Radiation Oncology Peer Review in a Community Setting

Abstract

Peer review is an important component of any radiation oncology continuous quality improvement program. While limited guidelines exist, there is no consensus about how peer review should be performed, and large variations exist among different institutions. The purpose of this report is to retrospectively describe our experience with peer review at a busy community radiation oncology clinic. Here we report the results of our program and its impact on the treatment process. In 2012 our clinic implemented a prospective peer review policy with a goal of reviewing all cases before treatment begins. As soon as treatment planning is completed, the patient is added to the peer review list for the upcoming weekly session. Peer review sessions are held weekly and attended by physicians, physicists and dosimetrists. Our targets of peer review include patient history, diagnosis, prescription, dosimetric constraints, and plan quality. Starting in 2015, every peer review session is tracked including recommended changes. Our clinical workflow is designed so that every new patient is peer reviewed. Between April 2015 and February 2019, a total of 2581 patients were peer reviewed. Out of those, 1317 were prospective reviews (51%). Those that were reviewed after the treatment had already begun, were reviewed within the first week of treatment. Only 30 plans (1.2 %) were changed based on peer review recommendations. Out of those that were changed, 25 (1%) were changed before the start of treatment. The changes to plans were made to reduce dose to organs at risk (OAR) (15), change prescription (5), change setup or rescan for anatomical changes (5), change treatment volume (4), and change OAR volume (1). Changes that were made to the 5 patients (0.2%) already on treatment were to reduce dose to OARs (bowel (2), brachial plexus, and contralateral breast) and change prescription dose (1). While there is no national standard for peer review, it is evident that prospective peer review is preferable. Since 49% of our patients were not prospectively reviewed, peer review at our institution should be revised in the future. Plans reviewed before treatment were 5 times more likely to be changed by peer review than those reviewed after the start of treatment (1% vs. 0.2%). This may reflect a subconscious reluctance to change plans already underway, which could be a barrier to improving plans with the peer review process. Rather than reviewing in a group setting, it would be ideal to individually assign review that is embedded in the clinical flow, assuring prospective review for all patients prior to final physician approval. Peer review in a group setting also may be less candid, due to interpersonal concerns about publicly disagreeing with colleagues. One of the biggest obstacles to prospective peer review is the limited time between simulation and treatment, and adding a required prospective peer review step could slow down the clinical flow and delay patients’ treatment.