Roads less travelled: The evolution of clinical pathways

At the fourth ICON conference in August 2016, three eminent international speakers validated ICON’s goals and processes – including its emphasis on better outcomes for patients, curbing of costs, and the promotion of ethical standards.

The standardisation of clinically proven and cost-effective guidelines and pathways was a key focus at the recent ICON conference, which had as its theme ‘Real World Oncology’. This, alongside the increasingly important role newer technologies can play in guiding more effective cancer care, was vividly brought to life in top quality presentations based on real-world data from around the world.

Keynote speakers Dr Matti Aapro, a Swiss-based breast cancer expert; Dr J. Russell Hoverman, a medical oncologist from US Oncology, an expert in the fields of value-based cancer care, cancer care pathways and NCCN guidelines; and Dr Fergus Macbeth, a clinical oncologist who worked for the NHS in England, Scotland and Wales for over 35 years, also serving within the National Institute for Health and Care Excellence (NICE), each shared personal experiences as leaders and doctors in their respective countries.

Dr Hoverman presented his thoughts on the benefits and outcomes of the evolution of clinical pathways. Describing a US government initiative to promote quality care, he showed evidence that clearly defined clinical pathways – task-oriented programmes that detail essential steps in patient care, with an expected outcome for specific clinical problems – not only resulted in better patient care but also reduced the costs of patient care without compromising survival.

The research he presented included a study conducted on the Innovent Oncology Programme, co-managed by Texas Oncology, McKesson Speciality Health and Aetna. The results strongly validated ICON’s approach and ethos – that is, promoting the greatest value for both patients and funders through evidence-based treatment guidelines. The study, which aimed to evaluate the impact of its approach on pathway compliance, monitored the rate and costs of chemotherapy-related emergency room visits and/or hospital admissions.

The results – based on observation of 221 patients – were telling. The programme positively affected patient care in several ways: fewer emergency visits and in-patient admissions, decreased in-patient days, a reduction in cancer-related use costs, and an increase in on-pathway adherence. It was possible to demonstrate a 20 to 30% saving on costs, but without compromising health outcomes of these study patients.

“It’s important to note that the benefits outlined by Dr Hoverman are primarily for patients and funders,” said Ernst Marais, COO of ISIMO Health and conference Co-Chair. “Dr Macbeth, with a long career advocating for effective clinical pathways, went on to emphasise that ethically, treatment guidelines should benefit patients and offer greater value through cost-effectiveness; the individual benefit of the doctor should not feature in treatment decisions.”

“This is a core part of ICON and ISIMO’s vision – that patient benefit should be foregrounded in our decision-making.”

Part of advancing equality in, and access to, quality care, added Dr Macbeth, lay in standardising treatment wherever possible. Guidelines, he argued, are “power tools”: they exist to minimise variation, ensure best practice, and deliver good outcomes for each patient. The aim is not to over-scrutinise patients, but rather to establish the best structure for a guideline group to make informed, balanced and representative recommendations. Ideally, he added, guideline groups should include high-profile specialists, day-to-day medical practitioners, and patients, to ensure a balanced approach. ‘Groupthink’, bias and professional dominance could all be prevented through diversity. In particular, the chairperson of guideline groups must ensure that due process is followed, all relevant viewpoints are represented, and credibility is maintained, he said.

“Combining the above insights, it becomes clear that building evidenced-based clinical pathways – as ICON aims to do in South Africa – is the direction in which leading oncology experts are moving globally. Their research (and experience) indicates that value is increased for funders, while clinical outcomes are maintained or improved for patients,” says Marais.

“However, while standardised treatment protocols are desirable, consideration of individual needs should not be abandoned. The option for off protocol or pathway treatment requests must exist and have clear processes in place.”

Marais believes that where clinicians along with their patients can apply for a particular care model using reliable IT networks – such as the ICON eAuth® system – the process of approvals is faster, and so treatment can be implemented sooner. It is also possible for patients and their doctors to explore, on an individual basis, which pathway of evidence-based treatments is appropriate in each case. While this type of technological advancement facilitates knowledge-gathering to standardise treatment protocols, it also preserves recognition of individual needs.

“If there was one take-home message from the conference – it was that the science of cancer care is moving rapidly ahead,” said Marais. “Ethics and clinical governance are more important than ever as these changes take place to ensure best practice.  Alongside this, efficient communication between all stakeholders holds the key to the best possible outcomes.”