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Implementing Clinical Pathways for Multiple Myeloma

In one survey of payers, 47.6% reported having pathways for multiple myeloma, with another 19.1% citing the cancer type as a high priority for pathway development, Edmund Pezalla, MD, MPH, chief executive officer of Enlightenment BioConsult, explained at the AMCP Annual Meeting 2017.

Oncology pathway programs are increasingly gaining traction among managed care organizations (MCOs). According to a recent survey, 38% of MCOs have initiated a cancer treatment pathway program. At the more than one-third of MCOs currently implementing value-based quality initiatives, adherence to clinical pathways or clinical practice guidelines has become one of the most common performance metrics. In 2015, 53% of MCOs initiated programs for measuring the clinical and financial impact of clinical pathways.

In a survey of community cancer center stakeholders, respondents expressed support for the use of pathways to improve care for patients with multiple myeloma. The need to offer personalized care to patients, as well as the importance of reviewing and following established guidelines for care, were both ranked highly by stakeholders as effective practices for improving care. Additionally, the stakeholders cited clear clinical pathways as being necessary for good patient care.

Dr Pezalla argued that pathways programs for multiple myeloma are needed not only to guide treatment but also diagnosis, surveillance, and supportive care. For example, the use of bisphosphonates for skeletal-related events secondary to multiple myeloma is associated with increased survival and decreased bone complications. Because Medicare costs for bone disease are estimated to be $25,000, the prevention of bone complications represents significant cost savings. However, the use of bisphosphonates is also associated with an increased risk for osteonecrosis of the jaw. Therefore, clinical pathways that incorporate recommendations for the use of bisphosphonates should also provide recommendations regarding the selection of zolendronic acid vs pamidronate, duration of treatment, and timing of dental examinations.

Another complication of multiple myeloma treatment which Dr Pezalla recommends addressing in clinical pathways for this disease are thrombotic complications. Rates of deep vein thrombosis reported with immunomodulatory drugs and dexamethasone can be as high as 25%, with associated treatment costs of $13,000.

Dr Pezalla noted that any pathways for multiple myeloma be developed in a way that would allow treatment plans to be personalized. One study of overall survival in patients with multiple myeloma found that patients could be grouped based on the expression of 70 genes into three prognosis groups: good, intermediate, or poor. Thus, the treatment pathways for these groups should be distinct, Dr Pezalla concluded. —Kara Rosania

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