Stephen B. Edge MD, FACS, FASCO of Roswell Park Comprehensive Cancer Center speaks about the ASCO 2020 Going off pathway: Problem or good care?
Decision support and benchmarking against national standards are supported by clinical oncology pathways (COP). Some organizations offer financial incentives to use care recommended by the COP (on the pathway: OnP). Recommended Rx (off-pathway: OffP) treatment (Rx) other than COP is sufficient for certain cases. Restricted data on the appropriateness of OffP Rx is available. This research explores rates and explanations in one cancer center for OffP Rx.
Both systemic Rx decisions entered into the ClinicalPath COP between 10/1/18 and 9/30/19 were listed as either OnP (including Rx in a clinical trial) or OffP and as either adjuvant/neoadjuvant (ADJ) or metastatic (MET) treatment. For Off Pathway Rx, oncologists must have free text explanations. A senior nurse-led team and physician reviewed reports of all OffP treatment to check and identify out-of-patient reasons. Cases were referred to the treating oncologist and/or multidisciplinary team for examination without adequate documentation. Reasons for Motivated OffP (R1-6) were graded as: R1. Known toxicity of the drug and/or co-morbidity restricting its treatment; R2. Prior care except the Rx route; R3. New indication or molecular targeted therapy for drugs not included in COP; R4. Rx continuation began prior to referral; R5. Other supplier or multidisciplinary team reasoning, clearly reported and reviewed; and R6. Preference for patients.
There were 2,997 decisions for 2,389 patients on medication with Officer. For ADJ the OnP ratio was higher than for MET Rx (87% vs. 78%). 1 percent of cases were compensated for by non-justified OffP treatment. 69% of OffP Rx was attributed to documented drug toxicity, therapy restricting co-morbidity, previous therapy precluding the option of COP, and new drug indications (Table).
The COPs have benchmarking help for decision making and practice. For advanced cancer, lower OnP rates for MET Rx are likely to reflect the complexities of Rx. Most Off Pathway treatment was warranted and necessary. In particular, given the high percentage of OffP decisions for drug toxicity, co-morbidity and new drug indications, financial incentives that concentrate on the percentage of COP OnP treatment might paradoxically harm the quality of care.