A Better Pathway? Building Consensus and Engaging Providers with Feedback to Improve and Standardize Cancer Care.

INTRODUCTION: Unwanted clinical variation is common across the United States health care system and is particularly vexing in oncology owing to the complexity, morbidity, and high cost of the disease. Efforts to standardize care including guidelines and continuing medical education have had only limited impact. Disease-specific oncology clinical pathways hold the promise of reducing variation but have been hampered by a lack of ownership and accountability among oncology providers. MATERIALS AND METHODS: We describe the utility of combining a patient simulation-based clinical variation measurement with the in-house development of multidisciplinary breast cancer pathways at a National Cancer Institute-designated cancer center. RESULTS: At baseline, we found high variation in care decisions across the multidisciplinary team and within individual specialties in the management of simulated patients. Development and introduction of breast cancer clinical pathways combined with individual and group feedback on pathway adherence led to significant increases in pathway-aligned care decisions and decreases in measured variation. Overall quality scores increased from 47.5% to 61.1% (P < .001), with the largest improvement in diagnostic accuracy (+22.1%). Providers also ordered fewer unnecessary tests, saving an estimated $305 per patient case. Adherence to preferred chemotherapy regimens increased for both medical oncologists (+16%) and other members of the multidisciplinary team (+19%). CONCLUSION: Our work shows that a structured process to measure clinical variation and provide personalized feedback to an oncology multidisciplinary team drives adoption of evidence-based pathways, less unneeded spending, and higher quality care for patients.

Is routine ureteral stenting cost-effective in renal transplantation?

PURPOSE: Recent collective reviews show that ureteral stenting provides a decrease in ureteroneocystostomy anastomotic complications following renal transplantation. We identified the specific morbidity associated with urinary complications following renal transplantation and quantified the health care resources required to treat these patients at a high volume center. MATERIALS AND METHODS: Prospective databases were used to identify patients with a renal transplant who had urinary complications and track postoperative hospital readmissions and admission diagnostic codes. Financial models were used to estimate the variable direct costs of prophylactic stent placement and removal. Cost based analysis was performed to assess the financial feasibility of routine stenting following renal transplantation. RESULTS: Patient specific morbidity and hospital readmissions were significantly increased in patients with a transplant who had a urinary complication. The incremental hospital costs incurred in a patient with a renal transplant who had urinary leakage during the first 12 months postoperatively was $20,121. Routine placement of an anastomotic stent was inexpensive. Approximately 22 or 23 stents could be placed at the same incremental cost of treating 1 patient with a urinary complication in the hospital. CONCLUSIONS: Urinary anastomotic complications following renal transplantation are highly morbid. Even with modest decreases in urinary complications prophylactic ureteral stent placement is financially advantageous.