Urologic Oncology Care Paths Focus on Best Practices, Value-Based Care

By Andrew Stephenson, MD

During the last few years, Cleveland Clinic has broken new ground by developing condition-specific care paths within our various clinical institutes. This effort focuses on operationalizing best practices to guide clinical workflow, with an emphasis on quality and value-based care.

What is a care path?

Cleveland Clinic care paths start with evidence- and consensus-based “guides,” which are succinct manuals detailing the appropriate steps in patient management for the condition at hand, with supporting rationales. The guides, developed by multidisciplinary teams of Cleveland Clinic experts, are translated into algorithms and workflows for practical application.

The care path initiative is focused on three major areas:

• Standardizing clinical management around the care path guide, with a focus on delivering consistent, value-based, patient-centered care.Integrating workflows and algorithms into the electronic medical record where appropriate and when possible.
• Tracking patient-reported outcomes to help drive care.

Urology and kidney care paths

Cleveland Clinic’s Glickman Urological & Kidney Institute has nearly 20 care paths completed or in development.

Two years ago, the Center for Urologic Oncology implemented two of the Urological & Kidney Institute’s first care paths — for bladder cancer and prostate cancer. These care paths have served as excellent models for the care paths that have followed, especially because one (bladder cancer) addresses a condition that is complex to treat, while the other (prostate cancer) is more straightforward. (On the horizon: a care path for localized kidney cancer.)

We took a comprehensive, inclusive approach to creating the care paths. They were developed and vetted in committees of relevant stakeholders, including — but not limited to — urologists, pathologists, radiologists, medical oncologists, radiation oncologists, nutritionists, pharmacists and nurses.

It’s important to note that care paths serve as best practices guidance, but they aren’t concrete or inflexible — we still encourage clinicians to use their professional judgment and experience to guide treatment plans and recommendations.

Prostate cancer care path

This was the first care path we implemented. The prostate cancer care path is short and straightforward, since the treatment for prostate cancer is now largely universally standardized. Therefore, this care path focuses on ensuring that clinicians use evidence-based medicine in the context of value-based care. Essentially, it provides guidance on eliminating unnecessary expensive tests in favor of less expensive ones.

Bladder cancer care path

The management of patients with invasive bladder cancer requires multidisciplinary care, making it complex and possibly leading to variability in treatment. In developing this care path, we identified the best guidance for multidisciplinary care of individual patients, incorporating not only evidence-based medicine and clinical guidelines, but also our institutional expertise.

The bladder cancer care path is a set of standardized steps to assess preoperative risk and to optimize patients prior to surgery, perioperatively and postoperatively, decreasing lengths of stay and reducing complications. For example, it includes discharge planning for cystectomy patients as a way to minimize readmissions and complications.

How care paths are working so far

The Urological & Kidney Institute’s overarching goal with care paths is to make it easier for clinicians to consistently deliver cost-effective, evidence-based care. Based on initial observations, we are making progress toward that goal.

Because we have codified best practices, our clinical teams are very clear about what the care paths entail, and we have seen good adherence. The Urological & Kidney Institute reduced its cystectomy costs by 15 percent from 2013 to 2014. Although we did not begin implementing our care paths until 2014, we believe they were a factor in those cost reductions.

Stay tuned. We’re hoping that our first two urologic cancer care paths soon will be integrated into our electronic medical record system, along with operational tools that will better allow us to measure the impact of these efforts. We’ll be monitoring clinician adherence, patient-reported outcomes and costs in 2016 and beyond.

Figure 1. Care path for non-muscle-invasive, low-grade bladder cancer.

Dr. Stephenson is Director of the Glickman Urological & Kidney Institute’s Center for Urologic Oncology and is a staff member of the Cleveland Clinic Cancer Center. He is also an Associate Professor of Medicine at Cleveland Clinic Lerner College of Medicine.