Houston, TX—At the Second Annual Association for Value-Based Cancer Care Conference on March 29-31, 2012, a panel of payers and providers considered the role of pathways in oncology practice and the potential implications for end-of-life concerns. Craig K. Deligdish, MD, Chief Medical Officer, Oncology Resource Networks of America, led the discussion and added his own comments.
Participants included Winston Wong, PharmD, Associate Vice President of Pharmacy Management with CareFirst BlueCross BlueShield in Maryland; Roy A. Beveridge, MD, Chief Medical Officer, US Oncology and McKesson Specialty Health, Fairfax, VA; and Peter G. Ellis, MD, Associate Clinical Professor of Medicine, University of Pittsburgh School of Medicine and Director, Medical Oncology Network, UPMC Cancer Centers in Pennsylvania.
Dr Deligdish: What is happening with prior authorizations in relation to pathways? More specifically, if a practice agrees to a pathway approach, should you eliminate all prior authorizations?
Dr Wong: Traditionally, health plans have emphasized prior authorizations, especially in the oncology world. One of the benefits to the practices that participated in our program at CareFirst BlueCross BlueShield was that, for the most part, all prior authorizations were eliminated. We were depending on the pathways and the judgment of the physician to use the drugs appropriately. The only thing we really did as a plan was to document that the pathways delineated by our steering committee were working. We as a plan did not drive the pathway process.
Dr Deligdish: I understand the benefit of pathways to the payers and the benefit to the providers. Have you measured the benefit to the patient? Are pathways also improving patient satisfaction?
Dr Beveridge: At McKesson Specialty Health/US Oncology Network, we have used our data analysis to determine that overall survival is the same or better using evidence-based medicine. That is a crucial acid test of overall efficacy. We found that our use of research has increased because of the associated logic tool, and our patient surveys indicate that an increased use of meaningful research is important to patients. We put 50,000 patients on studies last year, so we think that is important.
In terms of “Have we measured quality of life improvements?” the answer is “no.” But we are implementing patient portals that connect to the electronic health record, the FACT-G (Functional Assessment of Cancer Therapy-General), for example, and they will get these out on a weekly/monthly basis. With these, I think we will be able to demonstrate over the next 2 years an improvement in quality of life from a patient standpoint. We do not have those data yet.
Dr Ellis: Indeed, the Institute of Medicine feels strongly that if you apply evidence-based care, the patient’s outcome will be better. Pathways guarantee that evidence-based care is being applied to the patient, and they guarantee personalized medicine where it is appropriate and measurable.
The ability of pathways to also streamline practice mechanics—such as getting patients through the office faster; having more time with nurses who provide patient education with more standardized educational protocols; and reducing hospitalizations, emergency department visits, and toxicity— leads to better quality-of-life and better clinical outcomes. Also, the more we standardize care and the more we follow protocols, the fewer medical errors we see. We think that is an improvement in patient care.
Dr Beveridge: We have also been able to demonstrate that nursing errors decrease when we are on standardized pathways, which is a good thing for patients.
Dr Wong: We have also not measured patient satisfaction specifically, but at least under our first-generation oncology management program, we would have no reason to suspect that patient satisfaction would diminish; we are still encouraging physicians to practice in a manner that is in the best interest of that patient. That is why we did not set the threshold for pathway compliance to be 100%. We know there are individual patient situations where one-offs are going to be required.
The second-generation program will be a lot more comprehensive, and there will be more monitoring of the patients. If anything, patient satisfaction should increase, because we are “touching” the patient. We are following back up with the patient within 24 to 48 hours of treatment. We are making sure that they are staying out of the hospital. Based on the key principles we followed in forming the pathways, we believe patient satisfaction should go up.
Dr Deligdish: We should perhaps think of pathways as not just a pathway to a treatment, but as a pathway to the entire continuum from diagnosis to the end of life. Pathways that include advanced illness programs for patients who cannot be cured have been tested over the past decade. In randomized trials, they have clearly demonstrated improvements in quality of life and improvements in patient satisfaction.
This is in part a result of some of the things we talked about, such as reductions in emergency department visits and in hospitalization, but also as measured in true quality-of-life parameters. We also know there is more satisfaction among the patients’ families, who are frequently burdened with the responsibility of caring for the family member with cancer. As we begin to incorporate in our second and third generations a more comprehensive approach to pathways that includes these programs, we will start to see benefits to patients and their families.
Dr Beveridge: To emphasize this point, we have data in the community showing that the use of advanced-care planning, as built into various pathways, significantly reduces the number of patients who get chemotherapy within 14 days and 30 days of the end of life, and reduces the futility of care, namely the fourth- and fifth-line therapies. I think this is becoming increasingly well documented across the country, and that is where we are heading.
Dr Deligdish: A 20% deviation from pathways seems to be typical of most programs. Are these variations mostly in the first-line or second-line setting, and what were the criteria for having these variations approved?
Dr Beveridge: Our data suggest that most exceptions occur not in the adjuvant or first-line setting, and not in the second-line setting, but more in the third- and fourth-line settings. I think that the exception process is different, depending on geographic region. In our exception process, we have other members within that large practice— usually someone from the Pharmacy and Therapeutics Committee—review the exception within 24 hours. This person reviews the literature, and if the recommendation is within the compendia, there is a reasonable chance that it will be approved. Probably one third of our exceptions are for patients who have had second opinions in academic centers, such as “A major institution in Houston has suggested X, Y, and Z.” It is hard at that point not to apply X, Y, and Z. So that would be an exception that would be granted.
Dr Ellis: In many pathway programs, including ours at the University of Pittsburgh, you have to put the reason you went off pathway. We currently have a review board for radiation oncology pathway requests, but we do not have this on the medical side. We just ask the doctor to tell us why, and then we collate those and bring those back to the committee every quarter.
Also, to Dr Beveridge’s point, we very rarely see off-pathway treatments in the adjuvant setting, but more in the metastatic setting and then rarely in the first- or second-line setting. We see it either because the patient is 52 years old and has young children, has good performance status, and is beyond second line, and we do not have the pathway for that. They go off pathway because there are extenuating circumstances. We also see the academic second opinion.
Dr Beveridge: I think collating these exceptions is very important because (1) it tells us whether the evidence-based process is not keeping track with where clinical acumen is going, and (2) it serves not only as a check to ensure that our pathways are reasonable to clinicians, but it also sets up a system by which we can see what is happening within a practice. If a physician has a much greater number of exceptions, this may indicate a need for an educational intervention.
Dr Deligdish: One of the biggest challenges in oncology is end-of-life care and limiting futile therapy. How do you engage physicians to talk to their patients about this? Are there any educational tools or scripts that can be used?
Dr Beveridge: Changing physician behavior is challenging. We have generally found that no one likes to have these end-of-life discussions. Physicians, nurse practitioners, and nurses do not like to do it. We need a powerful educational methodology, and then we need to build this into our information technology infrastructure so that providers cannot avoid it.
Ideally, we need to have systems by which the responsibility is not just with the physician but with a manager within a practice or group. It is a true team approach. It is not just one conversation but multiple conversations, and it requires an attitude readjustment. In practices that successfully implement this, this will eventually change the global attitude of the environment where oncologists practice.
Dr Deligdish: When do you first introduce the topic of end-of-life goals? Is it early on, or is it once you have exhausted all the options?
Dr Ellis: Our Medical Oncology Network is no longer at University of Pittsburgh, but we are 110 doctors. So we face many of the same challenges, although on a smaller scale. We have 25 sites of service in western Pennsylvania, and the same thing applies. We too have been on a big educational program. I want to put a plug in also for a system like pathways, because you can educate but it still is not a pleasant thing. Reminders and prodding are necessary to some degree.
When you order a chemotherapy regimen, if you look at the Quality Oncology Practice Initiative guidelines, was it explained and documented that the patient is getting that chemotherapy regimen for curative intent or for palliative intent?
That question begets the entire discussion of end of life. If you are getting chemotherapy for palliative intent, it begets the conversation of “Oh, you mean I am not going to be cured, doctor?” “No, that means that you are not going to be cured. You are going to live with your disease, and eventually you are going to die of your disease.”
At least at the University of Pittsburgh Medical Center, whenever a patient with metastatic disease is placed on a chemotherapy regimen, that question is asked. Therefore the conversation is hopefully prompted.
Dr Beveridge: We need to be careful as oncologists to say, “Hi, Mrs Smith. I am meeting you for the first time. I am going to talk to you about treatment. Now, let me talk to you about advanced-care planning.” One needs to be moderately sophisticated in determining on an individual basis when that conversation should occur. We believe that, in some of our pilots that we are doing and rollouts, that if one has stage IV pancreatic or non–small-cell lung cancer, you better have that conversation very early.
We need to be rather careful with breast cancer, because women with metastatic breast cancer are living years and years. Ditto with myeloma and a number of other cancers. So you have to choose when you are going to do that.
Dr Deligdish: Let me just add on to that, that there really is no answer to that question. Because there are so many different issues involved, and we are hearing the answers from 2 people who have practiced oncology for decades. If we look at the greater issues in the United States about end of life, and how it is addressed, we have companies and organizations that have specially trained individuals to have those conversations.
There is so much going on in an oncology practice at any given time that to sit down with somebody and to really have that conversation and devote the amount of time, that is really necessary. It has been stated that it is not one conversation, but it is a series of conversations. In general, with the exception of a patient with stage IV pancreatic cancer, a hepatoma, or a disease that is imminently terminal, it is not something that we can generally do in the span of 15 minutes, with just the patient or the patient’s family.
So it is difficult, and it takes a lot of time. Those who expect that such conversations are going to happen only in the oncology office, when so much else is happening at the same time, are deluding themselves. It is something that has to be handled in a much more sophisticated way, by social workers and/or by nurses. It is a team approach, and it takes a lot of time.
