The Value of Level I Pathways at US Oncology

June 2012, Vol 3, No 4

Houston, TX—The use of the Level I Pathways Program at McKesson Specialty Health/US Oncology Network over the past 5 years has reduced treatment variability and resulting costs, according to Roy A. Beveridge, MD, chief medical officer, McKesson Specialty Health/US Oncology Network.

“We fundamentally believe that the use of these pathways significantly reduces the variation in patient care, and we have been able to demonstrate this,” Dr Beveridge said at the Second Annual Conference of the Association for Value-Based Cancer Care.

Level I pathways at McKesson/US Oncology have been used by more than 900 medical oncologists in 39 states for more than 5 years. They are based on US Oncology’s physician-created, evidence-based clinical guidelines, and provide a platform for standardization, outcomes measurement, and ongoing peer review. Currently, 20 medical oncology pathways and 17 radiation oncology pathways are used, including pathways for relatively rare cancers, such as mantle cell.

Parlaying evidence-based medicine into a level I pathway design creates the opportunity to improve quality and value to key healthcare stakeholders, Dr Beveridge pointed out. These results reduce variation in patient care, promote evidence-based medicine, offer up-to-date clinical tools, and are fiscally responsible. Pathways also distinguish practices that use them by streamlining and improving efficiencies and validating quality through measurement outcomes and benchmarking.

Table 1
 A More Precise Approach to Therapy.
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In short, level I pathways constitute a more precise approach to the delivery of patient care compared with the use of guidelines alone, he said (Table 1).

The Particulars of Level I Pathways at McKesson/US Oncology

The Level I Pathways Program at McKesson/US Oncology takes a stepwise approach to treatment, giving recommendations for drugs and modalities according to disease stage and line of therapy. The elimination of “futile therapy” is one of the aims, Dr Beveridge explained. “Apart from a research trial or hospice care, you do not find third- or fourth-line therapies in non–small-cell lung cancer or pancreatic cancer. Although we do have sixth-line therapies for metastatic breast cancer, because this actually works in some patients.”

Some exceptions are allowed, based on the belief that a physician who always adheres to the written pathway without deviation may be practicing “cookbook medicine,” Dr Beveridge noted, “and we think exceptions are appropriate to a certain level.”

McKesson/US Oncology also chose to include cost data in formulating the pathways. Where multiple regimens have equal efficacy, the choice should be based on the one with the lowest toxicity; given a similar toxicity profile, the lowest-cost regimen would be preferred.

Pathways Development

“The critical elements on the form are actually quite few,” Dr Beveridge noted. “We built in the logic and the ability for an electronic health record or a web portal to assist physicians in terms of how to treat patients with particular lines of therapy,” with regimens being organized by line of treatment.

The program incorporates the iKnowMed decision-support tool and Pathways Portal, a web-based clinical decision tool that recommends pathway treatment options based on patient-specific criteria (with literature references given).

Data are fed back to the physician practices so that physicians can learn their rates of compliance with appropriate treatments for each cancer type and setting, which thereby increases adherence. “Physicians are pretty competitive, so if you rank where they are in the universe of their peers, and they are in the bottom third, they will want to rise to the upper third,” he commented.

Proven Value of Pathways

Recent peer-review data indicate that treatment on pathway is cost-effective and provides similar results to treatment off pathway, he said. On-pathway treatment versus off-pathway treatment results in lower costs for chemotherapy, lower overall healthcare costs, fewer hospitalizations, and equivalent or slightly improved survival.

Dr Beveridge said he is able to satisfy payers’ concerns about survival. “Payers tell us, ‘Show us the overall survival curves. Show us that there is equivalence.’ And we have been able to do this now for multiple diseases,” he said.

Table 2
On-Pathway Cost Reductions.
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For example, the adjuvant treatment for colon cancer costs $103,000 on pathway but $156,000 off pathway, and survival at 5 years is improved on- pathway (Hoverman JR, et al. J Oncol Pract. 2011;7[3 suppl]:52s-59s). For patients with non–small-cell lung cancer, a similar pattern has been found, with on-pathway treatment being $18,000 compared with $28,000 for off-pathway treatment, with a total savings of $9695 per patient on pathway, a 35% reduction in overall medical cost, and a 37% reduction in chemotherapy cost (Table 2).

Linking electronic health record data on 1400 patients with lung cancer with data from a major payer, McKesson/US Oncology has drilled down to find the source of spending. “We found, on pathway, not only reductions in drug costs but reductions in emergency department visits and hospitalizations, because when pathways are followed, physicians are less likely to use futile therapies. They are not using fourth, fifth, and sixth lines, which is where you see an increased use of supportive medications and an increase in emergency department visits,” Dr Beveridge pointed out. “The cost-savings do not necessarily come with up-front therapy, but later on with the global overall care of the patient.”

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