Clinical pathways have become an integral part of oncology care. In use in oncology practices as early as the early 2000s, the prevalence of clinical pathways is expected to increase as the focus on value-based care increases. This is especially true as practices come under more pressure to take on more financial risk in terms of quality and cost parameters.
In order to understand how pathways have evolved as well as the landscape of where pathways are today, Journal of Clinical Pathways set out to conduct a survey of real-world clinical pathways stakeholders. By understanding where we are today, we can then set the vision as to where we need to go to tomorrow.
Survey Methodology
A questionnaire was developed with input from the Editorial Advisory Board of Journal of Clinical Pathways. It consisted of 10 questions focused on respondent demographics and 12 questions focused on respondent’s use of clinical pathways within their organizations.
Invitations to participate in the survey were sent via email to practicing oncology care providers. This included subscribers to the Journal of Clinical Pathways and Journal of Clinical Pathways e-newsletter recipients. The survey was also promoted by the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the Community Oncology Alliance to their memberships.
Survey Respondent Demographics
A total of 87 respondents completed the survey. The respondents were primarily direct care providers, mostly oncologists/hematologists as well as other clinicians (Figure 1). Respondents also included oncology/hematology nurse practitioners, nurses, pharmacists, and practice directors or managers.
The respondents’ organizations represented a variety of oncology care settings (Figure 2). A total of 35% of respondents work in community practice settings, 16% in multispecialty group practices, and 46% in institutional-based practices. The institutional-based practice breaks down to hospital systems, academic centers, as well as hospital affiliates.
Consistent with the distribution across care settings, 33% of respondents work in practices with 5 or fewer oncologists; the majority of respondents’ practices had 40 or fewer oncologists (Figure 3). Thus, the sample was representative of small- to medium-sized practices.
Respondents were asked to identify oncology-specific payment models being used at their institutions. The payment mix at these practices in terms of the reimbursement was typical to what would be seen in a normal practice: the primary payer models identified were fee-for-service as well as Medicare, both through the Merit-based Incentive Payment System (MIPS) as well as the Oncology Care Model (OCM) (Figure 4). Although less common, respondents did report some pay-for-performance and delegation of risk occurring in their practices, which may indicate growth of these models.
When asked specifically about their institutions’ current use of clinical pathways, 68% of respondents said that they are either using pathways currently or will be implementing pathways within the next year (Figure 5). Eight percent of the respondents said they had plans to implement a pathway at a future date beyond 1 year or unknown. Interestingly, 12% of respondents said that their institutions have no plans to implement pathways. It would be interesting to explore further whether this lack of interest is more common in small or rural practices where clinical pathways might not be as necessary, or whether practices that are financially struggling cannot afford to implement the systems and infrastructure required to support clinical pathways.
It is also interesting to note the self-selecting nature of the survey and that care providers who are not currently or even planning to implement clinical pathways were still interested in participating in the survey. Perhaps they responded because they are aware of the clinical pathways concept and are interested in it despite their institutions’ lack of interest.
Next, participants were asked about the reasons or goals for launching a pathways program. By far, the factor most commonly cited as being most important was to improve clinical outcomes (Figure 6). Similar factors, including improving toxicity management (46.9%), reducing inappropriate treatment use (49.4%), and reducing treatment variability (48.1%) were also cited as being very important to respondents. Given the number of new treatment options that are available in oncology, as well as the pace at which new information about these treatments is being published, it is not surprising that care providers are looking for tools to support their clinical decision making.
In contrast, cost savings was only cited as the most important factor by 22.2% of respondents. Though this response was less common, it is more in line with what is currently being measured in terms of the effectiveness of clinical pathways. This raises the question of whether care providers would prefer outcome measures for clinical pathways use that are more clinically based to evaluate the success of a clinical pathways program.
Current Trends in Clinical Pathways
Survey respondents who identified that they are currently using clinical pathways were asked to complete the second series of questions related to clinical pathways use at their institutions.
When asked what clinical pathways are currently being used for, most respondents identified medical oncology as the primary focus of their institution’s pathways program (90.5%; Figure 7), while all other aspects of care were less common. Surprisingly, the number of respondents who said that supportive care was included within their clinical pathways was relatively low (35.7%), especially with the advent of nurse navigators and the focus on using pathways to triage care for patients with chemotherapy-induced nausea and vomiting as well as neutropenia. The inclusion of radiation oncology and palliative care also ranked relatively low within the survey. Because we did not identify respondents’ specialties, it is possible that separate clinical pathways are being used by radiation oncologists and palliative care specialists, respectively.
As we take a look at the source of the clinical pathways that are in practice, the most common response was the use of NCCN guidelines or compendia (Figure 8). However, this was only 38%, whereas the second most common response (about 36%) was pathways developed internally by a clinical pathway committee. Worth exploring further is the extent to which these internal committees are using NCCN guidelines or compendia in their committee deliberations vs conducting their own analysis of primary clinical evidence.
This idea was addressed in the next survey question, which asked respondents what kind of evidence is considered in the development of their clinical pathways. In this case, 90.5% of the respondents said they use national clinical practice guidelines and/or compendia. The majority of respondents also reported that they consider published scientific, level 1 evidence as well (~86%). This may be attributed to the fact that new information that is published may not be reflected in clinical practice guidelines for some time, and clinical pathway developers are aiming to incorporate this data into their pathways more quickly.
The next survey question was aimed at understanding how frequently clinical pathways are typically updated. Of the respondents, 83% said that their pathways are updated at least annually, with 52% of them updating quarterly, monthly, or as soon as new information comes out (Figure 10).
When we asked whether oncologists within the organization are able to provide input into the pathway content, an impressive 88% said “yes” (Figure 11). This result makes a bit more sense within the context of our question about the source of pathways, which revealed that only 16.7% were using pathways provided by a third-party vendor, and only 2.4% reported using pathways provided by one or more payers (Figure 8). Therefore, our sample may have been skewed toward users of internally developed pathways, which would explain the high level of oncology provider input. It is important to note that oncologists using pathways from payers or third-party sources may be more likely to report having no input into the pathways that are being used.
For those respondents whose organizations are tying incentives to the use of clinical pathways, 31% said that financial incentives are being used to encourage adherence with clinical pathways, while 26.2% said that financial penalties are being used for nonadherence with the pathways (Figure 12). Other types of incentives reported (21.4% of respondents) included internal reporting requirements and “peer pressure.”
Given that monitoring of adherence appears to be ubiquitous, they survey also asked about the process for a nonapproved, nonpreferred, nonpathway regimen to be used. Many respondents reported that the decision would go through some type of peer review process or appeals process within the practice (38%), though the largest group said that off-pathway decisions are allowed without peer review (41%; Figure 13). Again, it is important to note the sample surveyed are largely using provider-generated rather than payer-generated pathways, so the review and appeals process that typically occurs with payer pathways may be underaccounted. The monitoring of clinical pathways adherence therefore appears to be occurring largely within the practice for this group of respondents.
In terms of how the pathways are accessed within the practices, 81% of the practices said that pathways are accessed electronically (Figure 14). However, only 45% said that the clinical pathways were integrated with their electronic medical record (EMR). When pathways are provided in a stand-alone decision support type system and are not interfaced with the EMR or an authorization system, this creates an administrative burden for the provider. We will start to see this issue addressed as EMR companies begin to develop their own pathway processes or modules within their systems.
Next, respondents were asked what real-world data is being collected within the clinical pathways program. In addition to treatment choice (61.9%) and patient characteristics (52.4%), the respondents reported a wide range of clinical outcomes being collected, including lines of therapy, clinical outcomes, and safety outcomes and adverse events (Figure 15). Approximately one-third of respondents said they are also tracking economic outcomes. Given the responses to our previous question about how providers interface with clinical pathways, one wonders whether there is an integration process that occurs when the pathways platform is separate from the EMR in order to bring this patient data together in one place.
We addressed this question of integration of the pathways by asking whether the prior authorization is done through the clinical pathways program or separately. While 57% said it was separate, more than one-quarter (26%) reported having prior authorization systems integrated with their clinical pathways (Figure 16).
In order to solicit open ended feedback from respondents, we asked participants to write in responses to the question of what kind of challenges and barriers they are experiencing with clinical pathways. One of the things that stood out in their responses was feeling a lack of provider buy-in (Figure 17). Many reported difficulties with accessing the pathways. Additionally, difficulty achieving consensus came up as a common theme, with respondents feeling that the pathways do not apply to all clinical scenarios. Some said that even scheduling pathway development committee meetings and trying to achieve consensus on even how to go about developing pathway processes and content could be challenging.
Another issue that was raised by multiple respondents was that of administrative burden. Lack of systems integration and reporting requirements were cited as major sources of this burden, as well as a lack of recognition among payers of the provider-developed pathways systems and a redundancy with prior authorization requirements.
Finally, many respondents questioned the financial return on investment of instituting pathways. One respondent questioned why a pathways program was necessary when payers were not requiring it.
Discussion
What do these survey results really tell us? For one, they provide a picture of where providers are currently with pathways.
ASCO developed a set of criteria in 2016 with the intent of defining high-quality clinical pathways (Figure 18). These were focused on three areas: development, implementation and use, and analytics. It is interesting to view our survey results in light of these criteria to determine where respondents are noting consistency with these criteria, and where they are not.
If we take a look at the development, the criteria say that a clinical pathways program and content should be expert-driven, transparent, evidence-based, and comprehensive, in addition to promoting participation in clinical trials. Based upon the responses to our survey, providers are reporting that their clinical pathways are based on evidence in the form of recognized clinical practice guidelines and level 1 evidence. Our respondents also reported having input on their pathways, suggesting that they are expert-driven. Most pathways were updated at least on an annual basis, with a good portion being updated on a quarterly basis or when new information comes out. However, in terms of comprehensiveness, the majority of the pathways in our survey focused on medical oncology, with much less representation of other areas of care. This suggests an area in need of improvement to make clinical pathways much more comprehensive in terms of what they cover.
Looking at the criteria for implementation and use, ASCO requires that the goals and the expected outcomes of the clinical pathways should be achievable; the pathways should be integrated with other systems that are used within the practice; and pathways use should involve an efficient process with the aim of alleviating administrative burden.
In our survey, about 30% of the pathway users were aware of a threshold of adherence with the pathway that they were responsible for meeting (data not shown). The majority of pathway users were not required to maintain a certain level of adherence, nor were they being incented through financial or other means to adhere to the pathways. In this way, one could say that the expectations around pathways use was achievable for these respondents.
Forty-five percent of the respondents said that their pathways program was integrated into their EMR, but the remainder accessed their pathways through a separate electronic platform or on paper. Providers also reported a lack of integration from the clinical pathway system into the prior authorization system. This suggests that the criteria for systems integration and alleviation of administrative burden are not being met.
Finally, looking at the criteria for pathways analytics, ASCO recommends efficiently measuring and reporting performance metrics; using outcomes-driven incentives, and promoting research to determine what the impact of clinical pathways are to the overall outcome of the patient.
In terms of measurement and reporting of performance metrics, our responds seem to indicate that this is occurring. Many said that they are required to report internally whether they are using their clinical pathways systems. Though respondents did report the use of incentives, we did not directly ask whether any incentives were tied to performance-based measured or clinical outcomes. This may be an area for further study.
Though we did not specifically ask what research is being done on the impact of the clinical pathways program on the overall outcomes of patients, we did find many respondents reporting that real-world data on these outcomes are being collected. One can presume that these may be the focus of ongoing research within the practices.
Conclusion
The results of this benchmarking survey provide a glimpse of the current state of clinical pathways. Obviously, the use of clinical pathways to support decision-making in oncology is still a work in process. There remains a need to obtain buy-in from the physician community in terms of the impact and the benefits that clinical pathways can have. For practices that do have clinical pathways in place, we need to continue to support them as their processes mature and evolve so that they can achieve high-value, high-quality programs.
Reference
1. Zon RT, Edge SB, Page RD, et al. American Society of Clinical Oncology Criteria for High-Quality Clinical Pathways. J Oncol Pract. 2017;13(3):207-210.
