Emerging as one of the many pieces to the puzzle is the adoption of pathways based on evidence-based medicine (EBM). It has long been theorized that the use of standardized care models not only improves the quality of care, but also reduces costs and makes costs more predictable.
The high cost of oncology is gaining a lot of attention these days. With cancer care accounting for ten percent of healthcare costs, payers are hungry to find ways to be more frugal. As oncologists, it is in our best interest, as well as the best interest of our patients, to take a proactive, leadership role in finding solutions that sustain our ability to deliver high-quality care.
Michael A. Kolodziej, MD
Emerging as one of the many pieces to the puzzle is the adoption of pathways based on evidence-based medicine (EBM). It has long been theorized that the use of standardized care models not only improves the quality of care, but also reduces costs and makes costs more predictable. However, until last year’s study of the use of EBM pathways in patients with non–small-cell lung cancer (NSCLC) revealed that evidence-based care resulted in an average cost-savings of 35% over 12 months and equivalent outcomes, there was limited evidence to support EBM as an effective cost controller. Now, with proof in hand, we better understand the specifics of how and why EBM reduces costs.
First, it is important to note that not all pathways are created equal. Most programs use minimum criteria to develop their pathways; these typically include assessment of efficacy and toxicity. A few pathway programs go beyond these minimum criteria and consider costs as well. These types of programs delineate treatment options based on maximum survival benefits, minimal toxicity, and cost-saving advantages.
With empirical studies suggesting that EBM improves patient outcomes and the NSCLC study showing that EBM can also effectively reduce the costs of cancer care, there is more reason than ever for oncologists to adopt standards of care. In evaluating various programs, consideration of several points may help ensure the greatest benefits; these points are specifically tied to the process by which the pathways have been developed:
• A multidisciplinary task force of physicians and pharmacists should work together to create the pathways.
• The task force should base the pathways on an extensive review of documented clinical evidence from an array of sources, including published, peer-reviewed outcomes data.
• Pathways should be subject to an ongoing review process that continually evaluates new agents and the most up-to-date data on health outcomes.
• When efficacy and toxicity for agents are roughly the same, the pathway should factor cost into the equation.
Oncology drug costs are exorbitant, making this line item an obvious target for payers as they search for ways to reduce costs. One way in which EBM can help reduce the costs of cancer care is by optimizing the appropriate use of less expensive drugs. When pathways are developed, it will often be found that evidence supports the use of less expensive therapies, without compromising outcomes or increasing toxicity. For example, if treatment pathways point to two potential therapies that are largely equivalent in efficacy and toxicity, yet these two drugs vary enormously in cost, pathways programs that consider cost a factor would ultimately point to the less expensive drug.
Obviously, there are some cases in which cost cannot be a determining factor in deciding which drug to use to treat a patient. Where one therapy is far more effective than others, it is the clear choice and will be indicated as the first choice for that setting. Take trastuzumab (Herceptin) as an example. Trastuzumab is unquestionably an expensive drug, but evidence for its efficacy in certain situations is indisputable. As pathways are developed, efficacy is given the highest priority, with cost being considered only when outcomes are equivalent. In the case of trastuzumab, the efficacy of the drug and the ack of available substitutes make it the correct choice regardless of its price tag.
Treatment guidelines, backed by evidentiary support, lead physicians to confidently recommend the most effective therapy as the first-line treatment with standard ordersets that define dosing strengths and number of cycles. For many cancers, especially solid tumors in adults, each successive line of treatment is less efficacious than the preceding line. When patients with late-stage disease face difficult decisions, some will wish to continue a line of treatment no matter what. Others express the desire to improve their quality of life, with many stating that they prefer to die at home rather than in the hospital. Third and fourth lines of treatments rarely change the course of the disease and can cause incapacitating adverse effects. More often than not, if a patient’s cancer has not responded to or has progressed after the first or second line of treatment, the best course for that patient may be to transition into end-of-life or palliative care.
A study by Milliman analyzing Medstat 2007 data revealed that out of those chemotherapy patients with 10 major cancer diagnoses who were identified as dying in an inpatient setting, 24% received chemotherapy within 14 days of death and 51% received chemotherapy within 30 days of death. While we cannot always predict when death will occur, pathways can help guide physicians in making decisions and treatment recommendations pertaining to whether to offer additional cycles of a treatment or move to second, third, and further lines of treatment. They can also provide practical guidance that can be helpful in end-of-life care discussions. This includes demonstrating that transitioning to hospice care can improve the patient’s and the family’s quality of life and can reduce the costs borne by the family and payers by avoiding unnecessary and ineffective chemotherapy administered within a few weeks of death.
When two or more therapies are equally effective against a disease, regimens lower in toxicity are typically chosen to be on-pathway. This leads those physicians who adhere to pathways to be less likely to prescribe expensive anti-emetics, growth factors, and other supportive care drugs absent strong evidence to validate their use. In fact, in the NSCLC study, these types of supportive care drugs were administered 23% fewer times in patients treated on pathway than in those treated off-pathway, because of the reduced need for such drugs.
One of the most common reasons patients require hospitalization during treatment is adverse effects and complications caused by the agents. The less toxic on-pathway regimens can result in fewer or less severe adverse reactions, therefore reducing the number of unplanned hospital visits.
Widespread adoption of electronic health records (EHR) systems will provide even more robust data for future studies of both efficacy and cost savings. As researchers continue to analyze the data and to conduct studies similar to the NSCLC study in other types of cancer, it is probable that support for EBM will be further strengthened.
Using this powerful information, oncologists can work with payers toward developing pay-for-performance opportunities that reward the use of EBM. These might include revenue opportunities above and beyond fee-for-service, opportunities that encourage a more comprehensive approach to patient care quality and that emphasize disease management and proactive end-of-life planning. Adopting this approach to care will lead us to more predictable patient outcomes and costs, as well as helping create a sustainable plan for delivering affordable, high quality treatment in the years ahead.
1. Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of nonâsmall-cell lung cancer in the community setting. J Oncol Pract. 2010;6:12-18.
2. Wennberg JE, Fisher ES, Goodman DC, Skinner JS. Tracking the care of patients with severe chronic illness. In: Dartmouth Institute for Health Policy and Clinical Practice. The Dartmouth atlas of health care 2008. Available at http://www.dartmouthatlas.org/downloads/atlases/2008_Chronic_Care_Atlas.pdf.
3. Fitch K, Pyenson B. Cancer patients receiving chemotherapy: opportunities for better management. New York: Milliman, Inc; March 30, 2010.