Clinical pathways, sometimes known as care pathways, are detailed plans that outline the treatment a cancer patient will receive. These pathways can help to ensure patients receive the best possible care based on the most recent scientific data. However, treatment is not a one-sized-fits-all sort of thing and some individuals may perform better on a treatment plan that is customized to their unique situation. Let’s break it down and discuss both sides of the clinical pathway issue.
There is solid evidence that the appropriate use of clinical pathways can improve patient outcomes. Cancer is a complex and difficult disease to treat and new data for cancer care is constantly emerging. Particularly for oncologists who treat many forms of cancer, it is a challenge to stay on top of the state-of-the-art care for multiple cancers. Clinical pathways can be a great resource to clinicians and a benefit to their patients.
Pathways are usually based on practice guidelines produced by groups of clinicians such as the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO). These are recommendations based on a review of the scientific evidence supporting the benefits and harms of a given treatment. Practice guidelines tend to be broad in nature. A clinical pathway essentially translates practice guidelines into a specific, standard care for a defined patient population. In other words, based on your diagnosis, it tells your doctor what to do.
There are many clinical pathways available, which are developed by both medical providers and insurance companies. This raises the question, why are there so many different pathways if there is a single best protocol for a specific patient group? Truth be told, there actually is not a single best protocol and some variation is appropriate. First, since there are usually not head-to-head comparisons of different medications, evidence is lacking on what might be best for a specific patient. Beyond the medical aspects, the hopes, dreams and lives of patients must be part of the treatment equation. For example, a patient who uses his or her hands for their job, such as a musician, would put a premium on avoiding neuropathy and may opt to deviate from the pathway due to this treatment goal. Some estimate that approximately 80 percent of patients benefit from adherence to a pathway and 20 percent need some variation.
Most insurance companies now incentivize healthcare professionals to use a clinical pathway when treating their patient and this is where clinical pathways can become slippery. If the compensation is tied to patient outcome, then it is positive to incentivize clinical pathways—in other words, the doctor does better if the patient does better. However, if compensation is tied to adherence to the pathway, then the doctor is incentivized not to deviate and makes more money by sticking to a cookie-cutter approach. This type of incentive is the opposite of personalized medicine. Then there is the issue of cost—to what degree should cost of a treatment be considered in the protocol? Is the doctor incentivized to limit choice in order to save money?
Another challenge is the number of clinical pathways available. Your oncologist’s practice group may have their clinical pathway, but so does your health insurance company. A clinician could treat five patients with the same cancer but have five different clinical pathways due to the variations determined by insurance companies.
So, clinical pathways do have some value, but their future is uncertain. As both providers and insurance companies utilize pathways in the future, it is important that they are a resource for clinicians and not a restriction on the care you receive. If there are incentives for using a pathway then the incentives must relate to improvements in your care—not blind adherence to a set of rules. Above all, let’s avoid the day that the insurance company logo on your chart is what defines your cancer care.
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