Development and Implementation of a Clinical Pathway for Radiation of Bone Metastases in a Complex Academic Radiation Oncology Organization

Background: Clinical pathways increase compliance with treatment guidelines, improve outcomes, and reduce costs. Evidence around treatment of complicated bone metastases is increasingly nuanced and although the American Society of Radiation Oncology and the American Association of Hospice and Palliative Medicine recommend single fraction radiation therapy (SFRT) for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on Brigham and Women’s/Dana Farber Cancer Center’s (BW/DFCC) palliative radiation treatment patterns, which are determined by a dedicated palliative radiation consult service (SPRO) at the main BW/DFCC campus, and network physicians who treat more than one disease type at community-based affiliated sites. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of SFRT for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. This was translated to a secure electronic interface as a decision support tool and integrated into daily workflows. Providers were surveyed pre and post implementation to assess expectations and elicit feedback. Rates of pathway compliance and reasons for non-compliance were assessed. Rates of appropriate SFRT use (defined as the number of times SFRT was delivered versus the number of times it was recommended) were compared pre and post implementation. Results: The final pathway includes twenty endpoints and integrates several validated scoring systems, including assessments of life expectancy, spinal stability, and appropriateness of surgical management. It has been used 265 times since launch in March 2016, representing a 35% utilization rate. Appropriate SFRT prescription rates averaged 47% after the pathway was introduced, versus 24% prior to pathway use but post-implementation of SPRO and 23% prior to SPRO’s introduction, representing a significant increase versus both periods (p < 0.01). Major reasons for denying pathway recommendations included clinicians disagreeing with the pathway’s life expectancy prognostication and needing to alter radiation courses for convenience of timing. In qualitative surveys, clinicians felt the pathway increased their confidence with providing guideline concordant care, enhanced their decision-making efficiency, and increased their comfort with treating uncomplicated bone metastases. Workflow disruptions and the inability of the pathway to guide the complicated, nuanced decisions often made at a tertiary care center emerged as pathway limitations. Conclusions: Our experience suggests the feasibility and utility of pathways-based decision support for bone metastases in a complex academic practice setting. Next steps include increasing the pathway’s ease of use to enhance utilization, refining the pathway’s prognostic abilities, and measuring patient reported outcomes and cost savings related to the pathway