Pathways Are Now a Popular Tool for Organizations Delivering Cancer Care

J Clin Pathways. 2024;10(4):18-20.

Clinical pathways are evidence-based guidelines that aim to im­prove the quality and efficiency of health care delivery. They can help to standardize treatment protocols, reduce variation in care, and improve patient outcomes. HMP Market Access Insights (MAI) examined the prevalence of clinical pathways in oncology care and commonalities in implementation.

Clinical pathways are evidence-based guidelines that aim to im­prove the quality and efficiency of health care delivery. They can help to standardize treatment protocols, reduce variation in care, and improve patient outcomes. HMP Market Access Insights (MAI) examined the prevalence of clinical pathways in oncology care and commonalities in implementation.

HMP MAI will conduct additional research in 2024 focused exclusively on providing further insights regarding the actual impact of pathway programs on treatment selections, but this column examines additional details of our provider studies, including the prevalence of pathway programs in integrated delivery networks (IDNs) and community oncology groups.

A substantial share of provider organizations have adopted some form of clinical pathway programs to encourage provid­ers to adhere to organization-wide best prescribing standards, although the prevalence varies between IDNs and community practices (Figure 1).

Many IDN-based and community-based organizations contin­ue to rely on National Comprehensive Care Network (NCCN) guidelines and/or US Food and Drug Administration (FDA) approvals as guidance, or they allow physicians to prescribe any product on their formularies freely. While the overall share of organizations with pathways appears to reflect widespread influence, two issues constrain their current impact:

1. Implementation is most frequently limited to sophisticated organizations with strong central committee structures seeking to develop and implement network-wide tools; and
2. Even where a provider organization has implemented a pathway program, the organization’s leadership may not be actively monitoring oncologists’ adherence.

Pathways are most prevalent among the largest and most centralized organizations, including highly integrated IDNs and community oncology groups that are members of the US Oncology and OneOncology networks (Figure 2a).

Pathways are relatively common in IDNs’ cancer programs in highly integrated, large organizations with an academic medical center (AMC) or teaching hospital in their networks. Implementation within these networks appears increasingly consistent, with 77% of respondents with a pathway pro­gram reporting that their institutions rolled out the program across their entire network. Discussions with oncologists and pharmacists over many years suggest that while a path­way may be in place in an AMC, compliance is expected and monitored primarily among non–key opinion leader (KOL) oncologists practicing in on- and off-campus settings, while KOLs focus on trial enrollment and see more complicated and rare cases for whom a pathway is unlikely to exist.

While the percentage of IDNs implementing a pathways program across their networks has increased, almost a quarter (23%) report a limited rollout, meaning the full impact of path­ways remains to be seen. The sprawling geographic footprint of some large, multiregional IDNs creates additional complexities, as some regions may lack the basic infrastructure or physician cultures required to implement a pathways program successfully.

Prevalence among community groups is also concentrated in the two largest networks in which all responding practices reported both use and, generally, high adherence with a for­mal pathway program (Figure 2b). Independent groups are more likely to focus on NCCN guidelines or allow complete prescribing autonomy constrained only by payers’ reimburse­ment policies or the group’s formulary.

While adherence is reportedly high, monitoring is incon­sistent. Most pathway programs seek to achieve adherence rates between 70% and 90%. Our research finds that a sizeable minority of provider organizations do not monitor oncolo­gists’ compliance with pathway programs that have been rolled out (Figure 3).

Monitoring is a key factor contributing to high levels of adherence. Our earlier pathway study found that adherence monitoring encourages oncologists to reference pathways dur­ing the treatment selection process, even without any system­atic rewards or punishments for adherence.

For several years, HMP MAI’s oncology provider studies have found a rising prevalence of pathways in both IDNs and community groups. Organizations with centralized structures and a strong commitment to quality through prescribing according to best practices were more likely to have implemented pathways, to have rolled them out across all sites, and to encourage adherence through comprehensive monitoring. Our 2024 pathway research program seeks to develop increasing insights into physicians’ motivations and approaches to using pathways.