Web-Based Pathways System Reduced Costs in Stage IV NSCLC

The use of a customized clinical pathways program that helps manage complexity and guide decisions resulted in a sharp decrease in costs per patient in an analysis of stage IV non–small-cell lung cancer (NSCLC). There was also a trend toward improved outcomes, though this did not reach significance.

“Modern oncologists in 2017 face an increasingly complex world,” said David M. Jackman, MD, of Dana-Farber Cancer Institute in Boston, at the American Society of Clinical Oncology (ASCO) 2017 Quality Care Symposium, held March 3–4 in Orlando, Florida (abstract 3). “One has to bring a real understanding of tumor biology, an understanding of the values and limitations of our radiographic and genomic studies, and then choose from an increasing array of medical therapies.” As complexity has increased, so have costs-Jackman said some estimates put the annual US expenditures on cancer approaching or exceeding $200 billion by 2020.

Jackman’s institute implemented a pathways program beginning in January 2014. The system is a web-based software program that is fully customizable; they began with lung cancer, and have since added pathways for ovarian cancer, genitourinary cancers, breast cancer, gastrointestinal malignancies, melanoma, and recently for most other solid tumors. The system, which is based outside the center’s electronic health record, helps with resource management and provides clinical decision support in real time.

The new analysis included 160 patients diagnosed with stage IV NSCLC before the pathways implementation, and 210 diagnosed after it was implemented. The two groups were generally well-matched, though there was a higher proportion of women in the pre-pathways cohort.

The researchers found that costs dropped dramatically after pathways implementation. In an unadjusted analysis, the cost per patient in the pre-pathways cohort was $64,508, compared with $48,515 with pathways, for a net change of –$15,993 (P = .03). After adjustments for clinical characteristics and other factors that could influence costs, the change was even greater, dropping from $69,122 to $52,037, for a net change of –$17,085 (P = .01).

Jackman said that chemotherapy represented “far and away the biggest line item where savings occurred,” accounting for $12,391 per patient. The majority of that, he said, came from a focus on avoiding one particular regimen (carboplatin, bevacizumab, and pemetrexed) that recent studies suggested offered no additional benefit but doubled costs over other options. Radiology (–$1,539), radiation oncology (–$1,200), and non-chemotherapy infusions (–$682) represented other major areas of savings.

There was a trend toward improved outcome with pathways, though this did not reach significance. The 12-month survival rate in the pre-pathways group was 52%, compared with 64% in the post-pathways group (P = .08).

Jackman noted that the analysis is limited by the fact that various changes in treatments could have occurred over the time period covered in this study. Also, the analysis lacks data on costs outside of oncology, such as emergency department visits, which could change the results; the group is looking into sharing data in order to fill those gaps.

“We hope that pathways can be an area for innovation, not to solely manage costs and make decisions based on evidence from yesteryear, but also to help us move forward,” Jackman said, adding that the systems have the potential to match patients with clinical trials based on genomic and other data, and could act as a sort of “nexus” where clinicians from various realms can connect to improve value and patient outcomes.