Discussion
PEDIATRIC CANCER
We created 14 pediatric cancer symptom management care pathway templates based on CPGs and developed a process to adapt them at 10 institutions. We found that most care pathway statements were adopted or adapted, with 6.4% of statements being rejected. Most commonly, the reason for statement rejection was not agreeing with the statement. We also found that that this process could be accomplished at each institution within a relatively short timeframe.Our description of the care pathway template development and adaptation process is important because implementation of institutional care pathways will likely be an important step toward optimizing supportive care delivery and may result in more consistent care delivery within and across institutions [We do not claim that this process is the only approach toward care pathway development and adaptation and the process will most likely evolve and improve as experience grows. However, the description of this process may facilitate care pathway implementation across institutions in multiple supportive care areas. While our process was successful, it did require considerable resources to enable real-time care pathway adaptations through a series of videoconference calls. It is possible that providing the initial templates to institutions and having them perform the adaptation process independently might be a feasible approach that is less resource intensive. This approach would likely benefit from a local champion to lead the adaptation process and provision of training to local champions. Software to facilitate this process also may be useful.There may be challenges to care pathway implementation [The key outcomes of this process have yet to be measured. They include whether clinicians provide care consistent with their institutional care pathways, and whether patient outcomes are improved when care pathway-consistent care is delivered. These outcomes will be measured and reported as part of the cluster randomized trial. However, as more institutions strive to develop and implement care pathways for supportive care, measuring these outcomes more widely would be useful to improve our fundamental understanding of how these interventions can and should be implemented. It is likely that multi-faceted interventions to improve care pathway implementation will be required.A strength of this work is its conduct at a relatively large number of institutions, providing reassurance that this process can be instituted across different types of institutions. Another strength is the careful documentation of adaptation decisions and the ability to compare these decisions across symptom management care pathways and across institutions. However, our results are limited by the conduct of this study only at institutions in the United States. It is possible that results may differ in other countries.