Impact of a Stage IV NSCLC care pathway on front-line (FL) and maintenance (M) chemotherapy use at the Cleveland Clinic Taussig Cancer Institute (TCI).

Background:  Care pathways can reduce cancer care costs and variability in NSCLC. Effective implementation requires measurable outcomes and available data in near real-time.  Methods:  Between 10/1/13 and 7/7/14, TCI developed an evidence and value-based Stage IV NSCLC pathway. For patients with non-squamous EGFR WT/ALK neg NSCLC, ECOG PS 0-2 and sufficient renal function, FL carboplatin/pemetrexed (pem) followed by M pem is recommended standard care while bevacizumab (bev) is not. The pathway recommends best supportive care for pts with ECOG PS ≥ 3. To test feasibility, 4 academic thoracic and 12 community oncologists implemented the pathway into their practices starting 7/7/14. This analysis studies pathway impact on FL and M treatment decisions and charges in patients with metastatic non-squamous EGFR WT/ALK negative NSCLC. 57 pts meeting pathway criteria initiated care with these oncologists from 7/7/14 to 12/31/14 (Cohort A). A retrospective cohort (Cohort B) of 181 pts meeting similar criteria initiated care from 1/1/12 to 7/1/13. Care patterns were defined by manual chart review through 1/8/15. As only 1 Cohort A pt has progressed on M therapy, charge results assume pts who have initiated M pem will receive the same average of 5.11 doses seen in Cohort B. For Cohort B, actual FL and M therapy charges are reported. 3 Cohort B pts remain on M therapy.  Results:  Care patterns in Cohorts A and B were compared. 53 (93%) vs 128 (71%) (p = 0.0003) pts received pathway recommended FL care respectively. 42 (74%) vs 110 (61%) received chemotherapy (p = 0.0839). In pts receiving FL platinum-based regimens, 2 (6%) vs 35 (39%) received bev (p < 0.0001) outside of pathway recommendations. In Cohort A, 6 (32%) completing FL therapy initiated M therapy vs 36 (40%) in Cohort B. In pts completing FL therapy, FL and M drug charges per pt were an estimated $107,258 vs $205,431 (48% decrease).  Conclusions:  Implementation and measurement of adherence to a stage IV NSCLC pathway is feasible at an academic oncology practice with a regional network. This implementation led to a significant improvement in care variation and nearly 50% reduction in chemotherapy charges primarily through decreased bev use.