The Lynx Group

Evidence-Based Practice Should Drive Patient Care

July 2011, Vol 2, No 4

Q: Are you concerned about the growing trend of payers demanding increased concordance with the National Comprehensive Cancer Network (NCCN) guidelines?
Dr Benson:
There is certainly a trend that emphasizes expectations that clinicians will practice evidence-based medicine. Providers should try to hone in on more appropriate use of drugs for an indication and not use agents when there is evidence that a regimen is no longer effective.

Because imaging can be a very critical expense, and with the growing use of diagnostics, payers will likely be very interested in how people are using imaging and diagnostic tests in the context of cancer treatment guidelines. It makes sense that we talk about utilization of healthcare dollars most effectively and try to avoid use when there is no projected added benefit.

It is equally important that we recognize that guidelines are not prescriptive but offer a medical decision tool for specific medical situations. The appropriate use of guidelines also is very critical in the discussions about measuring concordance to a specific guideline. For example, there may be an indication that for most people would be considered effective therapy, but for a patient with comorbid conditions may not be appropriate. We know therefore that 100% concordance to guidelines cannot be viewed as appropriate care given the variable of clinical situations. We always have to take the individual patient’s circumstances into account.

If a patient adheres more to guidelines where appropriate, that should result in better healthcare delivery and more efficient care, and also in appropriate care in terms of resource utilization.

Q: As an oncologist, do you have any concern about where patients are getting their information on the internet about care?
Dr Benson: Absolutely, and it is one of the reasons the NCCN is working on offering patient guidelines as a resource. For example, guidelines created for the layperson but mirror the clinical guidelines will enable patients to discuss treatment pathways with their clinicians. Patients will have a document to review with the clinician to see where they fall in a given guideline and what the rationale is for a decision in a particular situation. It is vital that people have reliable information, and it is often difficult for individuals to know what sites are indeed reliable. There are good re - sources, such as the American Society of Clinical Oncology, the National Cancer Institute, the Oncology Nursing Soci ety, the Association of Community Cancer Centers, and the NCCN. But in terms of actual treatment algorithms, the NCCN guidelines are actually able to direct an individual to the appropriate section that applies to that person as a component of the continuum of care.

If patients are newly diagnosed, in the middle of treatment, under surveillance, or need to make a treatment decision, they can at least see what experts and any available evidence suggest they do. We hope that the public begins to embrace utilization of evidence to help guide decisions.

Q: What if a patient insists on a certain treatment because a study showed positive benefits for a drug that is not in the guidelines?
Dr Benson: That would be a point of discussion. The clinician would need to see that study and discuss how it is relative to that individual. The clinician would also need to see if the drug is available and if it applies to that individual patient. With experimental therapy, the drug may simply not be available, or there may be another clinical trial for which the person would qualify, which would be great. However, if the data are not robust enough to integrate into routine practice, then the reality is that the patient may be denied reimbursement, which is another component in the equation. An increasing number of insurance carriers are going to link reimbursement with evidence, and if a treatment indication does not have a place in current guidelines, the carrier will deny that coverage.

Q: When developing guidelines, are there any cost considerations taken into account?
Dr Benson: Generally not, because the purpose of the guidelines is to look at what should be best practice based on the evidence. The introduction of an NCCN therapeutic index, which is currently under development, is an attempt to fine-tune therapeutic selection when there may be multiple options—for example, taking into account goals of therapy and toxicity, which is perhaps an even better way to guide selection of a treatment.

Q: Does it surprise you that a recent study showed a majority of women with epithelial ovarian cancer, advanced or not, were not being treated according to NCCN guidelines?
Dr Benson: As I have said, if more clinicians followed evidence-based practice, and more patients began to accept that evidence-based practice is the most appropriate way to care for people, in general, we not only would have the most optimal healthcare outcomes but also more effective use of our resources. This is something that people should explore to see why individuals are not treated according to guidelines and to come up with some solutions.

Q: Are drug shortages interfering with the ability of clinicians to follow the guidelines?
Dr Benson: In general, yes. The drug shortage issue is of enormous concern, because there is a potential that people will not be receiving the component of a regimen that leads to maximum benefit. These regimens are in the guidelines, so the ability to deliver appropriate medical care is affected. It is a particular concern when no adequate alternative therapy is available, or if a less effective therapy is the only remaining choice. This is a very serious problem that must be addressed by the US Food and Drug Administration, the pharmaceutical companies, and the oncology community at large.

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