Clinical pathways utilization and characteristics of non-adherence at Sidney Kimmel Cancer Center.

Abstract

e13505 Background: Clinical pathways are utilized by many oncology practices with goal to deliver high quality, consistent care across health systems. In pathway tools, evidence-based treatments are recommended using the following hierarchy 1) efficacy, 2) adverse events, 3) cost. Previous research has shown that increasing adherence to pathways delivers evidenced based care at reduced cost. However, this comes at the expense of increased “clicks” and inefficiencies in workflow. We hypothesized that at a large academic center with subspecialty oncologists that lack of adherence to pathway utilization did not result in decrease adherence to evidence-based medicine. Methods: At our institution’s main academic hub, all breast, genitourinary (GU), and gastrointestinal (GI) chemotherapy encounters ordered from July 2020 through June 2021 were identified. A subset of these encounters, those ordered without use of Elsevier’s ClinPath, “pathway-independent,” were identified. Chart review was performed to identify clinical characteristics, ordering physicians, and line of treatment. Treatment choice was compared to ClinPath pathways to determine if treatment was “on-pathway” or “off-pathway.” Treatment was also compared to NCCN guidelines, to determine if aligns with standard of care. Results: 1,111 breast, GU, and GI total chemotherapy ordering encounters were identified. Only 103 (9.3%) were pathway-independent orders. 41 were hepatobiliary orders, which do not have a ClinPath pathway at our institution, leaving 62 pathway-independent orders despite a pathway available. 87% of the pathway-independent encounters were on-pathway, just not utilizing the ClinPath tool, and 91.9% align with standard of care. Only 8 of the 62 (12.9%) pathway-independent encounters were off-pathway. Of these 8 encounters, 4 (50%) were GI and 4 (50%) GU chemotherapy. 5 were 1st line treatment, 2 were 2nd line, and 1 was 3rd line. 3 of 8 off-pathway encounters were in accordance with NCCN guidelines. There were justifications for 2 of the 8 off-pathway treatments: prohibitive hepatic dysfunction and patient preference to continue treatment ordered by outside institution. The remainder were by physician preference. Conclusions: At our academic institution, there was high utilization of ClinPath when ordering GI, GU, and breast chemotherapy, with 94.4% total encounters utilizing ClinPath. The vast majority of chemotherapy ordered at our center, even when ordered without ClinPath, aligns with standard of care. While the number of pathway-independent decisions was very small in this sample, it suggests that the clinical pathway tool may not influence clinical decision making as much as suggested in other studies, but likely adds administrative burden to physicians who practice in highly subspecialized areas.