December 2023 Pathways Impact Study Part 3: Importance of “on-Pathway” Status for Treatment Selection

J Clin Pathways. 2024;10(3):20-22.

HMP Market Access Insights (MAI) will conduct additional research in 2024, providing further insights regarding the actual impact of pathway programs on treatment selection.

This column examines further details of this study, including the importance of “on-pathway” status for physicians in select­ing treatments. It also investigates the actual impact at the brand level for pathways implemented by provider organizations.

Payer pathways were consistently less impactful than provider pathways on treatment selection across four tumor categories (Figure 1), with the relative importance assigned to “on-pathway” status ranging from small in the case of chronic lymphocytic leukemia (CLL) to large in the cases of myeloma and metastatic breast cancer (mBC). In all cases in our study, we found that an oncologist’s strong personal preference for a specific brand outweighed pathway status. In the case of pro­vider pathways, the difference between the relative importance assigned to a brand and a pathway status was generally small, whereas in payer pathways, the brand preference dominated pathway status.

Brand impacts could be significant and varied across tumor types included in this research. Our study examined physicians’ preferred choices among four treatments presented in the National Comprehensive Cancer Network’s (NCCN’s) recom­mended list in each of the tumor categories listed in Figure 1, their willingness to switch when their preferred choice was not in a pathway, and the net impact of a brand’s pathway status when oncologists select a treatment.

We asked oncologists in both arms for their most preferred treatment options for each tumor type before beginning the conjoint exercise, in which they traded their brand preference against pathway status, the extent of compliance monitoring, and financial incentives. Then, we compared each respondent’s initial choice with their final selection in the conjoint study. Finally, we computed the likeliness to switch and the impact of multiple pathway scenarios on a brand’s selection.

Compliance was highest for both payer and provider path­ways when the on-pathway recommendation(s) coincided with oncologists’ preferences; physicians with a strong preference for a regimen viewed as most appropriate for a patient were less likely to select an on-pathway option when the options did not include their initial preference. In cases where oncologists viewed several options as roughly equivalent, we saw a higher compliance with the on-pathway recommendation.

Figure 2 shows oncologists’ likeliness to switch to a selection other than their initial preference across four tumor types for provider-implemented and payer-implemented pathways. The likelihood of switching was highest in renal cell carcinoma (RCC) and hormone receptor–positive (HR+) mBC tu­mors, where interviewees generally saw at least three of the four treatment options as being roughly clinically equivalent, and less likely in myeloma and CLL, where respondents in follow-up interviews expressed strong preferences for a par­ticular treatment (venetoclax + obinutuzumab or acalabrutinib for CLL and daratumumab for myeloma). Those with strong preferences were less likely to switch to another option regard­less of its pathway or NCCN status.

In an example extracted from our data, participating inter­viewees saw all three cyclin-dependent kinase (CDK) 4/6 op­tions as clinically effective choices for HR+ mBC, with key differences in the potential for adverse events and patient man­agement requirements. Nearly all our interviewees were gener­ally open to accepting a provider pathway’s recommendation for any CDK4/6 agents in place of their initial preference.

Figure 3 illustrates the impact of pathway inclusion on brand selections in HR+ mBC. In this exercise, the oncologists se­lected an option for each tumor in 12 scenarios consisting of various combinations of the study’s attributes: brand, pathway status, financial incentives for compliance, and compliance monitoring. The figure illustrates the preference share for each treatment option (1-3 are CDK4/6 agents and 4 is anas­trozole). Each of these four agents was an option that included fulvestrant.

Our first pathway scenario showed brand preferences when no pathway recommendation existed; in this case, Treatment 1 led the other CDK4/6 agents, but the alternatives retained sig­nificant preference shares.

The second scenario (labeled “1 of 1”) showed the impact of an exclusive pathway that only included Treatment 1. Oncologists readily switched to Treatment 1, taking some pref­erence away from the other CDK4/6 agents and anastrozole. Treatment 1 reached an 83% preference share, approximating the maximum compliance that most pathway programs define as successful.

The third scenario included Treatments 1 and 2 as on the pathway and excluded the remaining two options. Treatment 2 mostly took preference away from Treatment 1 and exceeded its initial preference share, while Treatments 3 and 4 remained depressed. Overall preference share for the two treatments infers a compliance rate of 89%, well above most pathway programs’ compliance goals. As most pathways offer at least two options, we consider this scenario to roughly illustrate the impact many provider pathways will have on brands’ market shares.

The final scenario included all three CDK4/6 agents as on-pathway options, and the three agents returned nearly to their initial preference shares, taking nearly two-thirds of anastrozole’s initial share.

HMP MAI found that oncology pathways, particularly those implemented by providers, can influence oncologists’ treat­ment decisions for patients with cancer. The impact of path­ways varied depending on the source (provider vs payer), tumor type, and oncologist’s initial preference. The study suggests that provider-implemented pathways may be more effective in influencing treatment decisions while acknowledging the need for further research on the real-world impact of pathways on treatment selection.