Mehmud: From my perspective, guidelines are only a starting point. While they work well for a large proportion of patients, where
there is an existing good base of evidence that can be applied, what is necessary is more definitive and precise guidance
on how to use them in the clinical setting, including more subjective factors like patient satisfaction and quality of life
as well as cost effectiveness. There must be clarity and transparency in the methodology used in making the transition from
the evidence-based guidelines of NCCN to the point-of-care issues that are covered in Level I Pathways. We don't want a situation
where it all comes down to direct costs [e.g., drug acquisition], which can be very misleading and leads to frustration for
providers and their patients. Clarity in the process will allow pharmaceutical companies to ensure that they generate the
right evidence to support appropriate positioning and inclusion of their medicines in Level I pathways.
Dan Paterson, Verastem
Dan Paterson, Verastem: A physician-driven standard that enforces compliance through peer pressure is a good way to engage around these issues. If
you succeed in convincing payers at the macro level that your practicing physicians are providing good care that is also cost
effective, then you avoid a whole host of problems. One is that there will be less demand for prior authorizations, where
access to a medicine can appear to be determined arbitrarily, and impacted by things like a patient's particular benefit plan
or his/her home zip code.
Much of what we have been discussing so far relates to uptake—translating the evidence so that it is "cooked in" to the pathways
and then pushing this out to shape decisions taken at the bedside. Are the conditions ripe for widespread acceptance of pathways
as a benchmarking tool that will produce consensus in making patient welfare the focal point of treatment? Oncology does seem
to be one of the few therapy areas where pathways and guidelines are actually making a difference in resolving distortions
in practice patterns.
Fitzgerald: In the case of cancer care, I think we are indeed ahead of the curve. The McKesson decision support technology is going to
accelerate our progress. Where I see danger is the complexities of the US health reform agenda may lead to more efforts to
"reinvent the wheel." We already have a guidelines/pathway redundancy issue in this country.