What’s in a Pathway?

Whether or not a clinical pathways program will be effective is determined by the quality of the process used to develop the pathways. Which treatments go in the pathway; which stages of the care process are addressed by the pathway; how comprehensive the pathways are—these are all important considerations for clinical pathway development. 

This point was raised by the American Society for Clinical Oncology (ASCO) in their recently published “Policy Statement on Clinical Pathways in Oncology” (J Oncol Pract. published online before print January 12, 2016; doi:10.1200/JOP.2015.009134). Among ASCO’s recommendations to improve the development of clinical pathways were that clinical pathways be multidisciplinary and that they cover the full spectrum of care: from diagnosis, through treatment, and through survivorship and end-of-life care. In this month’s “Clinical Pathways GPS” column, Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD, and Donald Ohioma, MS, address the lack of adequate end-of-life provisions in current clinical pathways and provide suggestions for how pathways could include guidance to physicians on discontinuation of treatment (page 28).

Another ASCO recommendation for clinical pathway development is that pathways be updated continuously as new evidence becomes available. Real-world evidence of outcomes associated with different treatments or different routes of administration should be incorporated into the pathways so that they are refined enough to “address the distinct needs of different patient subpopulations.” In this issue, Robert M Rifkin and colleagues report the results of a retrospective observational study to evaluate the impact of route of administration of the drug bortezomib in patients with previously untreated multiple myeloma. Their findings, which suggest the potential for improved tolerability with subcutaneous versus intravenous bortezomib, have practical implications for clinical pathways for this disease (page 35).

In their “Guiding Principles for the Development of Clinical Pathways in Oncology,” ASCO recommends that “the costs of care associated with adherence to the oncology pathway” should be identified. This is a complex question, however, and one that is determined not only by the prices of medications set by pharmaceutical manufacturers but also by payer and government policies. Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD, and Scott Guerin, PhD, examine some of the ways in which government policy can affect drug pricing and utilization, which, in turn, can have an impact on the treatments selected for and placed within clinical pathways and the overall cost associated with the pathway as a whole (page 43).

The articles in this issue of Journal of Clinical Pathways aim to shed light on the issues identified by ASCO as being important to ensuring the future success of clinical pathways in oncology.