Looking for Leadership in Developing Pathways

A clinical pathway can be defined as an “optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure.” As organizations new to pathways look to develop their processes, it is highly beneficial to examine the foundations used by leaders within each therapeutic area of interest. The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 27 top cancer centers, is devoted to patient care, research, and education, and is dedicated to improving the quality, effectiveness, and efficiency of cancer care. The key learning opportunity for clinical pathway developers is that payers and at-risk providers will look to leaders in specific therapeutic areas to provide very specific guidelines and pathways that provide superior clinical and financial outcomes. Importantly, the patient stakeholder will access these same guidelines and push for treatments that provide the best outcomes, as well. This will add a layer of complexity that can only be fulfilled through clinical pathways becoming integrated into electronic health records and based on evidence of outcomes for a full range of patient types.

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A clinical pathway can be defined as an “optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure.”1 As organizations new to pathways look to develop their processes, it is highly beneficial to examine the foundations used by leaders within each therapeutic area of interest. The NCCN, a not-for-profit alliance of 27 top cancer centers, is devoted to patient care, research, and education, and is dedicated to improving the quality, effectiveness, and efficiency of cancer care. Working exclusively in oncology for more than 25 years, this organization is recognized as a leader in addressing optimal care in oncology. One significant contribution the NCCN offers is the development of clinical practice guidelines in oncology. The guidelines are comprehensive, based on the best evidence available, and are continuously updated to incorporate new data and clinical information. As a result, the NCCN guidelines are considered the standard of care for the treatment of cancer, and serve as the foundation for many oncology clinical pathways.2 

Categories of Preference

In order to assist in the use of cancer treatments, the NCCN has developed Categories of Preference3 to provide consistency and use in shared decision making. The NCCN believes that because fewer interventions used regularly results in safer and more efficient care. Restrictive pathways are being adopted in response to payer demands, so guidance on treatment selections are useful. The goals of the Categories of Preference are to stratify guidelines to clarify preferences for interventions; provide guidance to guideline users on which recommendations are considered optimal; and to provide a wide range of ongoing recommendations to address varying clinical circumstances and patient preferences. Initially, Categories of Preference will be published for drugs and biologics recommended within the guidelines for multiple myeloma, with additional cancer types to come.

The categories include:

  • Preferred intervention: Interventions that are based on superior efficacy, safety, evidence, and, when deemed appropriate, affordability.
  • Other recommended intervention: Other interventions that may be somewhat less efficacious, more toxic, or based on less mature data, or significantly less affordable for similar outcomes.
  • Useful in certain circumstances: Other interventions that may be used for selected patient populations (defined with recommendation).

The reference to affordability in the first bullet point refers to the overall cost of an intervention, including drug cost, required supportive care, infusions, toxicity monitoring, management of toxicity, and the probability of care being delivered in the hospital. It has been reported that NCCN panel members will only consider affordability when two or more regimens are clinically equivalent and there is a significant difference among them in cost.

Wide Range of Recommendations

Interestingly, although the NCCN goals calls for “a wide range of recommendations,” the NCCN’s reasons for instituting their Categories of Preference includes both the fact that restrictive pathways are being adopted in response to payer demands, and the realization that fewer interventions used regularly result in more efficient and safer care.

NCCN takes the position that treatment options are needed, as some patients have clinical situations that make using preferred or other recommended treatments inappropriate. For these cases, NCCN is now providing potential alternatives that would not be used in patients with good performance status and no significant comorbid conditions. Examples of this include regimens known to have cardiac adverse events for patients with serious cardiac dysfunction, or regimens associated with liver toxicity for patients with preexisting liver disease. This can be particularly important in succeeding lines of therapy, where organ function may be compromised by either disease progression or toxicity caused by earlier therapies. 

This adds a layer of complexity that can create difficulties for providers, but is especially troublesome for payers, who must attempt to secure cost-effective treatments while remaining limited in their access to clinical information. Although providers and payers are stakeholders, the center of all treatments is the patient. For this key stakeholder, NCCN provides guidelines for patients that offer translations of the NCCN clinical guidelines. These help patients with cancer talk with their physicians about the best treatment options for their disease and create a shared decision-making environment.

Conclusion

The key learning opportunity for clinical pathway developers is that payers and at-risk providers will look to leaders in specific therapeutic areas to provide very specific guidelines and pathways that provide superior clinical and financial outcomes. Importantly, the patient stakeholder will access these same guidelines and push for treatments that provide the best outcomes, as well. This will add a layer of complexity that can only be fulfilled through clinical pathways becoming integrated into electronic health records and based on evidence of outcomes for a full range of patient types. 

References

1. Kongstvedt PR. Essentials of Managed Health Care. 4th ed. Sudbury, MA: Jones and Bartlett; 2003;195.

2. About the NCCN clinical practice guidelines in oncology (NCCN Guidelines). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/default.aspx. Accessed October 3, 2017. 

3. NCCN categories of preference. Frequently asked questions.  National Comprehensive Cancer Network website. https://www.nccn.org/images/guidelines/PDF/NCCN_Categories_of_Preference_FAQ.pdf. Accessed October 3, 2017.