Dana-Farber Cancer Institute Analyzes Clinical Pathway Use to Reduce Unwarranted Variation


Researchers at the Dana-Farber Cancer Institute (Boston, MA) analyzed off-pathway cases to reduce unwarranted variation, understand practice patterns, and update their clinical pathways.

According to Julia Cooper Hall, MPH, Dana-Farber, and colleagues, a clinical pathways program requires regular updates to pathways content, real-time decision support, and data collection as well as analysis of decisions made. One of the goals of the Dana-Farber Pathways (DFP) program is to analyze data to reduce unwarranted variation and inform granular, warranted variation.

Dr Hall and colleagues will present the results of their 2017 clinical pathway data analysis at the American Society of Clinical Oncology (ASCO) Quality Care Symposium (September 28-29, 2018; Phoenix, AZ).

The 31 Dana-Farber medical oncology clinical pathways are created and updated by expert in-house clinicians and scientists. DFP is implemented through a web-based portal that offers real-time decision support. The program also captures on- and off-pathway treatment decisions; the reasoning for off-pathway decisions are shared and analyzed monthly with experts in each disease group. Each meeting includes an assessment of on-pathway rates and decisions for each node within the pathways. Low on-pathway rates leads to discussion about possible action – including provider education or pathway revision.


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Dr Hall and colleagues observed 7460 total treatment decisions collected through DFP in 2017, 78% of which were considered on-pathway. Among the clinical reasons for these off-pathway decisions were physician not agreeing with the pathway (37.7%), patient choice (8.5%), poor performance status (7.7%), second opinion from outside institution (5.2%), financial burden or insurance complications (0.4%), and other reasoning (eg, allergy, disease progression, mixed disease, and atypical tumor or mutation; 40.5%).

Researchers noted that off-pathway analysis has been utilized for three important purposes:

  • Catalyze change – they detected early adoption of immunotherapy in small cell lung cancer and discussed the relevant data. The pathway was updated to adopt this class of treatment.
  • Understand unexpected events – they identified a recent etoposide shortage and discussed alternate recommendations, which were added to the pathway in case of future shortages.
  • Provider education – they detected a consistently low on-pathway rate in one location, largely driven by a specific provider. This provided a mechanism to discuss practice patterns and provide targeted education.

“Off-pathway analysis provides insight into user variation, fosters and supports peer coaching, and supports the creation of dynamic, up-to-date pathways,” authors of the study concluded.—Zachary Bessette