Bruce Feinberg: Discussing the Clinical Pathways Development Process


Journal of Clinical Pathways spoke with Bruce Feinberg, DO, about the process of developing clinical pathways and his experience moderating the Breast Cancer Clinical Pathway Committee Development Meeting at the Clinical Pathways Congress (September 8-10, 2017; Washington, DC).

My name is Bruce Feinberg. I am chief medical officer and vice president for clinical affairs of Cardinal Health Specialty Solutions.

What do you believe were the biggest takeaways from the clinical pathway development session?

I think with all pathway programs that I’ve moderated, it’s this challenge of evidence versus experience. The role of behavioral economics and how we make decisions impacts us in almost everything in life and the experiences that we have become critical. We heard time and again observations from the physicians and we challenged them with the evidence and having to make decisions based on that.

How much do you think that bias came into play at the end of the session?

You have the greatest amount of evidence in the earlier forms of therapies – in adjuvant therapy and in first-line metastatic therapy. The evidence isn’t much stronger when you get into relapsed states. We’ve seen that in our data, where if you look at that compliance and that degree of variance, compliance is high in adjuvant therapy, fairly high in first-line metastatic, variance is fairly low, and variance continues to trail off as you go later in the course of disease. That’s natural in a way because where there is no evidence, it’s really hard to be able to ground people in one choice versus another.

Speaking about the audience Q&A at the break, what were you hearing as the largest concerns in a clinical pathway development session like this?

It’s always hard anytime you’re in a Q&A session because you may have people with different agendas who are in the audience participating. We heard the patient advocacy community more than anyone else speak up. It’s a natural concern when you see a pathway process. It looks overly clinical, there’s a focus on metastatic disease, and again the reason is because that’s where the variance occurs. It’s understandable that there may be this perception from the non-physician-specific medical oncology clinician community that it seems awfully narrow in perspective. From a standpoint of health care cost, health care variance, this is where the greatest opportunity exists. It’s sometimes uncomfortable I think to have to address that and deal with it, but it is natural.

How important are clinical pathways in health care moving forward?

There’s a great deal of misperception, misconception about clinical pathways – that somehow clinical pathways are in themselves a movement, rather than clinical pathways being the underpinning, the basic underlying architecture of health care reform. Whether you are moving into episode-based care, bundled care payments, patient-centered medical homes, the Oncology Care Model, or ACOs, whatever that vehicle is that is going to be the reforming of health care delivery, underlying all of it is the agreement of achieving of consensus around clinical evidence in order to narrow the variance and improve the predictability, the quality, and cost of care. That’s what clinical pathways are.