Clinical pathways: A roadmap to medical success

I recently wrote about the importance of enhanced recovery after surgery (ERAS) protocols and how they are one tool the average small-town urologist can use to ensure that their results match those of high-volume centers. The concept of protocols (or pathways) to ensure high-quality care is not, however, limited to major cases. Further, with the proper application of practice-specific data analysis and quality assurance, clinical pathways are a rare example in medicine where providing excellent medical care and dramatically improving patients’ lives is not only efficient but financially rewarding.

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Probably the best, though certainly not the only, example of a common urologic condition that can be addressed via a well-defined clinical pathway is overactive bladder (OAB). OAB is an exceptionally common condition, with the Urology Care Foundation stating that over 33 million Americans-30% of men and 40% of women-are actively living with OAB symptoms. Treatment ranges from conservative lifestyle changes to medications to neuromodulatory techniques to onabotulinum toxin (Botox) to aggressive surgery (although the indications for augmentation cystoplasty have certainly decreased over the last few decades).

Until recently, clinicians followed general principles (least invasive to more invasive) as well as their own personal experience when guiding patients on the best treatment options. But in 2014, the AUA in conjunction with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, published a well-researched clinical guideline on the treatment of OAB. This document offered specific guidance on the necessary diagnostic steps and offered help with sequencing the available treatment options.

More examples of pathways

The AUA is certainly not the only organization to issue guidelines for the treatment of this condition. For example, the United Kingdom has a well thought-out pathway and one of our industry partners, Medtronic, also offers guidelines.

The availability of guidelines does not ensure that patients are well treated or even treated at all. I learned this fact when I recently attended a dinner hosted by Medtronic. Yes, I understand the inherent conflict of interest that exists regarding Medtronic and OAB. But the company’s presentation is well footnoted, and I agree with its conclusions.

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With that caveat, according to a 2003 paper in the World Journal of Urology (2003; 20:327–36), of the approximately 37.4 millions Americans with OAB, 8.5 million of them actively seek treatment and 3.2 million of those actively seek further advanced treatments due to either medical treatment failure or an inability to tolerate medications (antimuscaranics certainly have their share of side effects). This means that 37% of all patients who seek care for OAB symptoms will need advanced treatments.       

Most practices do not approach that number of patients treated for OAB, according to data from Medtronic, which says as few as 1.8% of patients undergo treatment. Therein lies the opportunity to both improve patient care and thrive financially.

To get there, you need to better understand your own group’s dynamics and this involves data analytics and quality assurance. Like you, when I hear the phrase “data analytics and quality assurance,” I usually dismiss it as the language of a consultant who wants me to pay him or a bureaucrat who’s looking over my shoulder. But this is different. This is the step whereby practices can apply good, evidence-based, pathway-driven medicine to not only provide excellent outcomes for patients, but also be financially successful in the process.

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Do I have your attention yet? I should. To achieve this two-part goal, you need to start with data analytics. Honestly look at your own practice: Ask how many patients you treat with OAB? What insurance environment are we in and what medications are preferred? What advanced treatment option (neurmodulation via the sacral nerve or tibial nerve; Botox) does my group have the best results with? Take that data and use it to develop a practice-specific care pathway.

Creating a pathway

The Medtronic presentation gave examples from Vanderbilt, a large urology group (Metro Urology in metropolitan Minneapolis), and a solo urologist practice. Given the numerous official algorithms that exist (including the AUA’s and the UK’s), creating a pathway shouldn’t be that hard, although getting everyone in the group to agree to it might be.

One key aspect of the pathway is follow-up. The data suggest that as many as 86% of patients stop using medical treatments for OAB in the first few years due to cost, side effects, or low efficacy (Clin Interv Aging 2016; 11:755-60). With that in mind, these pathways suggest that someone (eg, a nurse care navigator) contacts the patient after each treatment intervention to re-assess. This limits the number of patients who “disappear” after one office visit. By maintaining contact with the patient, we can ensure they are getting good response from their treatment and can verify that those patients who fail first-line therapy are moved down the pathway toward more advanced treatments.

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Once you have that in place, the next step is to make sure that the pathway is being followed. This involves evaluating how patients were treated and how they are progressing down the pathway. This should not be seen as Big Brother looking over your shoulder. Instead, view it as an opportunity to identify patients who have veered off the care pathway and whose treatment can be maximized by getting them back on it. Creating a standardized pathway-and having the data to show how your group adheres to it-is also something to present to your local insurance companies and streamline the pre-authorization process and maximize reimbursement. Insurance companies manage risk; if you can help to define that risk, you will be rewarded.

In researching this blog, I quickly learned that the clinical pathways concept is widespread in larger academic centers and in many of the larger integrated urology groups. My hope is you now know that, even with a minimal amount of investment in time and energy, small-town plumbers like us can dramatically improve both patients’ lives and our bottom line.

If anyone else has experience with clinical pathways or has other ideas about how to combine good medicine with financial success, please write me at UT@advanstar.com or sign in below to post a comment. 

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