Prospective Case Review in Radiation Oncology Prior to Treatment Delivery

Abstract

AMISHI BAJAJ, BA, is a medical student at Loyola University Chicago. ABHISHEK A. SOLANKI, MD, MS, is Assistant Professor in the Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Stritch School of Medicine, Loyola University Chicago. WILLIAM SMALL, JR., MD, FACR, FACRO, FASTRO, is Professor and Chairman of the Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Stritch School of Medicine, Loyola University Chicago.Amishi Bajaj, BA: Amishi Bajaj, BAAbhishek A. Solanki, MD, MS: Abhishek A. Solanki, MD, MSWilliam Small, Jr., MD, FACR, FACRO, FASTRO: William Small, Jr., MD, FACR, FACRO, FASTROQuality and safety are key tenets in radiation oncology. Part of a robust quality management program within a radiation oncology department is peer review of patients undergoing radiation treatment. Peer review, defined as “the process whereby providers evaluate the quality of their colleagues' work to ensure that prevailing care standards are met,” (J Oncol Pract 2016;12(3),196-198) is a critical aspect of quality assurance in the practice of radiation oncology and allows for consistent, standardized, and guideline-concordant care to be delivered to patients. Prior studies investigating the impact of peer review have found that radiation therapy plans that deviate from standard protocols have been found to be associated with inferior outcomes relating to cancer control and survival. Chart Rounds The typical format of peer review within most radiation oncology departments is termed “chart rounds” conference. This conference usually convenes once weekly to review the cases of patients that have started radiation treatment in the prior week (J Oncol Pract 2016;12(3),196-198). A survey found that most institutions perform a chart rounds largely focused on the review of patient history, chart documentation, and dose prescription along with isodose coverage, intensity-modulated radiation therapy constraints, and dose-volume histograms. Historically, the peer review program in our department has modeled this approach. There are limitations to this “retrospective” weekly approach to chart rounds. It has been found that approximately 85 percent of plan reviews are performed after patients have already received ≥25 percent of planned radiation (J Oncol Pract 2016;12(3),196-198; J Oncol Pract 2016;12(1) 81-82). Once patients begin treatment, any changes that may be recommended or implemented can require significant effort and time to replan. The extra effort can create an added burden, lead to staff feeling rushed, and decrease productivity of radiation planning staff. The extra time can be important because it could lead to either unplanned treatment breaks or having to deliver a less than optimal plan for added treatments until the optimal plan can be created. Both of these issues are compounded by today's modern sophisticated and complex treatment planning techniques, as well as the movement of radiation therapy towards fewer fractions with higher doses per fraction. Moreover, radiation oncology departments seeking to determine the impact of their peer review processes have found that changes made to treatment plans range from 7-10 percent of cases reviewed (Pract Radiat Oncol 2015;5:32-38), which shows that a sizeable portion of plans undergo modification during the peer review process and many patients fall into the group who requires changes. Similarly, one survey reported that 60 percent of responding institutions held chart rounds for fewer than 2 hours per week, with the median time spent per patient during chart rounds being 2.7 minutes. Given the complexity of many patients, particularly those being treated with modalities such as stereotactic body radiotherapy or stereotactic radiosurgery, or those being treated with repeat courses of radiation, it can be difficult to thoroughly and critically analyze a large volume of cases in such a short period of time. Peer Review System In October 2015, we transitioned to a daily “prospective” peer review program to address these issues and advance our patient safety program. In our new peer review system, which we call our Contouring and Planning Rounds (CPR), we meet daily to review patient cases prior to treatment planning when possible. At the time of requesting the planning CT scan, physicians triage patients into five different treatment planning groups based on the clinical situation as described in the Figure. These categories determine how patients are presented at our CPR. Patients who fall into the Standard group are those undergoing treatment who could start ≥5 days after CT simulation and have relatively complex plans (such as intensity-modulated radiotherapy for prostate cancer, or fractionated stereotactic radiotherapy for meningiomas).FIGURE:: Patients Managed Based on Treatment Planning GroupThose in the Urgent group are those with similar complexity of plans, but who need to start treatment ≤4 days after simulation (i.e., stage IIIA lung cancer patient with rapidly growing tumor or mild hemoptysis, or a patient with a spine metastasis with epidural extension receiving stereotactic body radiotherapy). Patients in the Palliative Non-Emergent group are those requiring relatively simple planning (e.g., AP/PA for a bone metastasis), with anticipated start ≤4 days after simulation to palliate symptoms impairing the patient's quality of life in a timely fashion. Patients in the Emergent group are those patients who must start treatment prior to the next CPR, such as those admitted to the hospital with spinal cord compression or hemorrhage requiring palliative RT as soon as possible. Finally, patients in the Special Procedures group are those receiving special procedures, such as intracranial radiosurgery and brachytherapy. For the Standard group, the treatment target volumes and planning directive entered by the attending physician are reviewed at CPR prior to the start of planning. For the Urgent group, planning begins immediately to avoid delay, but the target volumes and directive are reviewed prior to the start of radiation treatment. For the Palliative Non-Emergent group, given that most patients have relatively simple radiation fields, these are reviewed at CPR prior to the start of treatment as these patients typically have pain or other symptoms requiring relatively urgent treatment. Because patients treated in the Emergent group usually require treatment within hours, it is not always possible to wait until the next CPR session for planning or treatment. Thus, these cases are reviewed prior to treatment if possible, but otherwise retrospectively the day after the start of treatment. Patients assigned to the Special Procedures group are reviewed prior to treatment when possible; otherwise, they are reviewed the day after treatment. We decided CPR would take place daily for 45 minutes at 12:15 p.m., a time of day when members of the treatment team are more likely to be available, in efforts to promote attendance of as many members of the treatment team as possible. Members of the treatment team encouraged to attend CPR include attending physicians, resident physicians, medical students, physicists, physics residents, dosimetrists, and radiation therapists. At least two physicians are mandatory for every session. Scoring Outcomes A scoring system was developed to record the outcome of case presentations, and scores are recorded by radiation therapists at each session. Three different scores were determined and are described in the Table. Cases given a score of 1 were those that were agreed upon by participants to be appropriate in treatment approach and intent, target, and dose/fractionation. This includes patients with minor documentation or nomenclature changes. The case then moves forward in the planning process according to the treatment group. For cases given a score of 2, changes regarding the target or dose/fractionation are made and the case is re-presented the following day after being updated, and once approved, the case then moves forward in the planning process according to the treatment group. Cases receiving a score of 3 are very rare, and are usually treated using an alternate approach other than radiotherapy.TABLE:: Scoring of Cases Reviewed at Chart RoundsThe very concept of scoring radiotherapy plans implies a competitive process and potential punitive implications of scores. However, this is not the case. The scores received during CPR are not used for any performance evaluation of participants, only for the purposes of the process. Taking this one step further, the term “peer review” is a misnomer to some degree. Our process is less a critical review of colleagues' work, but more a prospective collaborative treatment planning conference, focusing on ways to optimize the planning and radiotherapy delivery of patients treated in our department. Overall, the implementation of CPR at our institution was successful. After a learning curve, physicians have gained better understanding of the prioritization of patients based on their CPR category. Support from department administration, leadership, and frontline staff was crucial to the successful implementation of CPR at our institution. Buy-in from administrators and leadership encouraged department-wide attendance at CPR, which lent itself to greater interprofessional exchange at daily rounds and an enhanced department-wide desire to promote patient safety and quality assurance measures in each step of the treatment process. Over time, it was found that CPR improved the quality and accuracy of completion of the physician directive and documentation, in addition to facilitating compliance with the various requirements needed in the directive. Furthermore, resident education is an extremely important aspect of chart rounds that is improved by placing an emphasis on contouring and target delineation and dose/fractionation to targets and normal structures. The CPR conference also provides a forum for collaborative brainstorming for challenging cases prior to submission for planning and radiation treatment. This provides a very positive effect on resident education, as target delineation and dose/fractionation considerations are considered to be some of the most important aspects of a radiation oncologist's work. Other institutions have also transitioned to a “prospective” peer review process. Matuszak and colleagues at University of Michigan described their implementation of a pre-planning peer review conference for patients undergoing stereotactic body radiation therapy (SBRT) (Pract Radiat Oncol 2016;6:e39-46). Cox et al. reported on their experience with prospective contouring rounds for external beam radiation therapy (EBRT) cases at North Shore-LIJ Health System, in which patients were scheduled for presentation at chart rounds two days after simulation and case review included discussion of clinical suitability for radiation therapy and review of contours or treatment fields (Pract Radiat Oncol 2015; 5:e431-436). The authors found this new system to be impactful; over a third of cases reviewed in the first 6 months after implementation of prospective contouring rounds required some form of modification prior to treatment initiation. Furthermore, the authors found that they were able to spend much more time per case when chart rounds were held every day. Most recently, Mitchell et al. reported on their utilization of prospective peer review at a community radiation oncology clinic at the Travis Air Force Base in California (Pract Radiat Oncol 2016, In press). They hold chart rounds 3-4 days weekly with at least two attending physicians in attendance and, similarly, found that they could spend more time discussing each patient with daily peer review rounds (Pract Radiat Oncol 2016, In press). As we move forward, we plan to evaluate the clinical impact of our new peer review process by evaluating the incidence and types of changes noted compared to our older form of chart rounds, as well as trying to identify predictors associated with these changes to help further identify patients who may be at risk for having variations from our standard processes. Daily, prospective peer review with an emphasis on contouring and planning appears to hold great promise in promoting quality assurance and optimal, efficient patient care. We encourage other practitioners to consider implementing a similar approach when performing peer review at their own institutions.