Accounting for Patient Differences in the Pathway

At the first Clinical Pathways Congress (September 16-18; Boston, MA), the official meeting of Journal of Clinical Pathways, one of the themes that came up continuously throughout the meeting was the importance of considering what matters most to the patient when defining value in a clinical pathway. When evaluating different treatment options, patients each define value in their own way, depending on their specific financial, emotional, health, and lifestyle needs. Therefore, it is important for pathway developers and physicians not to take a one-size-fits-all approach to decision-making.

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In this issue, several articles discuss ways in which clinical pathways can be more personalized and patient-centered. One area that is inadequately addressed in pathways is patient-reported outcomes. Because a typical office visit does not allow enough time to adequately discuss patient concerns, health care providers are unlikely to prioritize addressing these concerns without their being included on the pathway. Therefore, Rahma Warsame, MD, and colleagues developed a clinical pathway for identifying patient-reported concerns, referring patients and their health care providers to the appropriate resources to address these concerns, and translating the recommendations in these resources into action. Dr Warsame and coauthors describe the development of the pathway and the outcomes of a quality improvement study to incorporate it into practice (page 35).

A key determinant of clinical pathway success is adherence to the pathway, which includes patient adherence to the medication treatment plan. Poor medication adherence results in greater variability, worse clinical outcomes, and increased health care expenditures. Therefore, clinical pathways programs should address medication adherence, which requires that adherence be measured in a consistent way using validated methods. Eugene Kreys, PharmD, PhD, BCPS, discusses the current lack of a gold standard measure of medication adherence and explore several candidates for this designation, weighing the strengths and limitations of several commonly used measures (page 43).

A fundamental concern about the use of clinical pathways is that it not restrict patient access to available treatments. In the case of patients whose insurers operate through a pharmacy benefit manager (PBM), which often will use a formulary to determine what drugs will be covered, access to costly treatments may be limited. Andrew Cournoyer, RPh, MBA, and Larry Blandford, Pharm D, address this issue, discussing how growing formulary exclusion lists are creating challenges for all stakeholders (page 33). Furthermore, actions by PBMs such as CVS CareMark to restrict physician dispensing of medications may also restrict patient access. In an interview, Ricky Newton, CPA, Community Oncology Alliance (COA), discusses what COA is doing to address this problem (page 26).

Also in this issue, Shelley Fuld Nasso, National Coalition for Cancer Survivorship, discusses how clinical pathways that extend into survivorship can more fully address patients’ care needs (page 22).