Prescription of Evidence-Based Single Fraction Radiation Therapy for Bone Metastases Can be Increased in a Meaningful and Sustained Way on a Population Level Using Quality Assurance Data

Abstract

There is ample evidence that a single fraction of radiation therapy (SFRT) is as equally efficacious as more costly and potentially morbid multi-fraction regimens. In our large provincial program, we previously demonstrated that a multi-pronged educational and audit intervention increased the use of SFRT in all regional cancer centers the year following. However, other investigators have demonstrated interventions focused on guideline dissemination were only associated with a transient one year change in prescribing practices, and therefore we sought to determine if our use of SFRT also returned to baseline or persisted. Several province-wide interventions were implemented in 2012 to increase the use of SFRT, including an audit of prescribing practices of individual physicians (anonymized) and center averages (non-anonymized) and subsequent presentation of these results to leaders and oncologists. After individual patient chart review, we subsequently compared the use of SFRT in all patients treated with bone metastases in our provincial program from 2007-2011 (pre-intervention) and 2013-2016 (post-intervention), and performed comparison across all six provincial cancer centers. Prior to the intervention, the rates of SFRT in 2007, 2008, 2009, 2010, and 2011 were 51, 51, 48, 49, and 48, while the rates post intervention in 2013, 2014, 2015, and 2016 were 60, 60, 57, and 54% (p <0.001). In the most recent year of this study (2016), 4 of the 6 provincial centers prescribed in a relatively narrow range (45, 48, 53, and 54%). However, there was little change in the center with the lowest use of SFRT (26% to 25%) or in the center with the highest use of SFRT (73% to 75%). Our audit and educational based intervention resulted in a lasting change in practice. A small trend toward decreasing SFRT in recent years was observed, though rates were still above our pre-intervention level and well above international comparisons. Our provincial rate is similar to a previously published recommended benchmarks rate of 60%, though we continue to see significant variation by center, suggesting further room for improvement in provincial standardization. With the potential of emerging evidence in support of stereotactic ablative radiation therapy for select populations of patients with bone metastases, future benchmark rates of SFRT use should be readdressed, though our data suggest programmatic comparison and dissemination of SFRT prescribing practices can achieve a population based SFRT utilization rate of over 50%.