2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

CLINICAL PATHWAYS STANDARDIZING PERSONALIZED MEDICINE
toxicity management, such as hospitalizations. Finally, if there
is more than one treatment with comparable efficacy and
toxicity, the committees look for the least costly alternative to
reduce unnecessary health care expenditures without compromising
clinical benefit. In addition to a single best therapy
as the primary pathway, the committees include options for
common scenarios, such as neuropathy, poor performance
status, drug shortages, etc. However, such options are only
presented and counted as “on pathway” when the physician
notes the specific scenarios. For those patient scenarios not
addressed by the pathway, it is anticipated and expected that
physicians will choose a treatment “off pathway.” There is
no penalty for such decisions and, in fact, adherence rates
approaching 100% would cause concern. The expectation of
the Via Oncology Pathways program’s disease committees is
adherence rates in the 70% to 90% range overall.
Imbedding Data-Driven Personalized Medicine within
the Via Oncology Pathways
As part of the quarterly process for the Via Oncology
Pathways, the disease committees review not only data
regarding alternative treatments but also biomarkers and
other prognostic testing to drive to “personalized” medicine
where the data are appropriate. The same level of rigor is
applied to all alternatives with the additional requirement
placed on biomarkers and prognostic tests of whether the
results actually drive care decisions. If the data are robust
and show a positive effect on care decisions, the pathways
are updated to include these tests as recommendations (eg,
anaplastic lymphoma kinase translocation–positive drives
to crizotinib, epidermal growth factor receptor mutation
drives to erlotinib, etc). For those tests without adequate
data or firm clinical relevance, the committees develop
literature-based explanations to be included in the pathways
to discourage the ordering of these high-cost tests. As
a result, the Via Oncology Pathways drive evidence-based
personalized medicine only when it has been shown to make
a difference in patient care.
Physician Engagement Strategies
A number of strategies have been successful in engaging
oncologists both at UPMC and in other markets in the
KEY POINTS
● Issues in oncology today of quality, variability, and
cost are driving the need for physician-led solutions.
● A rigorous clinical pathways program includes physician
experts who meet routinely to evaluate evidence
and develop care algorithms that standardize
personalized medicine.
● Strategies to engage physicians must be employed,
including involvement in the development and maintenance
of the pathways content.
● Decision support tools are critical components to
achieving adherence and measuring results.
● Early results demonstrate the success of clinical
pathways programs in terms of adoption, adherence,
reducing variability in care, patient outcomes, and
cost containment.
adoption of and adherence to the Via Oncology Pathways.
Key to their support is an understanding of the realities of
the rising costs of cancer care and the likely changes that
will be imposed by payers if no alternative solutions are
proposed. Beyond these compelling reasons, other factors
that drive physician acceptance include (1) creating an open
and transparent disease committee process that allows
participation by all physicians, (2) allowing unique patient
scenarios to be addressed in the pathways, and (3) emphasizing
that treating off-pathway is not a negative outcome
but an expected one because of the nature of the unique
patient scenarios encountered daily.
Decision Support Tools Are Critical for the Use and
Measurement of Clinical Pathways
The development and maintenance of the clinical content
of the Via Oncology Pathways are certainly the most critical
components in reducing unwarranted variability and adhering
to evidence-based medicine. However, without tools to
either deliver such content to the oncologists or measure
their adherence to the pathways, the clinical content alone is
no more valuable than other online resources or reference
textbooks. Within UPMC, the need for such tools became
evident quickly after the development of the clinical pathways
and the implementation of a cumbersome paper-based
process. Substantial investment was made by UPMC in
developing a Web-based software application for the delivery
of the Via Oncology Pathways via a decision-support tool
to the physicians. The delivery format is patient-specific and
provided in real time. The Via Oncology Pathways are
navigated through a question-and-answer format where the
critical questions that drive that disease-specific pathway
are presented and the physician is navigated to the appropriate
branch of the decision tree based on his or her
response. At the end of each node of the decision tree, local
clinical trial options are presented, followed by the pathway
treatment option including the full details of the order (ie,
drugs, doses, schedule, other medications, etc). An easy-touse
process is also available for selecting an off-pathway
treatment. Physicians are never prevented from going off
pathway but, rather, are asked to describe the reason for
going off pathway (from a predefined list).
Results of Via Oncology Pathways Use
Currently at UPMC, approximately 90 medical oncologists
and 30 radiation oncologists use the Via Oncology
Pathways in their daily patient care. These oncologists
practice at 40 sites of service, including the flagship academic
center in the heart of Pittsburgh and communitybased
sites over a 100-mile radius throughout Western
Pennsylvania. In 2011, the UPMC physicians confirmed a
pathways status for 94% of their patient visits (195,000
visits) and achieved an on-pathway rate of 82% 2 for their
treatment decisions (18,000 treatment decisions). The original
premise of Via Oncology Pathways was to find the
minimum number of therapies to meet the needs of the
majority of patient scenarios. This result seems to reflect
that the goals of reducing unwarranted variability, adhering
to evidence-based medicine, and ensuring that each patient’s
care is personalized, have been achieved. Other
practices using the Via Oncology Pathways have generated
comparable results.
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