An oncological clinical pathway (OCP) is defined by the American Society of Clinical Oncology (ASCO) as a “detailed protocol for delivering cancer care, including but not limited to anticancer drug regimens for specific patient populations.”1 ASCO’s report, The State of Cancer Care in America, 2017, found that 58% of practices reported using clinical pathways in 2016.2 Multiple studies have demonstrated that OCP’s deliver lower costs while maintaining or improving outcomes.3-6 Vendors have developed OCP’s for both the payer and provider markets.
A recent review1 of prominent pathway vendors revealed that most vendors met the key ASCO criteria for being expert-driven, patient-focused, up to date, and comprehensive. However, while the study found that vendors planned to offer integrated, cost effective technology and decision support, there was variation as to their accomplishments with respect to this criterion. For example, some vendors were not integrated with any electronic health record while others had forged integration relationships. In addition, some vendors provide prior authorization at the time of pathway therapy selection while others are not able to facilitate the data transfer or relationships with payers necessary to achieve this aim.
Incorporating OCP’s into oncology practice in way that lessens administrative burden has been an area of focus for practicing providers. An ASCO survey examining burnout in oncologists found that each additional hour per week spent on administrative tasks at work increased the risk of burnout by approximately 5% among private practice oncologists and 3.5% among academic practice oncologists.7
The four most commonly recognized administrative barriers faced by physicians using OCP’s are:
- Prior Authorizations
Many payers still require physicians and staff to obtain prior authorizations for treatments despite those treatments being pathway concordant. An American Medical Association (AMA)-led coalition including ASCO and 15 other health care organizations have urged payers to reform utilization management strategies according to 21 principles.8 They have found that nearly 90% of physicians surveyed reported that prior authorizations sometimes, often, or always delay access to care.8 A recent study of prior authorization for medications in a breast oncology practice found that 17 possible process steps and 10 decision points were required for patients to obtain medications requiring a prior authorization.9 One of the AMA reform principles is that health plans should offer alternatives to prior authorization requirements including physician-based, clinically driven alternatives such as clinical pathways.10
- Increased Electronic Health Record Time in Documentation
Many of the clinical pathway programs are not integrated into the practice’s electronic health record. Oncologists spend a significant amount of time on documentation already. Per a recent Medscape report, 43% of oncologists report spending 20 hours or more per week on paperwork and administration, time that could be otherwise spent with the patient. Thirty-five percent of oncologists reported spending 16 minutes or less with each patient.11 When pathways are not integrated into the electronic health record it requires redundant charting of data including diagnosis, stage, treatment plan, comorbidities, and other clinical information. There is also the time lost in logging into a new software program and toggling between tabs. This time could be saved if the pathway was integrated and able to extract this information from data already entered into the electronic record.
- Multiple Pathways
Often different health plans use different pathway programs. Providers seeing a mix of patients with different insurance plans will thus need to learn and keep track of the different plans’ programs. This ultimately translates in to more administrative time for physicians and their staff. One physician reported addressing this issue by using differently colored clipboards to remember which pathway is required for which patient depending on the payer.12
- Treatment past pathway
Many pathways do not provide guidance on use of third- or further-line therapies for some disease types. For patients who have maintained their performance status and wish to pursue additional antineoplastic treatment, this can create administrative challenges for the oncologist. If no clinical trial is available and the provider wants to use an off-pathway therapeutic, he or she might have to pursue approval from their organizational leadership to treat off pathway. While potentially ensuring that providers weigh the efficacy of treatment in these advanced cases, it also adds administrative burden to provider to gain these approvals.
OCPs hold much promise for improving cancer care. However, addressing these administrative burdens will be key in ensuring provider adoption and seamless patient care.
1. Daly B, Zon RT, Page RD, et al: Oncology Clinical Pathways: Charting the Landscape of Pathway Providers. J Oncol Pract:JOP1700033, 2018
2. American Society of Clinical O: The State of Cancer Care in America, 2017: A Report by the American Society of Clinical Oncology. J Oncol Pract 13:e353-e394, 2017
3. Neubauer MA, Hoverman JR, Kolodziej M, et al: Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract 6:12-8, 2010
4. Hoverman JR, Cartwright TH, Patt DA, et al: Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases. J Oncol Pract 7:52s-9s, 2011
5. Kreys ED, Koeller JM: Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer's perspective. J Oncol Pract 9:e241-7, 2013
6. Jackman DM, Zhang Y, Dalby C, et al: Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non-Small-Cell Lung Cancer. J Oncol Pract 13:e346-e352, 2017
7. Shanafelt TD, Gradishar WJ, Kosty M, et al: Burnout and career satisfaction among US oncologists. J Clin Oncol 32:678-86, 2014
8. Oncology ASoC: ASCO in action, 2017
9. Agarwal A, Freedman RA, Goicuria F, et al: Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process. J Oncol Pract 13:e273-e282, 2017
10. Association AM: Prior authorization and utilization reform principles,
11. Medscape: Medscape oncologist compensation report 2018, 2018
12. M R: Oncologists say clinical pathways are too confining, OncLive, 2015