December 2023 Pathways Impact Study Part 1: Awareness and Influencers of Use

J Clin Pathways. 2024;10(1)10-12.

Oncology clinical pathways and clinical decision-support (CDS) tools have been part of the oncology landscape in one form or another for many years. Both have evolved signifi­cantly in recent years, along with advances in cancer diagnosis and treatment, placing even greater demands on community oncologists, who may now see 30-40 patients each day.

The trend of new cancer drug approvals, and new indications for existing drugs, continues to rise. Many of the newest treat­ments have narrow indications or may be relatively complex to administer, challenging physicians’ ability to “stay up to date” when their practices include diagnosing and treating a wide vari­ety of tumors. The volume of clinical data published is expand­ing even faster and increasingly includes not only clinical trial reports but also studies using real-world evidence to examine clinical and economic outcomes. Payers increasingly seek to in­fluence treatment selection through coverage policies, formular­ies, and patient cost-sharing strategies, leading to payment delays and oncologist time spent appealing denials and discussing cases with payers. Finally, the universal adoption of electronic medical records facilitates providing CDS tools, including pathways, to practicing oncologists.

Treatment pathways may assist providers in navigating this complex environment that includes a rapidly evolving cancer ar­mamentarium. While several retrospective studies have examined compliance rates with pathways, these did not address physicians’ awareness of a pathway and its associated recommendations. Lit­tle or no insight has been published that addresses the extent to which pathways directly impact oncologists’ treatment selection.

HMP Market Access Insights (MAI) sought to examine the actual impact on oncologists’ treatment decisions through primary research conducted in Q4 2023. Our study enrolled 130 oncologists into two arms: One arm included only on­cologists whose medical group or integrated delivery network had implemented a pathway program (developed internally or licensed from a third-party vendor); a second arm included on­cologists whose organizations did not offer their own pathways but were subject to payer pathways. All participants stated they were aware of pathways and had at least occasionally consulted the pathway program.

A quantitative survey was conducted, followed by formal interviews and informal discussions with practicing oncologists and pathway developers. These were supplemented with inter­views and surveys conducted for HMP MAI’s provider and payer research programs in 2023. Finally, respondents complet­ed a conjoint exercise designed to identify the most significant variables that impact physician drug choice from a preselected set of attributes.

This approach addressed challenges with earlier research showing that while oncologists make many “pathway-com­pliant” treatment selections, these decisions may reflect the pathway’s consistency with National Comprehensive Cancer Network (NCCN) guidelines and do not indicate either aware­ness of or interest in the pathway’s recommendation. We de­scribe these decisions as evidence of “unconscious compliance.” For this research study, we included only oncologists who were aware of pathways and explicitly referred to pathways.

Pathway awareness is highest among community oncologists practicing in the most sophisticated organizations that have internally implemented pathway programs. Physicians in these organizations typically have access to clinical guidance through their electronic health records (EHRs), which either identify pathway recommendations or provide relatively easy access to a separate portal containing a decision-support tool and pathway recommendations. Figure 1 shows a very high level of aware­ness for oncologists practicing in The US Oncology Network– affiliated and OneOncology-affiliated medical groups com­pared to other community groups. Awareness varies widely among other community groups. Some of these do have path­way programs implemented internally, and most are subject to payer pathways, but oncologists’ awareness of the programs is generally inconsistent, as is their adherence.

Provider organizations may establish a “best practice” cul­ture in which oncologists experience pathways as a cultural imperative and may have financial or other incentives/disincen­tives for adherence. Financial incentives can be viewed as sub­stantial by some oncologists, but all our interviewees practicing in these groups also viewed pathways as helpful to ensuring high clinical quality and believed they were acting in patients’ best interests when selecting an appropriate pathway recommenda­tion. This contrasts with oncologists’ view of payer pathways. Adhering to payer pathways was frequently acceptable to on­cologists where the recommendation matched NCCN, but it was viewed as mostly driven by a desire to smooth the treat­ment authorization process, not an action meant to improve clinical quality.

Beyond culture, multiple pathway program attributes can en­courage or discourage the use of pathways. While awareness of a relevant pathway is key to conscious adherence, many on­cologists report a strong desire to understand the process for developing and maintaining pathways and to have input when appropriate.

Physicians in organizations with high awareness and ad­herence also enjoy relatively easy access to clinical guidance through their EHRs, which either identify pathway recom­mendations in the prescribing screens or provide access via a link to a separate portal containing a decision-support tool and pathway recommendations. Figure 2A shows that process transparency and streamlined access are important to encour­age physician buy-in. Absolute ratings on these encouraging attributes differ only moderately between the arms of the sur­vey, suggesting that these preferences are widespread among oncologists.

Attributes that discourage pathway use are also relatively consistent between the two arms and are more impactful than those that encourage use (Figure 2B). Disruptions to work­flows and low monitoring levels are among the attributes that discourage or do not encourage adoption. Interviewees be­lieved that extra steps in a treatment selection process that slow down or interrupt the oncologist’s workflow create high levels of dissatisfaction. Kaiser Permanente’s pathway implementa­tion set explicit goals for implementation to minimize work­flow disruptions. Oncologists in settings using external portals (eg, Elsevier’s ClinicalPath) may seek to memorize recommen­dations for their most commonly treated tumors, and “batch” their visits to the portal to enter data into the algorithm.

Oncologists continue to have strong personal preferences for selected brands, based on their interpretation of clinical data and personal experience in managing patients. Substan­tial variation exists in the physicians’ actions when a personal preference is excluded from a pathway, but with low levels of reward or punishment for nonadherence, payer pathways are less likely to effect a change than an internally implemented pathway program that includes rewards and penalties.

NCCN continues to be a critical source of guidance for all oncologists. Physicians in the provider pathway arm gener­ally refer to their pathways more frequently than they refer to NCCN. NCCN’s guidelines remain an important source of in­formation, however, when these oncologists require additional information. Information commonly sought includes guidance on a new treatment not yet in the pathways, guidance on a diagnostic workup, or (infrequently) to “double-check” a spe­cific pathway recommendation. Pathway programs do not rec­ommend treatments for all tumors or patients with unusual co­morbidities or late lines of therapy; in cases where no relevant pathway exists for a patient, oncologists typically refer to NCCN for information on current options (Figure 3).

Physicians in the payer pathway arm are more likely to seek information from NCCN than they are from the payer pathways. NCCN is seen as both the single most authoritative source of information for these oncologists and as leverage to use should a payer decline to authorize a treatment selec­tion. In practice, payer pathways are partially congruent with NCCN, and since most payers cover any treatment with an NCCN rating of 2A or better, oncologists find that adhering to NCCN guidance is a convenient approach to simplifying authorization and coverage without having to track down and consult a payer’s pathway.

Frequency of referral to NCCN and to pathway programs varies across tumor types, as oncologists in both arms appear more apt to look for information when dealing with either less familiar tumors or when a high-profile new treatment has been recently introduced.

Future columns will share additional insights looking at the quantitative impacts of payer and provider pathways in four tu­mors, including differences across tumors and among brands.

Author: Lee Blansett, MBA

Affiliation: Executive Vice President, HMP Market Access Insights, San Mateo, CA.

Disclosures: The author reported no relevant financial or other conflicts of interest.