Pathways Reduce Care Variation and Cost of Care, Improve Overall Outcomes

Wayne Kuznar

June 2015, Vol 6, No 5 - AVBCC 2015 5th Annual Conference


Washington, DC—The establishment of pathways in oncology can reduce care variation and enhance value in patient care, said Michael Kolodziej, MD, ­National Medical Director, Oncology Solutions, Aetna, at the Fifth Annual Conference of the Association for Value-Based Cancer Care.

Dr Kolodziej contrasted the viability of N of 1 drug evaluations with evidence-based cancer treatment pathways, also known as population management.

Value in oncology can be defined as achieving the best possible outcome at a fair price, he said (Figure 1). The price of new cancer drugs, however, does not reflect the amount of benefit they bring to society or to the patient. A recent examination by Mailankody and colleagues in JAMA Oncology (2015 Apr 2. Epub ahead of print) of the correlation between the cost of new cancer drugs at the time of their commercialization and clinically meaningful end points—such as response rate, progression-free survival, and overall survival—yielded a correlation coefficient of 0.1 (no correlation), “meaning that the price is determined by what the market will bear,” Dr Kolodziej said.

Figure 1

Pathways are a construct to identify the right treatment for a patient, a task made increasingly difficult in cancer with an expanding array of choices, such as in non–small-cell lung cancer (NSCLC). In the setting of NSCLC, pathways that adhere to evidence have been shown to lower cost without negatively impacting treatment efficacy.

“We started preaching the gospel of pathways,” said Dr Kolodziej. “Pathways are population management. They do not individualize therapy. They say that for the average patient, this is the best way to treat.”

Payers are catching on to the value of pathways, he said. National payers favor pathways, because they reduce care variability as well as costs, and they facilitate quality measurement and quality improvement. Physicians are starting to support pathways and are recognizing the value of an evidence-­based treatment plan.

A pilot study by Aetna to measure adherence to evidence-based medicine showed that before the institution of a clinical decision support system, for every 100 patients treated in 6 oncology practices over 6 months, only 62 patients received an evidence-based treatment plan. After the use of the clinical decision support system, adherence to evidence-based treatment increased to 87 of 100 patients over 6 months, which is a 43% relative improvement. “This occurred in every single disease, not just in rare cancers,” Dr Kolodziej noted.

Oncology practices do not have a process for weighing evidence, which is one of the elements required to develop a pathway (Figure 2). They also do not have any way to put evidence in front of the physician at the point of care. Second, practices do not have a method to document the decisions that physicians have made and to measure the consequences of those decisions.

Figure 2

Payers also like pathways because they allow a better understanding of a disease, by structuring the data.

“When you’re a payer and you’re looking at claims, you don’t have that clinical granularity that allows you to understand what’s going on,” Dr Kolodziej said. “Pathways are the first step to continuous quality improvement, being able to measure performance, look for opportunities for improvement, and improve processes of care.”