Can Clinical Pathways Help Combat Health Care Disparities?

February 24, 2021 Monica Soni, MD

A new research effort aims to gauge whether certain groups of patients receive high-value therapies at lower rates than others. 

Effective, appropriate, cost-saving—these are part of the lexicon of evidence-based clinical pathways.

But how about "equitable" or "just"? Should those terms be part of the conversation, too?  

In theory, well-designed clinical pathways aren't just a tool for ensuring individual patients receive the most effective therapies. They can also help combat health care disparities on a large scale. Basing treatment decisions on the best available evidence and patient-specific factors, pathways should help protect against inequalities and biases seeping into patient care.

Using oncology pathways, for example, providers enter the details of the patient's case—any genomic or molecular markers, previous rounds of treatment, and more—and receive a list of preferred regimens tailored to that individual patient. All patients should get the most effective, least toxic treatment available, regardless of race or ethnic group.

But does the theory hold? If not, which groups of patients are faring worse, and why? That’s something we’re hoping to discover this year at New Century Health, as we study prescribing patterns from our health plan partners.

The Burden of Disparities in Oncology and Cardiology

Health disparities have always plagued us, but the COVID-19 pandemic has magnified them. The drop in life expectancy among the Black population in the first half of 2020 was a stunning 2.7 years—nearly three times that of the overall population.

Aside from the risks posed by the coronavirus itself, the pandemic has led to delayed routine screenings, avoided emergency department visits, and interrupted therapy. It is reasonable to expect that the communities of color most affected by the pandemic will unfortunately be the same ones who suffer the most from undiagnosed and untreated diseases.

Oncology and cardiology—the specialties that New Century Health manages—will no doubt see an uptick in advanced stage and complicated presentations. And they are specialties where disparate treatments were already a problem. In oncology, Black patients with non-small cell lung cancer have been found to be less likely than white patients to be tested for a mutated gene, and also less likely to be treated with gene-targeted therapy. Hispanic and Black patients with stomach cancer have been shown to be less likely than white patients to receive chemotherapy before surgery. Women in rural areas with ductal carcinoma in situ receive radiotherapy less frequently after breast-conserving surgery than women in urban areas.

Similar findings exist in the treatment of cardiovascular diseases. For example, according to a study published last year, diagnoses of aortic stenosis were missed more frequently among underrepresented racial and ethnic minorities. Socioeconomic and racial disparities also characterized which patients underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. For every $10,000 in income, the odds of undergoing TAVR increased 10%.

But there's hope that standardizing care can blunt such differences. For example, computerized-decision support has helped reduce disparities in prophylaxis for harmful blood clots. Widely used surgical protocols eliminated disparities in postoperative length of stay for patients undergoing colorectal surgery. Logically, standardized clinical pathways should have the same effect.

A Learning Opportunity

New Century Health is well placed to understand the connection between pathways and disparities. Our payer partners cover millions of members, and we engage thousands of oncologists and cardiologists to ensure use of the most effective tests and treatments. We regularly report back to providers on their adherence to high-value care pathways and lead discussions around continued improvement.

What's new this year is that we are merging patient demographic information, which we haven't previously held, into our clinical data sets. We'll then begin querying this repository in search of patterns. Are there groups of patients who don't receive a high-value regimen as frequently as other patients with nearly identical cases? Are these disparities focused on certain disease groups or on physician practices?

If we don't discover any significant gaps, that will certainly be cause for celebration. If we do find disparities, it's an improvement opportunity. We’ll take what we've discovered back to payers and provider groups, seek to understand the causes, and talk strategically about how to improve. There might be issues that we can impact directly through better treatment decisions. There may also be more structural issues at play, such as network adequacy or transportation barriers that make it more difficult to follow the best available regimen.

Whatever our findings, this is an opportunity to contribute to knowledge about how we can eliminate the unequal outcomes that gnaw at our health care system. 

About the Author

Monica Soni, MD

As senior medical director for Medicaid and Exchange Solutions, Dr. Monica Soni works to ensure high-quality, cost-effective care for patients and the best possible experience for providers. She is a board-certified, practicing internal medicine physician with over a decade of experience in both inpatient and outpatient safety net care. Immediately prior to joining New Century Health, Dr. Soni served as the director of specialty care for the Los Angeles County Department of Health Services, the second-largest municipal health system in the United States. She is also an assistant clinical professor within the UCLA Department of Medicine.

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