title: How effective are clinical pathways with and without online peer-review? An analysis of bone metastases pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network.
abstract: OBJECTIVE
  Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network.
  
  
  METHODS
  In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10-14 fractions for certain clinical situations. The data were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010.
  
  
  RESULTS
  In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1-5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1-5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1-1.4) for community and 1.3 (confidence interval, 1.1-1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001).
  
  
  CONCLUSIONS
  This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice.
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA. beriwals@upmc.edu
authors.forename: Sushil
authors.initials: S
authors.lastname: Beriwal
authors.forename: Malolan S
authors.initials: MS
authors.lastname: Rajagopalan
authors.forename: John C
authors.initials: JC
authors.lastname: Flickinger
authors.forename: Susan M
authors.initials: SM
authors.lastname: Rakfal
authors.forename: Edwin
authors.initials: E
authors.lastname: Rodgers
authors.forename: Dwight E
authors.initials: DE
authors.lastname: Heron
mesh_terms: D001859:Bone Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D003365:Costs and Cost Analysis; D019091:Critical Pathways / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D020000:Decision Support Systems, Clinical; D019583:Dose Fractionation, Radiation; D006801:Humans; D054547:National Cancer Institute (U.S.); D009862:Online Systems; D059408:Pain Management / Q000379:methods; D010166:Palliative Care / Q000191:economics / Q000458:organization & administration / Q000592:standards; D010380:Peer Review / Q000379:methods*; D018787:Radiation Oncology / Q000191:economics / Q000458:organization & administration; D014481:United States