AND CANCER CARE DELIVERY David Jackman, MD Medical Director of - PowerPoint PPT Presentation

CLINICAL PATHWAYS AND CANCER CARE DELIVERY David Jackman, MD Medical Director of Clinical Pathways, Dana-Farber Cancer Institute Senior Physician, Thoracic Oncology, Dana-Farber Cancer Institute Assistant Professor, Harvard Medical School

DISCLOSURES o AstraZeneca o CVS Caremark o MOREHealth

CONTEXTUALIZING CANCER CARE SYSTEM INSTITUTION PATIENT CELL GENE • Define best care • Standardize and disseminate that care (and the information behind it) • Influence and oversee care across a network • Improve clinical trial awareness

CURRENT PORTFOLIO: MED ONC WHAT IS A CLINICAL Heme Malignancies Solid Tumors PATHWAY? Leukemia/MDS Breast Cancer Chronic myelogenous leukemia • GI Oncology: • Myelodysplastic Syndrome • Colorectal Lymphoma • Gastroesophageal Hodgkin’s • • A platform that provides real-time • Pancreatic adenocarcinoma • Non- Hodgkin’s GU Oncology: decision-making support across the • Burkitt’s Bladder • • CLL/SLL continuum of cancer care Prostate • • DLBCL / double-hit Renal Cell Carcinoma • lymphomas Reflects current standards of care • Testicular • Follicular • • Mantle Cell Attempts to decrease unwarranted • GYN Oncology: • Marginal Zone • Cervical variation, while supporting warranted, • T -cell • Endometrial/Uterine granular variation Plasma Cell Dyscrasias • Ovarian Amyloidosis • H&N: Squamous Cell Carcinoma Supports learning • Multiple Myeloma • • POEMS syndrome Melanoma • Waldenstrom’s Neuro-Onc: Glioblastoma Sarcoma: GI Stromal Tumor Thoracic: • Non-small cell lung cancer • Small cell lung cancer

CURRENT PORTFOLIO: RAD ONC WHAT IS A CLINICAL Radiation Oncology Pathways PATHWAY? Breast Cancer Hematologic Malignancies: • Leukemia & transplant GI Oncology: • Lymphoma: Hodgkin • Anal • Lymphoma: Non-Hodgkin • Esophgeal • Multiple Myeloma & • A platform that provides real-time • Gastric Plasmacytoma • Liver decision-making support across the • Pancreatic adenocarcinoma Soft Tissue: continuum of cancer care • Rectal • Sarcoma • Bone metastases GU Oncology: Reflects current standards of care • Bladder Skin: • Prostate Cutaneous (non-melanoma) • • Attempts to decrease unwarranted • Testicular Melanoma • • variation, while supporting warranted, GYN Oncology: Thoracic: granular variation • Cervical • Non-Small Cell Lung • Endometrial/Uterine • Small Cell Lung Supports learning • • Vaginal • Vulvar H&N: Squamous Cell Carcinoma Neuro-Onc: • Primary CNS tumor • Brain metastases

WHAT IS A CLINICAL CHALLENGES IN PATHWAY? IMPLEMENTATION • A platform that provides real-time • Role of pathways for expert users? decision-making support across the • Cancer care should not be one-size-fits-all continuum of cancer care • Impact on workflow Reflects current standards of care • • Pathways are too cost-driven Attempts to decrease unwarranted • variation, while supporting warranted, granular variation Supports learning •

WHAT IS A CLINICAL CHALLENGE: ROLE OF PATHWAY? PATHWAYS FOR EXPERT USERS • A platform that provides real-time DECISION- decision-making support across the DISCUSSION SUPPORT continuum of cancer care TOOL Reflects current standards of care • Attempts to decrease unwarranted • variation, while supporting warranted, granular variation DATA Supports learning • COLLECTION

CHALLENGE: CANCER CARE WHAT IS A CLINICAL SHOULD NOT BE ONE-SIZE- PATHWAY? FITS-ALL • A platform that provides real-time decision-making support across the Classic sensitizing Osimertinib 80 mg PO daily until EGFR mutation continuum of cancer care progression or unacceptable (Exon 19 deletion, toxicity Citation: Soria et al, NEJM 2018. Reflects current standards of care • L858R mutation) Attempts to decrease • Rare sensitizing Afatinib 40 mg PO daily until EGFR unwarranted variation, while progression or unacceptable EGFR mutations Mutation toxicity supporting warranted, granular (G719X, L861Q, Citation: Yang et al, Lancet Oncol S761I, etc) variation 2015 Supports learning • Other EGFR (if clinical trial, do that. mutations Otherwise:) (T790M, exon 20 Go to branch for “no targetable mutations” insertion, etc)

CHALLENGE: CANCER CARE WHAT IS A CLINICAL SHOULD NOT BE ONE-SIZE- PATHWAY? FITS-ALL FOLFOX + bevacizumab, ongoing at the discretion of the patient Primary • A platform that provides real-time and treating physician Recommendation decision-making support across the Citation: Saltz et al, JCO 2008. Emmanouilides et al, BMC Cancer 2007 continuum of cancer care FOLFOXIRI + bevacizumab, If Clinically Reflects current standards of care • ongoing at the discretion of the Colon Cancer, Aggressive patient and treating physician Stage IV, Citation: Loupakis et al, NEJM Attempts to decrease • Disease 2014 Unresectable, unwarranted variation, while KRAS+, CAPOX + bevacizumab, ongoing supporting warranted, granular BRAF WT, If not a candidate at the discretion of the patient variation Bev-eligible, for or refusing and treating physician Citation: Saltz et al, JCO 2008. PS 0-1 Infusional 5-FU Cassidy et al, JCO 2008. Supports learning • If neuropathy FOLFIRI + bevacizumab, ongoing at the discretion of the patient concerns, or if and treating physician received prior Citation: Hurwitz et al, NEJM oxaliplatin 2004

CHALLENGE: CANCER CARE WHAT IS A CLINICAL SHOULD NOT BE ONE-SIZE- PATHWAY? FITS-ALL • A platform that provides real-time MESSAGING and INCENTIVES decision-making support across the • continuum of cancer care Support physicians to provide the best • care for the patient in front of them Reflects current standards of care • Incentives: System usage, not on-pathway • Attempts to decrease unwarranted • rate variation, while supporting warranted, System usage supports learning • granular variation Supports learning •

WHAT IS A CLINICAL CHALLENGE: WORKFLOW PATHWAY? • A platform that provides real-time Click reduction decision-making support across the • continuum of cancer care Minimizing navigation • What can be imported? • Reflects current standards of care • Other opportunities for efficiency • Attempts to decrease unwarranted • Embedded resources • variation, while supporting warranted, Clinical trial links • granular variation Side effects / Chemo consent • Patient education sheets • Supports learning • Citations • Educational opportunities: • Minutes • Network Updates •

WHAT IS A CLINICAL CHALLENGE: PATHWAYS ARE PATHWAY? TOO COST DRIVEN • A platform that provides real-time Costs: Inclusion and Messaging decision-making support across the • continuum of cancer care Make cost a routine part of discussion • Medicare allowables – drug cost • Reflects current standards of care • Never margin/reimbursement • Attempts to decrease unwarranted • Opportunities for Cost Containment • variation, while supporting warranted, Prior Authorization • granular variation Cost-conscious pathway choices where • appropriate Supports learning •

WHAT IS A CLINICAL CHALLENGE: PATHWAYS ARE PATHWAY? TOO COST DRIVEN • A platform that provides real-time Cost Analysis Pre- and Post- decision-making support across the Pathways continuum of cancer care Reflects current standards of care • $69,122 $64,508 Attempts to decrease unwarranted • $52,037 variation, while supporting warranted, $48,515 granular variation Supports learning • UNADJUSTED COST ADJUSTED COST Pre-Pathways Post-Pathways Jackman et al. JOP 2017. 13(4): e346-e352

SCOPE OF EFFORT Prior state (Content Development, Program maintenance) • Leadership: Operations Director, Medical Director • Pathways Team: Program Manager, 3 project managers, data analyst, IT project manager • Pharmacy: Lead pathways pharmacist, 6 other pharmacists • MD champions: 28 Med Oncs, 16 Rad Oncs • 12 disease center research coordinators

PATHWAYS AS LEARNING TOOL

USAGE RATE AND DISTRIBUTION

USAGE RATE AND DISTRIBUTION

ON-PATHWAY RATE BY PROVIDER

DECISIONS BY BRANCH

SPECIFIC DECISIONS BY BRANCH

FUTURE STATE: WHERE DO PATHWAYS FIT DECISION- INTEGRATION DISCUSSION SUPPORT • To improve the decision-support tool TOOL • To facilitate data collection & analysis • To reduce inefficiencies DATA COLLECTION

ACKNOWLEDGEMENTS Pathways Architects Pharmacy Pathways T eam DFCI Support Caroline Block Houry Leblebjian Ursula Matulonis Carole Dalby Joseph Jacobson Susanna Campos Amal Arnaout Priscilla Merriam Teresa Greenberg Dorothy Puhy Matt Davids Hillary Prescott Jeff Meyerhardt Julia Hall Craig Bunnell Peter Enzinger Marina Kaymakcalan Oreofe Odehide Joanna Hamilton Eric Winer David Fisher Andrew Skirvin David Reardon Vicky Hayne Leslie Solomon Arnold Freeman Janine Nazarro Doug Rubinson Leah Stein Elizabeth Liebow Glenn Hanna Christy Harris Guru Sonpavde Linda Moroni Pasi Jänne Eric Jacobsen David Steensma Caron Jacobson Katherine Thornton Finance Kerry Kilbridge Martha Wadleigh Belen Fraile Ann LaCasce Brian Wolpin Yichen Zhang Jacob Laubach Matt Yurgulan