Dr Haumschild discusses the substantial impact of clinical pathways in the treatment of ovarian cancer.
Ryan Haumschild, PharmD, MS, MBA: Clinical pathways are so important, and utilizing them through an order set, your EMR [electronic medical records], or even a PDF helps synergize therapy and allows best practice to be achieved, not only in that subspecialty clinic but also among community providers. We rely on that. We make decisions as a shared decision-making group through a disease state working group, and we come to a recommendation. What would be a preferred therapy in the frontline setting? What genomic testing should we do to help initiate the right treatment? Ultimately, when you have that information built out, when you have patients being seen—whether it’s for ovarian, prostate, or breast cancer—the provider doesn’t have to sit there and go, “Which PARP inhibitor do I want to use? Which 1 can be dose reduced?” That pathway and that order set can lead them to that right treatment algorithm.
When you have premedication built in, you have labs and monitoring fields already built in. When you have the starting dose and dose reductions, that allows providers to rely on that shared decision-making and allows them to rely on the work of the pharmacy who built that order set. That way it will initiate best practice, no matter where that provider is seeing that patient. At the end of the day, there’s so much emerging data happening with PARP inhibitors. If we keep that updated in the EMR and the order sets, then providers have that comfort to know that when they initiate this treatment pathway or order set, they know the patient is getting the best therapy overall, the best monitoring. It will initiate the best education that’s needed for that therapy as well.
Clinical pathways are exciting, but the main concern some people have is that they don’t want to take away from patient-specific medicine, or practicing and trussing the best regimen for that individual patient. It’s a well-discussed point, but we’re getting to the point with the NCCN [National Comprehensive Cancer Network] and a lot of guideline-based therapy that there’s a best practice. The great thing about having order sets and clinical pathways built out is that you can guide the provider down. What are the key considerations? Does this patient have BRCA expression? Are they all comers? Is it first- or second-line [therapy]? When you look at it through that lens, there’s a consistent treatment pathway that you utilize.
At the end of the day, review: how do we want to treat patients with this expression? When do we want to order this precision medicine pathway? At what line of therapy? You get shared decision-making among clinical subspecialists and community oncologists, and then you’re leveraging the best information from some of the smartest people—pharmacists, physicians, APPs [advanced practice practitioners], nurses—into that order set. Therefore, no matter where that patient is treated—in their local community, at the main academic center—they know they’re going to get that best practice care that’s aligned across all locations. That’s been the key implementation.
Lastly, the obstacle. It takes a lot of time. You have leading practitioners and PharmDs giving their time to make these decisions, and that takes a lot of effort. We’ve made it more consistent. We’re getting updates monthly and reviewing updates. We’ve found that it takes a lot of time, but it allows for consistent practice. It’s allowing us to roll out the newest therapies, stay on top of the newest indications, and provide our patients with the best outcomes. That has allowed us to get through some of those initial barriers.
Pathways are a move in the right direction. They require a lot of effort, but they force the teams to get together, decide what is the best practice, and move forward. But not everyone is going to have that internal resource and internal infrastructure to develop clinical pathways. That’s important to recognize and understand. Also, you have third-party pathways—the sharing of mind, information, NCCN Guidelines, and the latest treatment data—that can be put together in a third party. As long as you agree with the methodology and how they came up with those clinical pathways, and to a further extent you’re allowed to customize them, both are great options. It’s recognizing where you are in your journey, what type of resources at your institution you can leverage, and if you want to purchase a third-party affiliate with a large NCI [National Cancer Institute]–designated comprehensive cancer center that’s developing pathways. Or start that infrastructural internally to develop these disease state teams, then formulate your individual pathways as you move forward. I don’t think 1 option is the best, but evaluating what is best for your facility is the first step in being successful toward implementation.
The stakeholders are not just physicians, but a lot of people think physicians making the decision. They’re a huge part of it, but we also have other interdisciplinary team members. We might have someone from nursing, we might have advanced practice practitioners, and we might have a lot of clinical pharmacists that are there, as well as pharmacy leadership and physician leadership. Diversity of perspectives, thought, and practice experiences make the difference. When you have physicians who might be subspecialists, and all they see are patients with ovarian cancer, they may have a really good understanding of the latest clinical data. They might have a good understanding of some of the progressive practices occurring within the space.
At the same time, you want to balance that out with your community oncologist. They’re the ones that are seeing a variety of solid tumors. They have unique patient experiences to share that a subspecialist may not always be aware of.When you create interdisciplinary care and also physicians and providers that practice in community and academic [settings], you’re going to have shared decision-making that takes into consideration the different treatment locations of patients, and you’re probably going to have some of the best recommendations moving forward.
Aligning formulary with recommended treatments is important. A lot of times you’re not able to order treatments if it’s not considered a best practice. That’s important. If through shared decision-making, the disease state working group has determined product A is the best treatment and someone consistently orders product B, then that’s not giving the patient consistent care. That’s not doing what’s best for them. You always want to have an exceptions process. You might have a couple of options within an order set for a specific line of therapy. But by aligning preferred and nonpreferred products with best practice, you drive appropriate utilization.
When you think about a large community oncology practice or academic center, it’s important to provide consistency among different treatment locations. By approving a medication on formulary, you understand the utilization of that product and can make sure it’s stocked in all your locations. You’re being cognizant, making sure you have drug on hand for that patient but also that you’re being a good steward of the cash and cash equivalence for that organization.
Lastly, you can build up good real-world evidence data on what the outcomes look like by treating patients with that unique product. You can understand the adverse effect profile, how we can best educate, what some of the predictors are, and when some of these adverse effects will occur, so we can better prepare our providers, patients, and pharmacist, who are consistently educating those starting these treatments.
Transcript edited for clarity.