Clinical Pathways Cut Costs of Care in Non–Small-Cell Lung Cancer While Preserving Survival Rates

Wayne Kuznar

June 2017, Vol 8, No 3 - Value in Oncology


Implementing clinical pathways for the management of patients with metastatic non–small-cell lung cancer (NSCLC) led to a dramatic reduction in the total cost of care, while maintaining clinical outcomes, according to a study of 370 patients with NSCLC conducted at Dana-Farber Cancer Institute in Boston.

The study compared the cost of care and survival rates in the first 12 months of care for this patient population before and after implementing the clinical pathways at the center.

“What we saw was survival preserved. There was certainly no negative impact from the implementation of pathways onto outcomes,” said lead investigator David Jackman, MD, Medical Director, Clinical Pathways, Dana-Farber Cancer Institute, and colleagues in a podcast that accompanied the publication of the results (Jackman DM, et al. J Oncol Pract. 2017;13:e346-e352).

“If anything, there looked like there was a slight trend toward improvement postpathways. And when we looked at cost, we found that we were saving money on the order of about $15,000 per patient over that first 12 months of care for these stage IV NSCLC patients,” Dr Jackman said.

The analysis showed no significant difference in the median overall survival before and after the implementation of clinical pathways—10.7 months before compared with 11.2 months after implementation (P = .08), reported Dr Jackman.

“While guidelines such as those developed by the National Comprehensive Cancer Network have been around for many years, some institutions are developing and operationalizing clinical pathways in a much more rigorous fashion to try to help control costs and ensure high-quality care,” said Nathan Pennell, MD, PhD, Medical Oncologist, Cleveland Clinic, during the podcast.

“But do these pathways really lower costs, and if they do lower costs, is that coming at a price of worse clinical outcomes for the patients?” Dr Pennell asked.

Chemotherapy Driving the Cost Difference

To study this question, Dana-Farber Cancer Institute created customized clinical pathways for NSCLC in late 2013 and introduced them in January 2014. Patients who were diagnosed with stage IV NSCLC and who received treatment within the network formed the study population.

The prepathway group included 160 patients who were diagnosed with stage IV NSCLC in 2012 (at least 12 months before the implementation of the pathways) and 210 patients who were diagnosed in 2014, after the rollout of the NSCLC clinical pathways.

The unadjusted, total 12-month cost of care for stage IV NSCLC was a reduction of $15,993 after implementing the clinical pathways. After adjusting for age, sex, race, distance to Dana-Farber Cancer Institute, clinical trial enrollment, and EGFR and ALK mutation status, the total 12-month cost of care was $15,013 lower per patient after the implementation of pathways compared with the period before the pathways ($52,037 vs $67,050, respectively).

These cost-savings were associated with no significant differences in median overall survival before (10.7 months) and after (11.2 months) implementing the clinical pathways (P = .08).

“This analysis is entirely based on outpatient costs,” said Dr Jackman. “That having been said, when we looked at what was driving the cost-savings, chemotherapy was the biggest line item for savings. A reduction in the cost of chemotherapy was the single largest contributor to savings,” he added.

The mean chemotherapy payment before the pathway implementation was $44,084 per patient, which was reduced to $31,846 after the pathway.

Stepping away from the use of pemetrexed in combination with bevacizu­mab (Avastin) and carboplatin in the first-line setting was responsible for much of the chemotherapy savings, said Dr Jackman.

Value of Clinical Pathways

“I don’t particularly like thinking about it from a cost control standpoint; I think the better term is resource management,” said Dr Jackman.

“In some cases, that means we’re trying to trim the fat and not use treatments that don’t necessarily add additional value, but in some situations, it’s making sure that our resources are being positively applied,” he explained.

In addition to demonstrating significant cost-savings in the care of patients with metastatic NSCLC, the use of clinical pathways has far-reaching implications with regard to the value that it can bring to patients, providers, payers, and other stakeholders. First, the study established that utilizing clinical pathways is feasible within an academic network.

In addition, with the increasing emphasis on lowering cancer care costs through value-based payment models, clinical pathways represent the quintessential combination of comparative outcomes, value, and standardization, the authors observed.