Using Clinical Pathways to Reduce Delays in Time to Treatment

Dennis R. Holmes, MD, FACS, director, Sam and Grace Carvajal Comprehensive Breast Center, Glendale, California, and CEO and co-founder of XpediteMD, recently spoke at the 2023 Clinical Pathways Congress + Cancer Care Business Exchange on how clinical pathways can help with delays in time to treatment.

Dr Holmes began his presentation highlighting the importance of the “golden hour,” which is the period of time immediately after a patient experiences a serious injury or stroke and appropriate life-saving medical or surgical intervention is needed for survival. He suggested that this approach can and should be applied to cancer care. 

According to Dr Holmes, delays in time to treatment initiation (TTI) for cancer patients are increasing, and it is a pervasive, structural, and systemic problem—underserved communities are impacted disproportionately. A study by Khorano et al, cited by Holmes, found that some of the factors that led to increased TTI included the following: if the patient was Black and/or had comorbidities, if the patient had a lower level of education, and what type of insurance status the patient had (Medicare, Medicaid, or non-insurance status). 

A 2017 case study at his own health care facility in Los Angeles—reflecting the general population of Los Angeles County—revealed a “shocking” statistic: that patients experienced a 4-month delay in treatment, even when 90% of them had received the authorization for treatment. Although these numbers are generally better now in Los Angeles county-wide, there are still significant delays (more than 60 days for the time to treatment), according to Dr Holmes. 

The Impact of Delays in Treatment

For those who are affected by these delays, the impact is significant, particularly on a patient’s overall survival and on the potential benefits they receive from adjuvant therapy. Dr Holmes cited a study by Cone et al that found that increasing time to treatment was generally associated with higher all-cause mortality for 2 241 706 patients with breast, prostate, non-small cell lung, and colon cancer. The degree of impact varied by cancer type and stage, but patients with colon and lung cancer had the highest mortality associated with increased time to treatment.

These delays impact not only a patient’s physical health but also their psychological health. Holmes referred to a study by Chino et al that investigated the patient experience with prior authorization and found that the process delayed care in 51% of 178 patients. In addition, 74% of patients experienced anxiety, 72% had “bad/horrible” experiences, 18% trusted the health care team less, 83% trusted the health system less, and 89% trusted the health insurer less. Holmes noted that the participants in this survey were predominately Caucasian and had higher levels of education, emphasizing that the psychological impact tends to be even greater within more underrepresented populations.

Delays in TTI also impact the total cost of cancer care. In 2019 there was an increase in the average cost of medical care for patients with Medicare from 37% to 110% and an increase of $66 billion in annual cost of treatment delays. 

So what causes these delays? According to Dr Holmes, common systemic barriers such as limited provider education, prior authorization, logistics, and scheduling can all lead to delays in treatment. For instance, it can take weeks for a patient beginning their treatment to see their next specialist referral or their next step in treatment (eg, radiology). Weeks can then turn into months, and so on. Additionally, current oncology guidelines and clinical pathways lack specific guidelines on timeliness, in contrast to areas such as trauma, which have clear and specific guidelines in this area. 

How Pathways Can Help

Dr Holmes suggests that clinical pathways can help mitigate these challenges by establishing time benchmarks for each step of the treatment process to improve how the steps can be completed by the patient. Other suggestions consist of tracking key steps in the process and using time-based prompts for patients and providers.

An example of this approach is the XpediteMD digital oncology care management platform, which provides clinical decision support, tracks patient and order progress, identifies and removes process gaps, enables real-time point of care authorizations, and more. In a trial with Intermountain Healthcare, the use of XpediteMD reduced the time to treatment by 77%, showing that applying time prompts can help maintain and improve quality by being more efficient with time.

In response to these challenges, different organizations, such as the Commission on Cancer, the Centers for Medicare & Medicaid Services, and the American Society of Breast Surgeons, have added time to treatment as a quality metric for their guidelines. Dr Holmes furthers this idea by suggesting that oncology guidelines follow a similar approach to trauma guidelines, where 25 of 82 quality indicators are related to TTI. These efforts would increase the accountability of physicians to keep on track with patient’s time to treatment.

“It’s only in the past five years that time matters in terms of saving lives. There wasn’t value in bemoaning time to treatment, but things are different. Now, we can’t avoid the matter,” Dr Holmes said.

References

1)    Khorano AA, et al. PLoS One. 2019;14(3):e0213209.
2)    Cone EB, et al. JAMA Netw Open. 2020;3(12):e2030072.
3)    Chino F, et al. J Clin Oncol. 2023;41(16_suppl):6561.
4)    Mariotto AB, et al. Cancer Epidemiol Biomarkers Prev. 2020;29(7):1304-1312.

Source

Holmes DR. Time to Treat: Why it Matters and How Pathways Can Help. Presented at: the 2023 Clinical Pathways Congress + Cancer Care Business Exchange; October 7, 2023; Boston, MA.