Clinical Pathways: A Systems Approach Toward More Patient-Centric Cancer Care Delivery

Cancer care outcomes continue to improve significantly. Based on data from 2005 to 2011, the National Cancer Institute estimates that 66.5% of patients diagnosed with cancer will survival 5 or more years.¹ However, despite the fundamental advances in cancer care technology and care delivery that have made these improvements possible, our delivery system remains quite inefficient and frequently falls short of being truly patient-centered. The Institute of Medi­cine estimates that 30% of all healthcare dollars are spent on unnecessary tests, procedures, and doctor and hospital visits. The key drivers of higher-cost, less patient-centered care in­clude the use of technologies of dubious clinical value; unnec­essary variability in clinical decision making and therapeutic selection; care delivery in higher-cost settings; overuse of im­aging, molecular diagnostics, and laboratory studies; and the use of treatments with low cost-to-benefit ratios; ineffective care coordination; and ineffective end-of-life care strategies. These represent systemic failures that both drive up costs and the patient centeredness of care.

Although the quest to improve value delivery is widely touted as an essential goal of healthcare reform, there is little agreement on what this really means and how best to accom­plish it. A Google search of the term “cancer care value” yield­ed 5.9 million results. Payers, pharmacy benefit managers, managed care organizations, state and federal governments, healthcare systems, physicians, and (most importantly) pa­tients have distinct—and sometimes nonoverlapping—ideas of what a system for value-based, patient-centered cancer care should look like. Much of the recent flurry of activity in the cancer value domain has focused on the application of novel value tools and alternative payment systems. The Na­tional Comprehensive Cancer Network’s Evidence Blocks and the recent American Society of Clinical Oncology’s Value Framework are proposed as tools for navigating the effective­ness and value conundrum.^2,3 Similarly, calls by HHS Secretary Sylvia Burwell to shift our payment system from one that re­wards volume to one that rewards value delivery is meant to drive transformation of our care delivery system.⁴

Unfortunately, too little of the focus on enhancing value has been on how best to build robust systems for supporting and sustaining a high-functioning, highly effective, cost-efficient cancer care delivery. Systems delivery breakdowns include failing to consistently perform patient risk assessments and establish patient-centered goals of care, failures in intra-team communication and communication between team and pa­tient, technology/goals of care mismatches, scope of care/ goals of care mismatches, technology/risk mismatches, and failure to reevaluate patient/goals of care on an iterative basis. Absent a system-based solution for ensuring consistent appli­cation of a coherent vision of enhanced value delivery, these piecemeal efforts are unlikely to bring sustainable systemic change.

The ultimate goal of a patient-centered, value-based, cancer care system is to create a deeply integrated healthcare sys­tem that brings systemness to care delivery. This includes the regular application of a model of care that can make rigorous clinical risk/appropriate technology assessments, establish clear goals of care, and construct an evidence-based care plan tailored on individualized patient needs. Ideally this would also entail multidisciplinary team engagement centered upon patient care needs, seamless communication between team members, and an “eyes-on-the-prize” care perspective, with care focused on coherent, patient-centered goals rather than on the next intervention.

Clinical pathways are a set of systems-based tools for cre­ating greater cohesion in cancer care. They do so by creating greater transparency around care decision making, therapeu­tic selection, and care delivery, and also help to improve qual­ity and efficiency by reducing nonvalue-added intra-provider variability in care. Care pathways have the potential to help patients and physicians successfully navigate the tension between personalized medicine and population-based care models. Moreover, they provide systems-based tools that can move us from cost-insensitive to effective, value-based care at the lowest-priced care setting; articulate rationale care escala­tion schemes; systemize opportunities for increasing efficien­cy; consistently help to reduce duplicative testing and imag­ing; and helps to define and avoid the use of nonvalue-added care. Care pathways have the potential to evolve as medical technologies advance so that physicians can practice effective stewardship of healthcare resources, including molecular di­agnostic and imaging studies and high-cost pharmaceuticals.

In this issue of Evidence-Based Oncology, we explore the po­tential of clinical pathways as systems-based tools that bring us closer to a model of patient-centered, economically sus­tainable care. Bernardo Goulart, MD, MPH, reviews the evi­dence for improved patient outcomes and cost-effectiveness of care through the use of clinical pathways. Peter Ellis, MD, a medical oncologist at UPMC CancerCenter and medical director at Via Oncology, describes the development and ap­plication of cancer care pathways at his institution. Finally, our multi-stakeholder expert panel explores the importance of clinical pathways in cancer care delivery and discuss the challenges with their development and implementation.

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While we navigate the enormity of creating a more effec­tive and efficient cancer care system that can better and more sustainably address the needs of our patients, cancer care pathways are one of the tools that can help to empower this transformation. As healthcare primes to make the quantum leap from a system that has aligned economic incentives with a transactional model of cancer care to one that focuses on effective longitudinal, sustainable, patient-centered decision making, we can ensure that the system serves our patients and their families in increasingly transformative ways.

Joseph Alvarnas, MD, is associate clinical professor and director of medical quality and quality, risk, and regulatory management, City of Hope, Duarte, CA. He is also the editor in chief of Evidence-Based Oncology.

References

1. SEER Stat fact sheets: all cancer sites. National Cancer Institute website. http://seer. cancer.gov/statfacts/html/all.html. Accessed April 4, 2016.

2. Schnipper LE, Davidson NE, Wollins DS, et al; American Society of Clinical Oncology. American Society of Clinical Oncology statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol. 2015;33(23):2563-2577. doi:10.1200/ JCO.2015.61.6706.

3. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) with NCCN Evidence Blocks. National Comprehensive Cancer Network website. http://www.nccn.org/evidence­blocks/. Accessed April 4, 2016.

4. Joszt L. HHS sets goals to move Medicare payments from volume to value. The American Journal of Managed Care website. http://www.ajmc.com/newsroom/hhs-sets-goals-to-move-medicare-payments-from-volume-to-value. Published January 26, 2015. Accessed April 4, 2016.

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