typically get four or five dozen physicians that participate in those committees.

Robin Zon, MD (RZ) Michiana Hematology Oncology: If there are treatment choices, I always try to accommodate the patient preference. ‘Treatment algorithms’ is the term I use with patients, and explain we are using accepted guidelines by the National Comprehensive Cancer Network (NCCN).

When I’m going through treatment choices with the patient, very often I will show them the pathway, as well as the data points I’m entering, so they can better understand the pathway process. I really like to engage my patients so they know exactly what I’m doing and how the pathway works while explaining how the options reflect accepted expert driven guidance.

– Dr. Robin Zon

Keeping up with advancing medical knowledge

How do clinical pathways help providers track clinical trials?

SE: If there is a clinical trial available for that patient, it shows up [in ClinicalPath] as the first choice for recommended treatment. In fact, the doctor has to take an active action on that clinical trial before they can move on to the standard treatments. The doctor has to accept that they would like to have the patient screen for the trial or respond no… but they have to take an active step, and Elsevier works with us on that.

Only those clinical trials that are actually open today at our center show up in the pathways. If they were suspended yesterday, it won’t show up as being active today.

– Dr. Stephen Edge

Supporting reimbursement of care

How can pathways assist with payers and reimbursement?

ND: The elephant in the room for payers is the high cost of drugs. Pathways can serve as a tool to prove or reassure payers that treatment choices are appropriate. Alternatively, pathways can also minimize any inappropriate treatment.

We are currently working hard to convince payers to remove prior authorizations for treatments on pathway.

In addition, for value-based care models, we are trying to convince payers to use pathway utilization and compliance (which we can control) as a quality metric to ensure appropriate high quality drug choices, instead of using drug prices (which we can’t control) as a part of a total cost of care model to accomplish the same thing.

Finally, operationally it is important to convince payers to agree on a single pathway that our entire practice can adopt, instead of requiring different pathways for each payer. We have done well with this for the majority of payers, except for one who does not accept our pathway. But it’s interesting: for the one payer that does not accept our pathway, we find that when we are compliant with our own pathway we tend to be compliant with them.

SE: We’ve used them to demonstrate the quality care and have had some payments associated with them. They’re actually not wanting to do that much anymore. They sort of assume that we’re using the pathway, and that we provide good care, so they want us to move beyond. They want us to move beyond, as do we.

What advice do you have for oncology leaders implementing pathways when working with payers?

SE: I think you need to go down this path. No pun intended. Our patients deserve it.

RZ: Clinical pathways can be a very effective management tool for doctors and a way to manage the ever-increasing clinical knowledge… But it is the total cost of patient care we should be managing because the patient that sits in front of you is experiencing the entire cancer care journey from diagnosis through treatment.

So, I would advise the practice physicians and administrators to carefully vet the pathway programs and compare them to the ASCO Criteria for High-Quality Pathways as they make the investment decisions for which pathway product they select.

ND: I’ll reiterate that cost is something that we should work on… You [should] try to engage the payers to help support the implementation and the integration costs into the pathway system. Payers are focused on drug costs, so we all need to start ensuring appropriate drug utilization (which most of us do) and almost more importantly, proving to payers through pathways that this is indeed already the case.

ER: A payer engagement strategy is really what is necessary. Some of the people here have done that. Having some type of payer strategy to either subsidize the cost of implementing clinical pathways or some other form of being able to just ensure that patients are getting the right care for their disease.

We want pathways integrated into workflow and to be cost effective. It should not be something that just adds additional burden of costs to the healthcare system. It should be integrated into the evolving technology and decision support platforms, so that we have the results we’re looking for with the advancements in care.

– Ed Rodgers

Addressing challenges

What challenges do smaller hospitals and community practices face using clinical pathways?

RZ: Community practices are experiencing the same pressures that many institutions are facing. But because our practice is smaller compared to some of the institutions you heard from today, we have had to develop very creative business models to enable us to deliver high quality and cost-effective care while operating on a limited budget.

Improved decision making and outcomes

What is the value of clinical pathways?

SE: The value that we see is first and foremost to help provide good care for patients and to provide a decision support tool that assists with treatment decisions. Pathways allow us to know at a very high level what’s happening with cancer patients across our network.

ER: What we’re trying to do with pathways is get to a place where we can deliver cancer care efficiently, be outcomes driven, align with market incentives and promote research as well as continuous quality improvement.

About Executives for Health Innovation (EHI)

Executives for Health Innovation (EHI) is a catalyst for healthcare transformation, convening diverse leaders from across the industry to unlock opportunities for collaborative innovation. EHI, along with its coalition of members, focuses on education, thought leadership, and advocacy. Learn more: ehidc.org

About Elsevier

Elsevier is a leader in information and analytics for customers across the global research and health ecosystems. Elsevier helps researchers and healthcare professionals advance science and improve health outcomes for the benefit of society. We do this by facilitating insights and critical decision-making for customers across the global research and health ecosystems.

Elsevier’s many digital solutions such as ClinicalPath, ScienceDirect, and Scopus, support strategic research management, R&D performance, clinical decision support, and health education.

Sources

1. https://old-prod.asco.org/news-initiatives/ current-initiatives/cancer-care-initiatives/ clinical-pathways

2. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3116346/