2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

A key question in the implementation of a pathways
program is whether such reductions in variability also
reduce or slow the rate of growth in cancer care costs. UPMC
has collaborated with two external parties to explore these
questions in three separate studies. First, through a multiyear
effort with Highmark Blue Cross Blue Shield of Pennsylvania
(Highmark), the largest commercial payer for
UPMC, two studies were conducted to compare the effects
of implementing the Via Oncology Pathways (then called
the UPMC Pathways) program on growth rate in the total
costs of cancer care with providers without such a program
(Robert Wanovich, BOCP, Highmark Blue Cross Blue
Shield, email communication, July 2007 and August 2009).
To determine if a growth-rate reduction occurred, it was
necessary to also study the rate of growth of cancer costs in
a control arm of patients being treated by non-UPMC
physicians who do not use any type of formal pathways
program. The two studies examined the effects of implementing
the pathways for non–small cell lung cancer and
breast cancer. In both studies, two periods were measured:
the 12-month period before the implementation of the pathway
within UPMC and the 12-month period after the implementation.
Total costs of care were calculated by Highmark
for the control arm and the experimental arm, using data
sets of actual claims payments for inpatient, outpatient, and
pharmacy benefit claims. The results in both studies demonstrated
a positive difference in the rate of growth favoring
the experimental (i.e., UPMC) arm.
In the study of the breast cancer pathway, preliminary
results showed a 16% growth rate of costs for the nonpathways
arm between the two 12-month periods compared with
7% for the UPMC arm. In addition, hospital admissions per
100 patients decreased by 15% in the UPMC arm compared
with a 2% increase in the nonpathways arm. This difference
suggests that reductions in unwarranted variability combined
with a prioritization of treatments with lower toxicities
can affect the rate of hospitalizations for patients with
cancer. Such a reduction is not only a source of cost savings
but also a likely improvement in patient quality of life and
overall outcomes.
In the study of the non–small cell lung cancer pathway,
actual growth rates between the two 12-month periods were
6% for the control arm and 1% for the UPMC arm. Included
in this growth rate difference were reduced hospitalization
costs of 12% in the UPMC arm, compared with a 4% increase
in the control arm.
Although the Highmark studies focused on the effect of
the Via Oncology Pathways program on the rate of growth
in cancer costs in Western Pennsylvania, a third study with
IntrinsiQ examined the possible implications of the Via
Oncology Pathways program on the care provided elsewhere
in the United States (Ed Kissell, IntrinsiQ, email communication,
September 2009). IntrinsiQ is a national leader in
the field of oncology information management and their
proprietary chemotherapy ordering software, Intellidose, is
used by approximately 700 oncologists in more than 100
practices. Their data set is widely used by key information
consumers such as pharmaceutical companies because of its
comprehensive nature, both in terms of clinical granularity
and its ability to accurately project patterns of care for the
entire United States. By reviewing the actual treatment
decisions made by its oncologist customers and comparing
those decisions to the Via Oncology Pathways recommenda-
e64
Table 1. Adjuvant Chemotherapy Usage and Clinical Trial
Participation Rates for 174 Patients Node-Negative,
HER2/Neu-Negative/Unknown, ER-Positive Breast Cancer
(On-Pathway Rate: 90.8%)
Treatment Selected, %
Clinical
Oncotype Risk n TC AC Tamoxifen Anastrozole Trial
High 34 76.5 11.8 — — 5.9
Intermediate 73 80.8 2.7 6.8 6.8 1.4
Low 40 — — 55.0 30.0 7.5
Not Ranked 27 59.3 7.4 14.8 3.7 7.4
Abbreviations: AC, doxorubicin/cyclophosphamide; ER, estrogen receptor;
HER2/neu, human epidermal growth factor receptor-2; TC, docetaxel/cyclophosphamide.
tions, IntrinsiQ was able to calculate the financial effects on
the costs of drugs to payers if actual care had instead
complied with the Via Oncology Pathways. By its calculations,
payers could save approximately 40% on oncology
drug costs if the Via Oncology Pathways had been followed
in all retrospective prescribing decisions. Assuming that
actual Via Oncology Pathways are followed in only 80% to
85% of patient scenarios, such savings would likely be in the
24% to 32% range.
Finally, a pilot study of Via Oncology Pathways and
Horizon Blue Cross Blue Shield of New Jersey (Horizon) has
generated encouraging results in an early analysis (Richard
Popiel, MD, Horizon Healthcare Innovations, and Richard
Weininger, MD, CareCore National, email communication,
February 2012). Two large practices in northern and southern
New Jersey implemented the Via Oncology Pathways in
the third quarter of 2010. The study compares total cost of
care (excluding radiation oncology, because the participating
practices provided only medical oncology services) between
these Via Oncology Pathways practices (experimental arm)
and the remaining practices in New Jersey (control arm)
over the same periods. The initial results are being validated
by Horizon with possible publication in the second half of
2012.
Breast Cancer Treatment Patterns at UPMC-CC
An analysis of the patterns of care for patients with breast
cancer within UPMC-CC for the 12 months that ended May
31, 2011, was performed to describe utilization patterns and
concordance with the Via Oncology Pathways. This period
was selected to avoid the confounding changes in care
patterns in the second half of 2011 because of concerns from
the United States Food and Drug Administration over the
use of bevacuzimab to treat patients with breast cancer. The
analysis included new chemotherapy treatment decisions for
Table 2. Frequency and Description of Treatment Decisions
According to the Via Oncology Pathways and Accrual to Clinical
Trials for 104 Patients with HER2/Neu-Negative/Unknown,
ER-Negative, PR-Negative Breast Cancer Receiving Adjuvant
Chemotherapy (On-Pathway Rate: 79.8%)
Node Statis
No. of
Patients
BRUFSKY, LOKAY, AND MCDONALD
Treatment Selected, %
TC AC TAC Other
Clinical
Trial
Negative 82 62.2 17.1 — 11 9.8
Positive (1–3 nodes) 22 18.2 59.1 4.5 4.5 13.6
Abbreviations: AC, doxorubicin/cyclophosphamide; ER, estrogen receptor;
HER2/neu, human epidermal growth factor receptor-2; PR, progesterone receptor;
TAC, docetaxel/doxorubicin/cyclophosphamide; TC, docetaxel/cyclophosphamide.