Study Finds Almost All Deviations From Clinical Pathways Were Justified

A study of how well a cancer center complied with clinical onocology pathways over a year found that just 1% of the deviations off the pathway were unjustified, and that most were due to a patient’s history of toxicity with a therapy, or a comorbidity or prior therapy that precluded use of the preferred pathway option.

The other chief reason for pathway noncompliance? Physicians are aware of a brand new drug or indication that has not made it on to the pathway, which means sometimes a diversion from a pathway represents cutting-edge care.

The study, led by Stephen B. Edge, MD, vice president for Healthcare Outcomes Policy and professor of oncology, Roswell Park Comprehensive Cancer Center in Buffalo, New York, was presented recently at the American Society of Clinical Oncology 2020 virtual meeting.

The study evaluated 2997 treatment decisions from October 1, 2018, through September 30, 2019, involving 2389 patients. The Roswell team found that compliance with the ClinicalPath decision support system was fairly high regardless of setting: 87% for adjuvant or neoadjuvant therapy, compared with 78% for therapy in the metastatic setting.

Under the system physicians were asked to document 1 of 6 reasons for pathway deviation: (1) documented toxicity, (2) prior treatment that precludes the pathway recommendation, (3) a new drug indication or molecular targeted therapy not on the pathway, (4) continuation of treatment started prior to referral, (5) other “clearly documented and reviewed provider or multidisciplinary team rationale,” and (6) patient’s preference.

According to the study, “most off pathway care was justified and appropriate.” The researchers warned that financial incentives that focus on a percentage of pathway compliance could “paradoxically harm the quality of care, especially given the high percentage of off pathway decisions for reasons of drug toxicity, comorbidity, and new drug indications.”

Reference

Edge SB, Liu L, Stefaniak N, et al. Going off pathway? Problem or good care? J Clin Oncol. 2020;38(suppl; asbtr 7014) doi:10.1200/JCO.2020.38.15_suppl.7014