Oncologist use of clinical pathways (OCP) has reached 58%. Clinicians and payers have aggressively adopted OCPs as a means of delivering high value care because pathways promise to weigh the efficacy and toxicity of a regimen and, if no significant difference is found, make a therapy determination based on cost. This method facilitates changes in prescribing behavior. One study that measured the effect of a substitution of panitumumab for cetuximab across metastatic colorectal cancer pathways at 2 large health care networks found that selections for cetuximab plummeted from 93.5% to 18.1%.1 The determination of “on-pathway” is frequently subjective depending on a committee’s evaluation of the available data. The American Society of Clinical Oncology advocates for the disclosure of conflicts of interest for OCP committee members and those that contribute to development. We sought to quantify those financial conflicts of interest.
A 2017 OCP market review identified 5 vendors who control 61% of market share: eviti, New Century Health, P4 Pathways, Value Pathways powered by the National Comprehensive Cancer Network (NCCN), and Via Oncology.2 We used the public Centers for Medicare & Medicaid Services Open Payments database (https://www.cms.gov/openpayments/) to abstract the 2015 financial conflicts of interest for the 2016 voting members of Value Pathways powered by NCCN (a collaboration of McKesson Specialty Health, US Oncology, and NCCN), the medical oncology committee chairs for Via Oncology, and the medical advisory board for eviti. We excluded New Century Health because their committees are not public and P4 because Cardinal Health has sunset this product.
This study was not submitted for institutional review board approval because it did not involve health care records and all data are publicly available. The Physician Payments Sunshine Act requires pharmaceutical manufacturers to report physician payments of $10 or more. Payment categorizations include (1) general payments, including consulting fees, meals, and grants; and (2) research payments related to clinical investigations (https://www.cms.gov/OpenPayments/Downloads/Affordable-Care-Act-Section-6002-Final-Rule.pdf). We excluded research payments because physicians included in shaping practice guidelines are often those involved in research and these payments are generally not accrued for personal use. Inaccuracies in this database have been identified,3 but it remains the most comprehensive source for financial payments to physicians.
Nearly all physicians received nonresearch payments, including 92% of US Oncology voting members, 86% of NCCN voting members, 84% of Via Oncology chairs, and 69% of the eviti medical advisory board (Table). Fifteen percent of US Oncology voting members, 19% of the eviti medical advisory board, 28% of Via Oncology chairs, and 47% of the NCCN voting members received $10 000 or more in general payments (Figure).
In critical care, the Surviving Sepsis campaign demonstrated the perils that FCOI can play in pathway development. Eichacker et al4 found that these protocols were “usurped” for commercial purposes and future policies should “prohibit the pharmaceutical and medical-device industries from directly or indirectly funding or influencing practice standards.” Recently, California introduced the Oncology Clinical Pathways Act of 2017, requiring a health care service plan that develops and implements an OCP to provide to practitioners upon request “the names, qualifications, institutional affiliations, and any conflicts of interest of the physicians and other individuals who conducted the research, developed the analysis, and assessed the oncology clinical pathways.”5 The California Association of Health Plans opposed this bill, asserting that by releasing panelists’ names they would be subject to lobbying by numerous entities. This proposed legislation and the California Association of Health Plans’ response highlight the concern and complexity around OCP transparency. Collaboration with industry is key to innovation; however, to ensure patient and clinician trust and maintain their momentum in the value space, pathway developers will need to be transparent about FCOI and how those interests are managed. Many vendors have begun this process, and 1 suggestion would be to take guidance from the Institute of Medicine’s recommendations for groups charged with clinical practice guideline development.6
Accepted for Publication: October 9, 2017.
Corresponding Author: Bobby Daly, MD, MBA, Memorial Sloan Kettering Cancer Center, 885 Second Ave, New York, NY 10017 (email@example.com).
Published Online: December 21, 2017. doi:10.1001/jamaoncol.2017.4473
Author Contributions: Dr Daly had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Daly, Bach.
Acquisition, analysis, or interpretation of data: Daly, Page.
Drafting of the manuscript: Daly.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Daly.
Administrative, technical, or material support: Daly.
Study supervision: Bach.
Conflict of Interest Disclosures: Dr Daly reports serving in a leadership role in Quadrant Holdings and owning stock or other assets in Quadrant Holdings and Walgreens Boots Alliance. Dr Page serves as a consultant for Via Oncology Pathways.
et al. Clinical pathways: management of quality and cost in oncology networks in the metastatic colorectal cancer setting. J Oncol Pract
. 2017;13(5):e522-e529.PubMedGoogle ScholarCrossref
A. Clinical pathways: a current snapshot, and the journey ahead. J Clin Pathways
. 2017;3(2):33-40.Google Scholar
JS. Financial relationships with industry among National Comprehensive Cancer Center Network guideline authors. JAMA Oncol
. 2016;2(12):1660.PubMedGoogle ScholarCrossref
RL. Surviving sepsis—practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med
. 2006;355(16):1640-1642.PubMedGoogle ScholarCrossref
Oncology Clinical Pathways Act of 2017, AB 1107, California Assembly Committee on Health (April 2017).
Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: National Academies Press; 2009.