Protection of quality and innovation in radiation oncology: the prospective multicenter trial QUIRO of DEGRO: evaluation of time, attendance of medical staff, and resources during radiotherapy with tomotherapy

A taskforce for national improvement of innovation implementation in radiotherapy

BACKGROUND AND PURPOSE

Previous research among Dutch radiotherapy centres (RTCs) showed that 69% of innovations was simultaneously implemented in 7/19 centres, with a success rate of 51%. However, no structure to share lessons learned about the implementation process existed. Therefore, a national Taskforce Implementation (TTI) was raised to stimulate efficient implementation of innovations. The aim of the current study was to develop and pilot-evaluate a website for facilitating mutual learning on implementation issues.

MATERIAL AND METHODS

First, we made an inventory in all Dutch RTCs on their 10 most valuable innovations between 2019 and 2022. In-depth interviews, structured according to the Consolidated Framework for Implementation Research, were performed on the four most mentioned topics. A website was built, and pilot evaluated 1 year after the launch, using a qualitative survey amongst the TTI members.

RESULTS

In 13/18 centres, 19 interviews were conducted on 1) automation, 2) patient participation, 3) adaptive radiotherapy 4) surface guided radiotherapy and tracking. Most innovations (13/16) were implemented with a delay, with many comparable challenges: e.g. shortage of personnel (7/16) and prioritization of projects (9/16). The website allows users to upload and search for projects, including implementation experiences. After 1 year, 14 projects were uploaded. The qualitative evaluation was largely positive with room for improvement, i.e.75 % would recommend the website to others.

CONCLUSION

This study showed that RTCs experience comparable challenges when implementing innovations, thereby underlining the need for a platform to share implementation-lessons learned. The first concept of this platform was evaluated positively.

Multinational Enterprises’ Knowledge Transfer Received Dimensions and Subsidiary Innovation Performance: The Impact of Human Resource Management Practices and Training and Development Types

In this paper, we adopt the resource-based view theory as the theoretical framework to empirically investigate the relationship among knowledge transfer received dimensions (i.e., tacit and explicit), human resource management practices, training and development types (i.e., on-the-job training and development, and off-the-job training and development) and subsidiary innovation performance. Using a survey dataset from 314 subsidiaries of foreign multinational enterprises located in China, we find that: (1) knowledge transfer received dimensions contribute to subsidiary innovation performance; (2) human resource management practices can positively moderate knowledge transfer received dimensions and subsidiary innovation performance; (3) the positive effect of human resource management practices on the knowledge transfer received dimensions- subsidiary innovation performance link increases when on-the-job training and development and off-the-job training and development is high. The study also provides insight into how knowledge transfer received dimensions, human resource management practices, and training and development types matter importantly to the subsidiary’s innovation performance.

Implementation of MR-linac and proton therapy in two radiotherapy departments in The Netherlands: Recommendations based on lessons learned

Recently, two new treatment techniques, i.e. proton therapy and MR-linac based radiotherapy (RT), have been introduced in Dutch RT centres with major impact on daily practice. The content and context of these techniques are frequently described in scientific literature while little is reported about the implementation phase. This process is complex due to a variety of aspects, such as the involvement of multiple stakeholders, significant unpredictability in the start-up phase, the impact of the learning curve, standard operating procedures under development, new catchment areas, and extensive training programs. Insight about implementation in daily care is utterly important for clinics that are about to introduce these new technologies in order to prevent that every centre needs to reinvent the wheel. This position paper gives an overview of the implementation of proton therapy and MR-linac based RT in two large academic RT centres in the Netherlands, i.e. Maastro and Radboudumc respectively. With this paper we aim to report our lessons learned, in order to facilitate other RT centres that consider introducing these and other new techniques in their departments.

Current status and developments of German curriculum-based residency training programmes in radiation oncology

Purpose

The current status of German residency training in the field of radiation oncology is provided and compared to programmes in other countries. In particular, we present the DEGRO-Academy within the international context.

Methods

Certified courses from 2018 and 2019 were systematically assigned to the DEGRO-Curriculum, retrospectively for 2018 and prospectively for 2019. In addition, questionnaires of course evaluations were provided, answered by course participants and collected centrally.

Results

Our data reveal a clear increase in curriculum coverage by certified courses from 57.6% in 2018 to 77.5% in 2019. The analyses enable potential improvements in German curriculum-based education. Specific topics of the DEGRO-Curriculum are still underrepresented, while others decreased in representation between 2018 and 2019. It was found that several topics in the DEGRO-Curriculum require more attention because of a low DEGRO-curriculum coverage. Evaluation results of certified courses improved significantly with a median grade of 1.62 in 2018 to 1.47 in 2019 (p = 0.0319).

Conclusion

The increase of curriculum coverage and the simultaneous improvement of course evaluations are promising with respect to educational standards in Germany. Additionally, the early integration of radiation oncology into medical education is a prerequisite for resident training because of rising demands on quality control and increasing patient numbers. This intensified focus is a requirement for continued high standards and quality of curriculum-based education in radiation oncology both in Germany and other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01785-7.

Accurate method for evaluating the duration of the entire radiotherapy process

BACKGROUND AND PURPOSE

Along with the increasing demand for high-quality radiotherapy and the growing number of high-precision radiotherapy devices, precise radiotherapy workflow management and accurate time evaluation of the entire radiotherapy process are crucial to providing appropriate, timely treatment for cancer patients. This study therefore aimed to establish an accurate, reliable method for evaluating the duration of the radiotherapy process, from beginning to end, based on real-time measurement data. These data are vital for improving the quality and efficiency of radiotherapy delivery.

MATERIALS AND METHODS

Altogether, 17 620 cancer patients' radiotherapy experiences were measured in real time in our radiation oncology department. The process was divided into five sequential core modules, with the start and stop times of each module automatically recorded using MOSAIQ software, an automated radiotherapy management system. The duration for each module and the total duration of the entire process were then automatically calculated and qualitatively analyzed.

RESULTS

The analysis showed significant treatment-time differences depending on the tumor site, which provided a practical reference for improvement of previous treatment modules and appointments management. In all, >60% of the cancer patients' total treatment time could be shortened.

CONCLUSIONS

We established a reliable method for evaluating the overall duration of radiotherapy protocols. The results pointed out a clear pathway by which we could improve future radiotherapy workflow management and appointment systems.

Helical tomotherapy: Comparison of Hi-ART and Radixact clinical patient treatments at the Technical University of Munich

The helical tomotherapy (HT) Hi-ART system was installed at our department in April 2007. In July 2018 the first Radixact system in Germany has been launched for clinical use. We present differences, advantages and disadvantages and show future perspectives in patient treatment using two HT devices. We investigate patient characteristics, image quality, radiotherapy treatment specifications and analyze the time effort for treatments with the Hi-ART system from April 2010 until May 2017 and compare it to the data acquired in the first nine months of usage of the Radixact system. Comparing the Hi-ART and Radixact system, the unique option of integrated MVCT image acquisition has experienced distinct improvement in image quality. Time effort for irradiation treatment could be improved resulting in a mean beam on time for craniospinal axis treatment of 636.2 s for the Radixact system compared to 915.9 s for the Hi-ART system. The beneficial use of tomotherapy for complex target volumes is demonstrated by a head and neck tumor case and craniospinal axis treatment. With the Radixact system MVCT image quality has been improved allowing for fast and precise interfraction dose adaptation. The improved time effort for patient treatment could increase the accessibility for clinical usage.

Effectiveness of tomotherapy vs linear accelerator image-guided intensity-modulated radiotherapy for localized pharyngeal cancer treated with definitive concurrent chemoradiotherapy: a Taiwanese population-based propensity score-matched analysis

OBJECTIVE

This study used a population-based propensity score (PS)-matched analysis to compare the effectiveness of tomotherapy-based image-guided intensity-modulated radiotherapy (referred to as T-IMRT) with that of linear accelerator based (referred to as L-IMRT) for clinically localized pharyngeal cancer (LPC, divided into nasopharyngeal cancer and non-nasopharyngeal cancer) with definitive concurrent chemoradiotherapy (CCRT).

METHODS

Eligible LPC patients diagnosed between 2007 and 2014 were identified among all citizens in Taiwan from the Health and Welfare Data Science Center database. A PS-matched sample based on the PS estimated from the covariables of interest was constructed to compare the effectiveness of T-IMRT with L-IMRT. In the primary analysis, overall survival (OS) was compared for assessment of effectiveness. We also evaluated freedom from local regional recurrence and pharyngeal cancer-specific survival and performed supplementary analyses.

RESULTS

The study population included 960 patients equally divided into two groups. OS did not differ significantly between the T-IMRT and L-IMRT groups (hazard ratio for death: 0.82, p = 0.15, 5-year OS rate: 79 and 74% for T-IMRT and L-IMRT, respectively), and there were no significant differences in the other endpoints or supplementary analyses.

CONCLUSION

For LPC patients treated with definitive CCRT, we found no significant difference in disease control or survival between the T-IMRT and L-IMRT groups. However, further studies, especially randomized trials or studies focusing on other dimensions, such as quality of life, are needed. Advances in knowledge: We provide the first population-based study, as well as the largest study, on the clinical effectiveness of T-IMRT compared with L-IMRT in conjunction with CCRT in LPC patients.

What is the impact of innovation on output in healthcare with a special focus on treatment innovations in radiotherapy? A literature review

Objective:

To analyse how often innovations in healthcare are evaluated regarding output, especially in radiotherapy. Output was defined as either survival, toxicity, safety, service, efficiency or cost-effectiveness.

Methods:

A systematic literature review was conducted, using three search strategies: (1) innovations in general healthcare; (2) radiotherapy-specific innovations, i.e. organizational innovations and general implementation of innovations; (3) innovations per tumour group/radiotherapy technique. Scientific levels were classified according to the system used in European Society for Medical Oncology guidelines. Finally, we calculated the percentage of implemented innovations in Dutch radiotherapy centres for which we found evidence regarding output in the literature review.

Results:

Only 94/1072 unique articles matched the inclusion criteria. Significant results on patient outcome, service or safety were reported in 65% of papers, which rose to 76% if confined to radiotherapy reviews. A significant technological improvement was identified in 26%, cost-effectiveness in 10% and costs/efficiency in 36% of the papers. The scientific level of organizational innovations was lower than that of clinical papers. Dutch radiotherapy treatment innovations were adequately evaluated on outcome data before implementation in clinical routine in a minimum of 64–92% of cases.

Conclusion:

Only few studies report on output when considering innovations in general, but radiotherapy reviews give a reasonably good insight into innovation output effects, with a higher level of evidence. In Dutch radiotherapy centres only small improvements are possible regarding evaluation of treatment innovations before implementation.

Advances in knowledge:

This study is the first of its kind measuring how innovations are evaluated in scientific literature, before implementation in clinical practice.

What is the degree of innovation routinely implemented in Dutch radiotherapy centres? A multicentre cross-sectional study

Objective:

To study the implementation of innovation activities in Dutch radiotherapy (RT) centres in a broad sense (product, technological, market and organizational innovations).

Methods:

A descriptive cross-sectional study was conducted in 15 Dutch RT centres. A list of innovations implemented from 2011 to 2013 was drawn up for each centre using semi-structured interviews. These innovations were classified into innovation categories according to previously defined innovation indicators. Where applicable, each innovation was rated by each centre on the effort required to implement it and on its expected effects, to get an impression of how far reaching and radical the innovations were and to be able to compare the number of innovations between centres.

Results:

The participating RT centres in the Netherlands implemented 12 innovations per year on average (range 5–25); this number was not significantly different for academic (n = 13) or non-academic centres (n = 10). Several centres were dealing with the same innovations at the same time. The average required effort and expected output did not differ significantly between product, technological and organizational innovation or between academic and non-academic centres.

Conclusion:

The number of innovations observed per centre varied across a large range, with a large overlap in terms of the type of innovations that were implemented. Registering innovations using the innovation indicators applied in our study would make it possible to improve collaboration between centres, e.g. with common training modules, to avoid duplication of work.

Advances in knowledge:

This study is the first of its kind investigating innovation implementation in RT in a broad sense.

Developing and implementing a Radiotherapy Research Activity Assessment Tool (RAAT): a prospective feasibility study

Aim

Cancer research in the National Health Service has increased by 10·5% in 3 years since the formation of the National Cancer Research networks in 2000. The initial enthusiasm from clinical staffs to embark on a project has to be balanced against the implications of resources, costs and other developments. There is no standardised method to assess the impact of research projects on clinical practice. The aim of this project was to develop and implement a Radiotherapy Research Activity Assessment Tool (RAAT) to assess the feasibility of newly proposed projects within clinical settings.

Methods and materials

A multi-step development method was used. The steps involved the principles of quality function deployment. The consecutive steps involved developing a user-friendly and replicable tool and would fit on one A4 page. The process involved multi-professionals and patients throughout the design process. The tool was preliminary tested on usability among eight stakeholders on a ten-point scale (1=poor; 10=very good). Percentage agreement was evaluated at 6 month post initial RAAT assessment scoring by the seven multi-disciplinary team (MDT) members.

Findings

The RAAT was developed in an e-form available in Microsoft Excel. The tool scored a mode of 6 for usability. Interrater reliability testing between the radiotherapy MDT resulted in 88% agreement. The RAAT seems to be feasible in clinical practice, and provide a framework to guide the decision-making process. The study calls for further testing of usability and review of long-term implications on all stakeholders.

How efficient is translational research in radiation oncology? The example of a large Dutch academic radiation oncology department

Objective:

To study the efficiency of research implementation in a large radiotherapy institute, in either an internal review board-approved clinical trial or clinical routine.

Methods:

Scientific publications of the institute were listed. We asked clinicians from tumour expert groups whether the study had been implemented yet in a clinical trial or in clinical practice and which facilitators or barriers were relevant. An independent investigator verified all results. We calculated the implementation rates and the frequency of mentioned facilitators and barriers.

Results:

Resident researchers had published 234 studies over the past 4 years. Overall, 70/234 (30%) technical or preclinical studies were tested or implemented in a clinical environment in either trials or routine. In total, 45/234 (19%) studies were routinely implemented; in the 61 clinical studies, this percentage was higher: 38% (23/61). The main facilitator was the level of evidence and the main barriers were workload and high complexity.

Conclusion:

We were able to calculate the implementation ratio of published research into clinical practice and set benchmark figures for other radiotherapy clinics. Level of evidence was an important facilitator, while workload and high complexity of the new procedures were important barriers for implementation. Recent articles suggest that academic entrepreneurship will facilitate this process further.

Advances in knowledge:

This study is the first of its kind calculating implementation rates of published studies in the clinical environment and can contribute to the efficiency of translational research in radiotherapy. We propose to use this metric as a quality indicator to evaluate academic departments.

Evaluation of the time required for overhead tasks performed by physicians, medical physicists, and technicians in radiation oncology institutions: the DEGRO-QUIRO study

OBJECTIVE

Developments in radiation oncology in recent years have highlighted the increasing deployment of personnel resources for tasks not directly related to patients. These tasks include patient-related activities such as treatment planning, reviewing files, and administrative duties (e.g., invoicing for services, documentation). The aim of the present study, part of the QUIRO project of the German Society of Radiation Oncology (DEGRO), was to describe, on the basis of valid data, the deployment of personnel resources in radiation oncology centers for "overhead" tasks.

METHODS

Questionnaires were used to analyze the percentages of time needed for various tasks. The target group comprised physicians, medical physics experts (MPE), and medical technical radiology assistants (MTRA). A total of 760 personnel from 65 radio-oncology centers in the German inpatient and outpatient sector participated (32 % physicians, 23 % MPE, and 45 % MTRA).

RESULTS

High percentages of overhead tasks during working time were measured for each of the three personnel groups considered (physicians, MPE, and MTRA). Patient-related efficiency, i.e., the percentage of working time associated directly or indirectly with the patient, was highest among MTRA and lowest among MPE. Particular features could be seen in the activity profiles of personnel in university clinics. Duties in the areas of research and teaching resulted in a greater percentage of overhead tasks for physicians and MPE. Irrespective of function (physician, MPE, or MTRA), a managerial role resulted in lower patient-related efficiency, as well as a narrower time budget for direct patient care compared with non-managerial employees.

CONCLUSION

Using the data gathered, it was possible to systematically investigate the time required for overhead tasks in radio-oncological centers. Overall, relatively high time requirements for a variety of overhead tasks were measured. These time requirements, generated for example by administrative duties or research and teaching, are currently not taken into adequate consideration in terms of remuneration or personnel capacity planning.