“I sleep better at night:” How peer review of radiation treatment plans indirectly improves quality of care across radiation treatment programs

A Blinded, Prospective Study of Error Detection During Physician Chart Rounds in Radiation Oncology

PURPOSE

Peer review during physician chart rounds is a major quality assurance and patient safety step in radiation oncology. However, the effectiveness of chart rounds in detecting problematic treatment plans is unknown. We performed a prospective blinded study of error detection at chart rounds to clarify the effectiveness of this quality assurance step.

METHODS AND MATERIALS

Radiation Oncology Incident Learning System publications were queried for problematic plans approved for treatment that would be detectable at chart rounds. A resident physician, physicist, and dosimetrist collaboratively generated 20 treatment plans with simulated errors identical in nature to those reported to the Radiation Oncology Incident Learning System. These were inserted randomly into weekly chart rounds over 9 weeks, with a median of 2 problematic plans presented per chart rounds (range, 1-4). Data were collected on detection, attendance, length, and number of cases presented at chart rounds. Data were analyzed using descriptive statistics and univariable logistic regression with odds ratios.

RESULTS

The median length of chart rounds over the study period was 60 minutes (range, 42-79); median number of cases presented per chart rounds was 45 (range, 38-50). The overall detection rate was 55% (11 of 20). Detection rates were higher for cases presented earlier in chart rounds: 75% versus 25% of problematic plans were detected within 30 minutes of start of chart rounds versus after 30 minutes (odds ratio, 0.11; 95% confidence interval, 0.01-0.88; P = .037). Detection rates showed a trend toward increase during the study period but this was not significant: 33% in weeks 1 to 5 and 73% during weeks 6 to 9 (5.3; 95% confidence interval, 0.78-36; P = .08).

CONCLUSIONS

The detection of clinically significant problematic plans during chart rounds could be significantly improved. Problematic plans are more frequently detected earlier in chart rounds and inserting such plans into chart rounds may enhance detection; however, larger studies are needed to confirm these findings. A multi-institutional study is planned.

Development of Best Practices of Peer Review for Lung Radiation Therapy

PURPOSE

Peer review (PR) is an important component in ensuring high-quality lung radiotherapy (RT) plans. However, there are inconsistencies in the extent, timing, and minimum requirements for PR. We sought to develop guidelines of best practices for PR in curative lung RT through an expert consensus process.

METHODS

A modified Delphi process was conducted that consisted of an initial review by a dedicated steering committee followed by a pan-Canadian, multidisciplinary Delphi panel with 3 rounds (premeeting survey, face-to-face meeting, and postmeeting ratification survey). Candidate PR elements were ranked by importance and stratified by treatment of locally advanced (LA) disease with conventional RT or stereotactic ablative body RT (SABR) for early-stage disease.

RESULTS

For the LA case, 6 elements (indications for RT, gross tumor volume [GTV], clinical target volume [CTV], internal target volume [ITV], dose/fractionation, and normal lung dosimetry) were considered as essential PR elements. Of these, 90%-100% of the panel endorsed them to be important to PR, and 80% believed that the PR should be done by a second radiation oncologist (RO). In the SABR case, 6 PR elements (indications for RT, GTV, CTV/ITV, organs at risk contours, dose/fractionation, and composite plan review) were deemed essential. Of these, 90%-100% of panel members believed these elements to be important to PR and unanimously agreed that PR should be done by a second RO.

CONCLUSION

A suite of PR elements for lung RT has been developed and endorsed with high consensus. This suite should serve as a basis to help to harmonize PR practices across centers and to help to develop novel PR approaches going forward.

Implementation of peer-review quality rounds for gynecologic brachytherapy in a high-volume academic center

PURPOSE

While peer review is critical for quality and safety in radiotherapy, there are neither formal guidelines nor format examples for brachytherapy (BT) peer review. We report on a gynecologic BT peer-review method implemented at a high-volume academic center.

METHODS AND MATERIALS

We analyzed discussions at bimonthly gynecologic BT peer-review rounds between July and December 2018. Rounds consisted of 2-5 attending physicians with gynecologic BT expertise, 1-2 BT physicists, and trainees. Peer-review targets included clinical case review, contours, implant technique, dose/fractionation, and target/organ-at-risk (OAR) dosimetry. The projected/final target and OAR dosimetry were analyzed.

RESULTS

55 separate implants from 44 patients were reviewed. Implants were mostly reviewed after the first BT fraction (n = 16, 29%) or at another time point during BT (n = 20, 36%). One (2%) implant was presented prospectively. The applicator type and BT technique were reviewed for all implants. Dose/fractionation was evaluated for 46 implants (84%); contours were discussed for 21 (38%). Target and OAR dosimetry were reviewed for 54 (98%) and 28 implants (51%), respectively. Six cases (11%) underwent minor changes to the applicator type to improve target and/or OAR dosimetry. One case (2%) had a major change recommended to the dose/fractionation.

CONCLUSIONS

Gynecologic BT peer review may enhance BT quality by allowing for implant optimization and formal review of challenging cases, ultimately improving medical decision-making and team communication. Peer review should be implemented in centers offering gynecologic BT.

Outcomes of Peer Review for Radiotherapy Treatment Plans With Palliative Intent

PURPOSE

Peer review of a proposed treatment plan is increasingly recognized as an important quality activity in radiation medicine. Although peer review has been emphasized in the curative setting, applying peer review for treatment plans that have palliative intent is receiving increased attention. This study reports peer review outcomes for a regional cancer center that applied routine interprofessional peer review as a standard practice for palliative radiotherapy.

METHODS AND MATERIALS

Peer review outcomes for palliative radiotherapy plans were recorded prospectively for patients who began radiotherapy between October 1, 2015, and September 30, 2017. Recommended and implemented changes were recorded. The content of detailed discussions was recorded to gain insight into the complexities of palliative treatment plans considered during peer review.

RESULTS

Peer review outcomes were reviewed for 1,413 treatment plans with palliative intent. The proportions of detailed discussions and changes recommended were found to be 139 (9.8%) and 29 (2.1%), respectively. The content of detailed discussions and changes recommended was categorized. Major changes represented 75.9% of recommended changes, of which 84.2% were implemented clinically.

CONCLUSION

Many complexities exist that are specific to palliative radiotherapy. Interprofessional peer review provides a forum for these complexities to be openly discussed and is an important activity to optimize the quality of care for patients with treatment plans that have palliative intent.

Radiation therapy quality assurance in head and neck radiotherapy - Moving forward

Head and Neck Cancer (HNC) radiation oncologists (ROs) enjoy the immense pleasure of curing patients, working within a large multidisciplinary team to effectively deliver curative intent treatment whilst also aiming to minimise late treatment toxicity. Secondary analyses of large-scale HNC clinical trials have shown the critical impact of the quality of radiotherapy plans, where protocol non-compliant plans have yielded inferior survival rates approximating 20%. The peer review process in routine day-to-day HNC practice shows that even in major academic centers a significant proportion of RT plans may require changes to the radiotherapy planning volume. Optimising the therapeutic ratio in HNC has been dramatically facilitated by intensity modulated radiotherapy (IMRT), but that technology has also increased the complexity of HNC radiotherapy treatment and high-volume centers with experienced clinicians may be best placed to deliver this most accurately. International consensus guidelines to standardise or benchmark best practice with respect to the RT-QA process in HNC are needed. The aim of this paper is to highlight the importance of the RT-QA process in the HNC treatment process and to make some recommendations for its inclusion in both clinical trials and routine clinical practice.