Abstract: The United States health care system continues moving away from an unsustainable fee-for-service payment model to more novel measures of care delivery. Clinical pathways have emerged as one of the leading value-based care models used by hospital systems. They serve as a tool for delivering evidence-based, best practice care. Pathways have the potential to not only reduce variation in costs and outcomes but also improve clinical effectiveness. Seattle Cancer Care Alliance has emerged as a leading purveyor of regional clinical pathway development since the establishment of its Clinical Pathways Office in 2013. Since then, clinical pathways have been developed for 27 distinct cancer types, and more than 80% of patients treated at Seattle Cancer Care Alliance are now on a clinical pathway. This paper examines the establishment of that office, as well as the goals of clinical pathway development from the standpoint of a regional hospital system.
The current health care landscape continues to move away from the unsustainable fee-for-service payment system to more novel measures of care delivery. Clinical pathways offer a potential to maximize opportunities for value-based care and outcomes. They serve as a tool for delivering evidence-based, best practice care. Pathways have the potential to not only reduce variation in costs and outcomes but also improve clinical effectiveness.1 They support the Institute of Healthcare Improvement’s Triple Aim2 for improving the population health, improving the patient experience, and reducing the per capita cost of health care.
Pathways establish clear, achievable, and expected outcomes from treatment, and enable the integration of continuous quality improvement and quality data at point of care.
Why Clinical Pathways?
Seattle Cancer Care Alliance (SCCA) has chosen to pursue the development of clinical pathways to improve the overall quality of care for its patients. The primary focus of pathway development is to reduce variability in cancer care delivery. Unnecessary variation can lead to high costs, without any guarantee that better care would be the end result.3
The standardization of care also allows SCCA, as an institution, to study patient outcomes, survival rates, and quality of life among the patients we treat. These goals include the development of a framework and platform for advanced clinical intelligence that will support concordance reporting, predictive, and prescriptive analysis; the identification of clusters, trends, and patterns within patient treatments and outcomes; providing recommendations for appropriate patient-education materials, survivorship, follow-up care, end-of-life care, and for additional services and resources available to patients and their families; and optimization of the patient experience, by engaging them as partners in their care. Clinical pathways also serve to establish local and regional standards of care, by synthesizing guidelines based on scientific evidence and local treatment practice preferences.
Clinical Pathways Office
The Clinical Pathways Office (CPO) at SCCA was formally established in 2013. The program is aligned with the goal of providing the highest patient value by demonstrating superior outcomes at a reasonable cost.
A SCCA clinical pathway represents research-driven, evidence-based best practices along the continuum of care. During the preventive and active treatment phases, this includes prevention, treatment, and supportive care. The postcare continuum focuses on long-term follow-up care, recovery, and survivorship or palliative care.
A pathway algorithm depicts treatment options based on the stage of disease. The algorithm incorporates initial workup, treatment options (surgical, medical, and radiation oncology), references, and histologies. Additionally, clinical pathways are increasingly integrating targeted and precision medicine. It is important that pathways remain current as medicine evolves, which means continuously incorporating cutting-edge techniques as they are introduced and validated. Clinical pathways will also include quality measures and patient-reported outcomes (PROs) in the near future. It has become increasingly clear that PROs have a place in the treatment conversation. We intend to incorporate PROs in the most appropriate way.
Identification of disease groups for new pathway development is based on guiding principles. This includes diseases that demonstrate most variable treatment, draw higher volumes of patients, and are the most costly to treat.
A number of factors are considered in the development of the pathway. These include selecting the best evidence-based treatment options for our patients; focusing on effectiveness; balancing toxicity; and weighing the potential impact of each treatment option. Pathways are developed through a multidisciplinary partnership with physicians, disease group program leaders, and allied health teams. They are constructed through a collaborative, transparent, and consensus-driven approach. Inherent in their development is a commitment to demonstrating that care provided by SCCA is guided by the right treatment for the right patient at the right time, and ensuring our organization is collectively operating at the highest standard of care.
The active pathway audience includes treating providers, allied health professionals, and clinical staff. The passive audience includes service line managers, management, medical leadership, and administrative leadership.
CPO Leadership
The CPO team is comprised of a director, responsible for advancing the visions and goals of the office; clinical pathways associates, who are in charge of pathway content development, implementation, and maintenance; data scientists, who lead the development of advanced clinical intelligence and concordance reporting; data abstractors, who perform manual data abstraction for the reporting platform; and a program coordinator, who provides project management and operational support.
Additionally, research and data experiments are conducted by PhD student interns, both in content development and reporting areas. Physician consultants deliver expert clinical guidance and coaching to the team on an ad-hoc basis. The office is organized under the Medical Director’s Office.
The team follows the agile method to monitor progress on daily tasks and other ad-hoc assignments. The entire team comes together every morning for a brief stand-up meeting, where every individual on the team provides a quick overview of their tasks for the day. After the overview is complete, any questions, feedback, or broader updates are discussed prior to dispersal. Additionally, these tasks map up to a departmental strategic roadmap, which contains broader goal categories for the next 2 to 3 years.
The team closely partners with SCCA’s Quality, Finance and Information Technology departments. The Clinical Pathway Associates collaborate with SCCA Network Affiliates and Community Sites during content development sessions. We are developing a program to assist our external partners in their pathway integration efforts through training and support.
Conclusion
Since SCCA established its CPO in 2013, approximately 80% of patients treated at SCCA now receive their treatment on a clinical pathway, across 27 distinct cancer types.4 Pathways continue to evolve, as new treatment options are approved and introduced within the cancer treatment landscape. The SCCA CPO will continue to report on new clinical pathway developments as they are made.
References
1. Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate [published online May 27, 2010]. BMC Med. doi:10.1186/1741-7015-8-31
2. The IHI Triple Aim. Institute for Healthcare Improvement website. https://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 29, 2017.
3. Wade JC. Unwanted variation in cancer care: it is time to innovate and change. J Clin Oncol. 2017;13(1):6-8.
4. Omer S. What are clinical pathways. Seattle Cancer Care Alliance website. https://www.sccablog.org/2017/08/what-are-clinical-pathways/. Published August 1, 2017. Accessed August 29, 2017.
