Establishing a Radiation Oncology Quality Surveillance Program

Abstract

Veterans Health Administration’s (VHA) National Radiation Oncology Program (NROP) has established a quality surveillance program (VA-ROQS) evaluating its radiation oncology practices against metrics established in partnership with ASTRO. VA-ROQS provides comprehensive assessments through continuous, passive, electronic scoring of patient treatments. The VA-ROQS pilot examined 1567 cases, serially selected to include intermediate-risk or high-risk carcinomas of the prostate (CAP), stage IIIA/B non-small cell lung cancer (NSCCa) or limited-stage small cell lung carcinomas (SCCa). Data, collected from the electronic medical records (EMR), treatment management (TMS) or planning (TPS) systems were curated to score 19 Quality Metrics (QM) for lung tumors and 26 QM for prostate cancers. Tumor site panels comprised of nationally-recognized experts identified QM as currently expected, aspirational or for surveillance. Panels selected 34 additional measures based upon dose-volume criteria. Case scores, aggregate scoring and scores relative to other centers were delivered to VHA providers via a Web Portal. Overall, the pass rate for 45 QM was 82.4%. Pass rates for prostate and lung cases were 87.2% and 78.0%, respectively. While aspirational CAP QM for quality of life determinations at consult and at follow-up scored below 50% for 12 and 17 centers, respectively, survivorship care plans and bone health assessments scored uniformly low. Two measures, treatment options discussed for intermediate risk CAP and frequency of follow-up evaluations, varied widely among the practices. QM passing scores for lung cancer assessments were similar among all centers with the exception of the following: addressing smoking cessation, evaluating implanted cardiac devices, motion management, prophylactic cranial irradiation, and follow-up frequency scored <68%. QM identified as aspirational by the panelists included three for treatment timeliness, which passed in >60% of cases. Collection of molecular markers and clinical trial participation scored low. Panels recommended 34 QM related to dose-volume (QMDVH). Mean pass rates were >90% for 10 of the 16 GU-QMDVH, but only 3 of 18 LU-QMDVH. Mean pass rates exceeded 80% for the other LU-QMDVH with the exception of the brachial plexus dose, 53% pass rate, and three ipsilateral lung QMDVH, passing in <30% of cases. The VA-ROQS pilot shows the feasibility of defining and scoring a detailed set of QM for those common tumor presentations for which substantial clinical data exist. Focusing on intermediate and high-risk CAP, stage IIIA/B NSCCa and limited stage SCCa, panels were able to form consensus QM. Moreover, the data necessary to evaluate these metrics were successfully abstracted from electronic sources setting the stage for continuous, remote, fully-electronic peer-reviews. QM derived and evaluated in this way offer a personal pathway for performance improvement.