Clinical Pathways: Are They Enough to Improve Cancer Care?
The goals of the Triple Aim are to improve clinical outcomes, improve patient satisfaction, and control cost. Certainly, the goals of the Triple Aim have led to various alternative care and financial models that are being piloted today, headlined by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), creating the Merit-based Incentive Program (MIPS) and the Alternative Payment Models (APMs) programs. Payers are implementing pilots program, utilizing similar frameworks in the private sector. Many believe that clinical pathways are essential for medical practices to succeed in these programs. But are clinical pathways, as we normally think of them, enough to achieve the goals of the Triple Aim?
We normally think of clinical pathways outlining the most cost-effective treatment options, based upon clinical efficacy, tolerability, and cost. The determination is based upon the medical literature and physician experience. Clinical pathways are treatment centric. As such, they should result in at least comparable clinical outcomes, and hopefully improved outcomes. Perhaps the improvement in clinical outcome maybe achieving the desired clinical endpoint sooner, at least in oncology. The use of clinical pathways in other chronic disease states is not as mature as it is in oncology. I would speculate that while showing an improvement in clinical outcomes may be difficult in the oncology space, as we start to see the application of clinical pathways in other chronic diseases, an improvement in clinical outcomes will be evident. Therefore, clinical pathways, as we commonly refer to today, will potentially impact only the clinical outcome and financial objectives of the Triple Aim.
What is missing? We are missing the patient experience aim when we refer to clinical pathways. The ASCO criteria for clinical pathway development maintains that clinical pathways should be comprehensive, addressing diagnostics through the end-of-life.
In the October issue of the Journal of Clinical Pathways, Gina Cook, BA, cofounder and chief executive officer of Navigating Cancer, suggests that clinical pathways should include symptom management. Much in the same manner that we see clinical pathways decreasing the variability of how patients are treated, Cook suggests that a symptom management pathway would enable nurses to perform a thorough evaluation of symptoms the patient may be experiencing, and determine a course of action as part of an efficient standardized process. This process can rapidly determine if the patient is experiencing expected or unexpected symptoms and whether those symptoms can be managed on an ambulatory basis or require more acute attention. Standing treatment orders can be developed to support the mitigation of the symptoms. As Cook presents, symptoms can be preemptively managed, thus keeping the patients healthier during treatment, leading to better outcomes and lower costs.
Patient navigation programs have a role in attaining the Triple Aim, as well as allowing practices to perform well under a MIPS and APM model. We have seen aspects of patient navigation programs in other areas. For many years, pharmacists have managed anticoagulant clinics under established treatment protocols. Follow-up and monitoring patient bleeding times and adjusting the anticoagulant dose accordingly is an example of a patient navigation program. We see other examples in the Certified Diabetic Educators, or various cardiac programs in high cholesterol and congestive heart failure. As with clinical pathways, formalization and standardization is key to ensure patient navigation programs are effective and comprehensive.
We can no longer take it for granted, nor can the health care system afford to assume that the patient should simply accept that the symptoms he or she are experiencing is simply caused by the treatment regimen. Even if the symptoms are caused by the treatment regimen, they can be addressed. Patient engagement is vital to patient compliance and adherence, and patient compliance and adherence is vital to achieving optimal clinical outcomes, while maintaining a positive patient experience and controlling cost.