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Thaker NG, Kudchadker RJ, Incalcaterra JR, Bathala TK, Kaplan RS, Agarwal A, Kuban DA, Frank BD, Das P, Feeley TW, Frank SJ. Improving efficiency and reducing costs of MRI-Guided prostate brachytherapy using Time-Driven Activity-Based costing. Brachytherapy 2021; 21:49-54. [PMID: 34389265 DOI: 10.1016/j.brachy.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Integrated quality improvement (QI) and cost reduction strategies can help increase value in cancer care. Time-driven activity-based costing (TDABC) is a bottom-up costing tool that measures resource use over the full care cycle. We applied standard QI and TDABC methods to improve workflow efficiency and reduce costs for MRI-guided prostate brachytherapy. METHODS AND MATERIALS We constructed process maps of the baseline prostate brachytherapy workflow from initial consultation through one year after treatment. Process maps reflected resources and time required at each step. TDABC costs were calculated by multiplying each process time by the cost per min of the resource(s) used at that step. We then used plan-do-study-act methodology to identify workflow inefficiencies and implement solutions to reduce resource consumption. RESULTS The highest cost components at baseline were the operating room (OR) (40%), imaging (8.7%), and consultation (7.6%). Higher-than-expected costs (3%) were incurred during surgery scheduling. After targeted QI initiatives, OR time was reduced from 90 to 70 min, which reduced overall cost by 5%. Personnel task downshifting reduced costs by 10% at consultation and 77% at surgery scheduling. Re-engineering of follow-up protocols reduced costs by 8.4%. Costs under the new workflow decreased by 18.2%. CONCLUSIONS TDABC complements traditional QI initiatives by quantifying the highest cost steps and focusing QI initiatives to reduce costs and improve efficiency. As payment reform evolves toward bundled payments, TDABC and QI initiatives will help providers understand, communicate, and improve the value of cancer care.
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Affiliation(s)
- Nikhil G Thaker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Division of Radiation Oncology, Arizona Oncology, The US Oncology Network, Tucson, AZ
| | - Rajat J Kudchadker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James R Incalcaterra
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Ankit Agarwal
- Department of Radiation Oncology, The University of North Carolina, Chapel Hill, NC
| | - Deborah A Kuban
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Sanders JW, Venkatesan AM, Levitt CA, Bathala T, Kudchadker RJ, Tang C, Bruno TL, Starks C, Santiago E, Wells M, Weaver CP, Ma J, Frank SJ. Fully Balanced SSFP Without an Endorectal Coil for Postimplant QA of MRI-Assisted Radiosurgery (MARS) of Prostate Cancer: A Prospective Study. Int J Radiat Oncol Biol Phys 2021; 109:614-625. [PMID: 32980498 DOI: 10.1016/j.ijrobp.2020.09.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE To investigate fully balanced steady-state free precession (bSSFP) with optimized acquisition protocols for magnetic resonance imaging (MRI)-based postimplant quality assessment of low-dose-rate (LDR) prostate brachytherapy without an endorectal coil (ERC). METHODS AND MATERIALS Seventeen patients at a major academic cancer center who underwent MRI-assisted radiosurgery (MARS) LDR prostate cancer brachytherapy were imaged with moderate, high, or very high spatial resolution fully bSSFP MRIs without using an ERC. Between 1 and 3 signal averages (NEX) were acquired with acceleration factors (R) between 1 and 2, with the goal of keeping scan times between 4 and 6 minutes. Acquisitions with R >1 were reconstructed with parallel imaging and compressed sensing (PICS) algorithms. Radioactive seeds were identified by 3 medical dosimetrists. Additionally, some of the MRI techniques were implemented and tested at a community hospital; 3 patients underwent MARS LDR prostate brachytherapy and were imaged without an ERC. RESULTS Increasing the in-plane spatial resolution mitigated partial volume artifacts and improved overall seed and seed marker visualization at the expense of reduced signal-to-noise ratio (SNR). The reduced SNR as a result of imaging at higher spatial resolution and without an ERC was partially compensated for by the multi-NEX acquisitions enabled by PICS. Resultant image quality was superior to the current clinical standard. All 3 dosimetrists achieved near-perfect precision and recall for seed identification in the 17 patients. The 3 postimplant MRIs acquired at the community hospital were sufficient to identify 208 out of 211 seeds implanted without reference to computed tomography (CT). CONCLUSIONS Acquiring postimplant prostate brachytherapy MRI without an ERC has several advantages including better patient tolerance, lower costs, higher clinical throughput, and widespread access to precision LDR prostate brachytherapy. This prospective study confirms that the use of an ERC can be circumvented with fully bSSFP and advanced MRI scan techniques in a major academic cancer center and community hospital, potentially enabling postimplant assessment of MARS LDR prostate brachytherapy without CT.
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Affiliation(s)
- Jeremiah W Sanders
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, Texas; Medical Physics Graduate Program, MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas.
| | | | - Chad A Levitt
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Rajat J Kudchadker
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chad Tang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Teresa L Bruno
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christine Starks
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edwin Santiago
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michelle Wells
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carl P Weaver
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jingfei Ma
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, Texas; Medical Physics Graduate Program, MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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The Role of Magnetic Resonance Imaging in Brachytherapy. Clin Oncol (R Coll Radiol) 2018; 30:728-736. [DOI: 10.1016/j.clon.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 11/19/2022]
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Martin GV, Pugh TJ, Mahmood U, Kudchadker RJ, Wang J, Bruno TL, Bathala T, Blanchard P, Frank SJ. Permanent prostate brachytherapy postimplant magnetic resonance imaging dosimetry using positive contrast magnetic resonance imaging markers. Brachytherapy 2017; 16:761-769. [PMID: 28501429 DOI: 10.1016/j.brachy.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/23/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Permanent prostate brachytherapy dosimetry using computed tomography-magnetic resonance imaging (CT-MRI) fusion combines the anatomic detail of MRI with seed localization on CT but requires multimodality imaging acquisition and fusion. The purpose of this study was to compare the utility of MRI only postimplant dosimetry to standard CT-MRI fusion-based dosimetry. METHODS AND MATERIALS Twenty-three patients undergoing permanent prostate brachytherapy with use of positive contrast MRI markers were included in this study. Dose calculation to the whole prostate, apex, mid-gland, and base was performed via standard CT-MRI fusion and MRI only dosimetry with prostate delineated on the same T2 MRI sequence. The 3-dimensional (3D) distances between seed positions of these two methods were also evaluated. Wilcoxon-matched-pair signed-rank test compared the D90 and V100 of the prostate and its sectors between methods. RESULTS The day 0 D90 and V100 for the prostate were 98% versus 94% and 88% versus 86% for CT-MRI fusion and MRI only dosimetry. There were no differences in the D90 or V100 of the whole prostate, mid-gland, or base between dosimetric methods (p > 0.19), but prostate apex D90 was high by 13% with MRI dosimetry (p = 0.034). The average distance between seeds on CT-MRI fusion and MRI alone was 5.5 mm. After additional automated rigid registration of 3D seed positions, the average distance between seeds was 0.3 mm, and the previously observed differences in apex dose between methods was eliminated (p > 0.11). CONCLUSIONS Permanent prostate brachytherapy dosimetry based only on MRI using positive contrast MRI markers is feasible, accurate, and reduces the uncertainties arising from CT-MRI fusion abating the need for postimplant multimodality imaging.
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Affiliation(s)
- Geoffrey V Martin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas J Pugh
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - Usama Mahmood
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rajat J Kudchadker
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Teresa L Bruno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tharakeswara Bathala
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pierre Blanchard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Clinical use of magnetic resonance imaging across the prostate brachytherapy workflow. Brachytherapy 2017; 16:734-742. [PMID: 28153700 DOI: 10.1016/j.brachy.2016.11.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/08/2016] [Accepted: 11/29/2016] [Indexed: 11/21/2022]
Abstract
MRI produces better soft tissue contrast than does ultrasonography or computed tomography for visualizing male pelvic anatomy and prostate cancer. Better visualization of the tumor and organs at risk could allow better conformation of the dose to the target volumes while at the same time minimizing the dose to critical structures and the associated toxicity. Although the use of MRI for prostate brachytherapy would theoretically result in an improved therapeutic ratio, its implementation been slow, mostly because of technical challenges. In this review, we describe the potential role of MRI at different steps in the treatment workflow for prostate brachytherapy: for patient selection, treatment planning, in the operating room, or for postimplant assessment. We further present the current clinical experience with MRI-guided prostate brachytherapy, both for permanent seed implantation and high-dose-rate brachytherapy.
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Pulse sequence considerations for simulation and postimplant dosimetry of prostate brachytherapy. Brachytherapy 2017; 16:743-753. [PMID: 28063817 DOI: 10.1016/j.brachy.2016.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 11/24/2016] [Accepted: 11/28/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this work is to present a brief review of MRI physics principles pertinent to prostate brachytherapy, and a summary of our experience in optimizing protocols for prostate brachytherapy applications. METHODS AND MATERIALS We summarized essential MR imaging characteristics and their interplays that need to be considered for prostate brachytherapy applications. These include spatial resolution, signal-to-noise ratio, image contrast, artifacts, geometric distortion, specific absorption rate, and total scan time. We further described the optimization of the protocols for three pulse sequences: three-dimensional (3D) fast-spoiled gradient echo sequence for T1-weighted imaging, 3D fast-spin echo sequence for T2-weighted imaging, and 3D fast imaging in steady-state precession sequence for combined T1 and T2-weighed imaging. The utilization of an endorectal coil was also described. RESULTS Using the optimized protocols, we acquired high-quality images of the entire prostate within 3-5 minutes for each sequence. These images display the desired image contrasts and a spatial resolution that is equal to or better than 0.59 mm × 0.73 mm × 1.2 mm. While 3D fast-spoiled gradient echo sequence and 3D fast-spin echo sequence depict radioactive seed markers and anatomic structures separately, 3D fast imaging in steady-state precession sequence demonstrates great promise for imaging both seed markers and prostate anatomy simultaneously in a single acquisition. CONCLUSIONS We have optimized current MRI protocols and demonstrated that the anatomic structures and positive contrast radioactive seed markers for prostate post-implant dosimetry can be adequately imaged either separately or simultaneously using different pulse sequences within a total scan time of 3-5 minutes each.
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