Peer review encourages physician compliance with evidence-based cancer treatment plans

September 29, 2016

Evidence-based treatment pathways implemented by UPMC 15 years ago to guide cancer care have become integral to ensuring that each patient receives the most up-to-date course of treatment specific to his or her cancer. That's the conclusion of a recent University of Pittsburgh Cancer Institute (UPCI) analysis showing the high physician compliance rate with the pathways—a standardization concept borrowed from the manufacturing sector.

The analysis, presented today at the American Society for Radiation Oncology (ASTRO) 2016 Annual Meeting in Boston, found that UPMC CancerCenter physicians nearly always complied with the standard, evidence-based treatment pathways or presented an acceptable alternative to a review panel of their peers.

"Research and clinical trials are continuously yielding new and better cancer treatments, but it can take time for treatment protocols to be updated, and, even then, physicians may be unfamiliar with rapid advances in treatment," said lead author Brian Gebhardt, M.D., a third-year resident in the UPCI Radiation Oncology Residency Program. "Our treatment management process—called Clinical Pathways —is updated as often as necessary to ensure that our patients receive the best care. We set treatment protocols according to national guidelines, published literature and institutional experience, and then evaluate each option based on efficacy, toxicity and cost, in that order."

UPMC CancerCenter physicians enter their treatment decisions into the online Clinical Pathways support tool that is integrated with patient electronic medical records. Sometimes for a specific cancer, there is only one type of treatment recommended, but often there is more than one evidence-backed option. If the physician wants to provide a treatment recommendation not compliant with the pathways, the tool launches a peer-review process that usually yields a ruling within two days.

Dr. Gebhardt and his colleagues evaluated 6,965 treatment decisions entered in 2015 across 22 UPMC CancerCenter sites and found that 91.3 percent followed the Clinical Pathways recommendation. In 605 decisions (the remaining 8.7 percent), the physician wanted to pursue a different treatment protocol than was recommended. Those cases were sent to peer review for evaluation. More than 99 percent were approved.

The reasons for an off-pathway treatment were: The patient was in poor health, and an aggressive approach was not warranted (53.2 percent); the patient was doing better than expected on standard treatment and wanted more aggressive treatment (17.1 percent); the financial burden of treatment was too great (1 percent); the patient refused standard treatment (13.8 percent); or the physician didn't agree with the Clinical Pathways-recommended treatment for some other reason (14.9 percent).

"Since less than 1 percent of the were ultimately rejected following peer review, we believe that we've hit upon a really positive, efficient method to widely disseminate the latest cancer treatment options throughout our UPMC CancerCenter sites," said Dr. Gebhardt. "The peer-review process is a strong way to encourage compliance and ensure consistent, high-quality care across a large network."

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