Feedback System Improves Physician Adherence to Oncology Clinical Pathways

While clinical pathways have emerged as a way of reducing care variability and standardizing best practice, some institutions that implement these tools still face difficulties with physician buy-in and adherence to pathways. A study published in BMJ Open has found that a measurement and feedback system may help to engage providers and improve physician adherence to clinical pathways. 
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In response to widespread variation among health care providers, oncology organizations and health systems have developed clinical practice guidelines on diagnosis and treatment that are in line with evidence-based standards of care. However, a lack of adequate time to review guidelines and difficulties with applying guidelines to specific patient cases have prevented some clinicians from using them in their own practices. Clinical pathways have since been used as a way of filling this gap and offering more directive solutions for providers, though challenges persist with encouraging providers to adhere to these pathways. 

At Moffitt Cancer Center (MCC) in Tampa, FL—one of the first cancer centers to introduce a pathway approach—the M-QURE initiative was developed to help advance the use of MCC’s Clinical Pathways in breast, lung and gastrointestinal (GI) cancers. M-QURE uses a provider engagement system built on the idea that: (1) personalized measurement and confidential feedback of provider performance drive clinical pathway adherence and clinical practice change; and (2) giving providers the opportunity to be involved in a system that supports education, practice change, care coordination, and value-driven care buttresses health system efforts to standardize practice and reach system-level goals.

Researchers led by Timothy Kubal, MD, MBA, Moffitt Cancer Center, conducted a study reporting on the M-QURE experience and its impact on clinical pathways adherence. Three non-overlapping cohorts at MCC participated in the study. Participants were asked to complete a set of clinical performance and value (CPV) vignettes in breast, lung, or GI cancer, depending on their specialty, using the M-QURE. Each vignette was written in a way to address pathway-specific diagnostic, therapeutic, and cost challenges associated with typical clinical encounters. Respondents to the vignettes received scores on history, physical, workup, and diagnosis with treatment plan, with a score of 100% denoting perfect adherence to clinical pathways. Vignettes were administered in three successive rounds, and scores were compared between the rounds.

Overall, 14 breast cancer providers, 17 lung cancer providers, and 27 GI providers participated in completing the vignettes. Scores at baseline for each of these groups were 56.3%, 52.6%, and 65.3%, respectively. By the third round, scores rose for each group except for the GI providers, whose scores fell slightly to 63.9%. Scores for the breast and lung cancer groups improved by 13.6% and 12.1%, respectively. For all groups, the most significant areas of improvement were in diagnosis and treatment.

Authors of the study concluded that feedback and group measurement systems like the M-QURE could help to account for differing skill levels among multidisciplinary care teams and improve adherence to clinical pathways. 

“Using group-level measurement and individual feedback, MCC successfully improved overall adherence to clinical pathways in a short timeframe—in just 9 months and after only 3 rounds—for breast and lung cancers,” authors wrote. “One aspiration of pathway implementation is for there to be a basic reference standard that can be accessed (as it was in this study) and used by all providers. These results suggest that high rates of adherence to clinical pathways can be implemented using methods similar to the one described in this study.”

The study was limited by the lack of long-term follow-up data, which prevented researchers from determining whether changes in adherence are maintained over longer periods of time.—Sean McGuire

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Kubal T, Letson DG, Chiappori AA, et al. Longitudinal cohort study to determine effectiveness of a novel simulated case and feedback system to improve clinical pathway adherence in breast, lung and GI cancers. BMJ Open. 2016;6(9):e012312.