Peer Review In Radiation Oncology Research Articles

Peer Review in Radiation Oncology: Where Does the Middle East, North Africa, and Türkiye Region Stand?

This study aims to assess the status of radiation oncology peer review procedures across the Middle East, North Africa, and Türkiye (MENAT) region. A cross-sectional electronic survey was conducted among radiotherapy centers in the MENAT region in March 2024. It assessed peer review practices, departmental demographics, perceived importance of peer review, and potential barriers. Data from 177 radiation oncology centers revealed varying peer review implementation across the MENAT region. Egypt had the highest participation (16.4%) among all responders. Most centers (31%) treated 500-1,000 cases annually. The majority (77.4%) implemented peer review, with varying levels between countries and across different centers. Advanced radiotherapy techniques significantly correlated with implementation of peer review (P < .05). Peer review meetings were mostly scheduled on a weekly basis (46%) and organized by radiation oncologists (84.7%). Target volume contouring (89%) and radiotherapy prescription (82%) were frequently peer-reviewed. Respondents with peer review at their institutions significantly valued peer review for education, adherence to guidelines, improving planning protocols, and reducing variation in practice institutions without peer review (P < .05). The most frequently reported barriers to peer review were having a high number of patients (56%) and shortage of time (54%). Peer review is essential for improving the quality of practice in radiation oncology. Despite some discrepancies, numerous obstacles, and challenges in implementation, it is instrumental in the improvement of patient care in most centers throughout the region. Raising awareness among radiation oncologists about the importance of peer review is paramount to lead to better outcomes.

Pilot study of radiation oncology peer review in low middle income country (LMIC) through cloud-based platform

ABSTRACT Purpose: Peer review is an essential step in clinical quality assurance for radiation therapy. There are very little data on peer reviews from low-middle-income countries (LMIC). With increasing access to advanced technologies in LMIC also, peer review is becoming more important to ensure quality and standard of care. We evaluated cloud-based e-Peer review in our network of cancer centers in India with an aim to study its feasibility and impact on care. Materials and Methods: Four out of 13 cancer centers across India were selected for this pilot study. All team members were trained on the e-Peer review platform before the initiation of the study. A lead dosimetrist from a centralized planning site was selected to share new cases every week. Cases treated with only definitive intent were selected. The link to the cases was sent through an email to reviewing physicians. The following aspects were reviewed for each case. 1) Work up and staging. 2) Treatment intent and prescription. 3) Target contours. 4) Normal organ at risk contours. 5) Dose–volume–histogram (DVH) with clinical goals attached. Cases were marked as “Not Appropriate,” “Appropriate,” “Appropriate with minor finding,” and “Represent with major revisions” as per volume and plan review. Results: Over a period of 3 months, 100 cases underwent peer review before the start of treatment. Median turnover time was 48 (interquartile range: 24-96) hours. The median time for review was 8 min with time to review cases requiring major and minor changes being 12 and 6 min, respectively (P &lt; 0.001). Of all the cases reviewed, no changes, minor changes, and major changes were suggested for 36%, 48%, and 16% of cases, respectively. The most frequent reason for major changes was contouring corrections (15%). Also, 31.3% of major changes underwent recontouring and replanning before initiation of treatment. Conclusion: Peer review was feasible in our setting through this cloud-based peer review system, with median turnover time and time taken for review being 48 h and 8 min, respectively. Like published data from the Western world, peer review led to changes that could impact patient care delivery and outcome. We plan to implement this across the remaining centers in our network.

Provider perspectives on radiation oncology quality practices in peer review.

411 Background: Radiation oncology peer review involves presentation of new cases including pertinent patient history and case-specific qualitative treatment planning decisions. Yet implementation of peer recommendations is inconsistent. Thus, we sought to understand multidisciplinary perspectives on peer review to identify factors affecting stakeholder engagement. Methods: Participants in radiation oncology peer review completed semi-structured interviews and Likert surveys to explore the perceived value in peer review and its influence on their clinical practice and plan changes. Interviews were audio-recorded and transcribed, and two independent coders utilized a grounded theory approach to extract dominant themes. ANOVA and students t-test were used to analyze Likert scores. Results: Participants included 6 academic and 3 community radiation oncologists, 2 radiation oncology residents, 2 medical physicist, 2 radiation therapists, 4 dosimetrists and 1 industry representative. Analysis of interviews regarding perceived priorities of peer review revealed the following themes: understanding the clinical background to inform decision-making, detection of rare errors not found in other quality assurance processes, coherence in practice within an organization, and education on new techniques. Key facilitators included pre-planning communication between multidisciplinary teams, particularly for replanning and reirradiation scenarios. Barriers to adaptation of recommendations included resource limitations and lack of supporting data. Likert surveys (0=no importance, 10=highest importance) assigned a high value to the overall process (mean score: 8.3), reducing variation in practice (8.0), conformity of plans with institutional guidelines (7.8), and participant education (7.6), with a lower value placed on the detection of medical errors (7.4) and reduction of treatment incidents (6.9). When comparing Likert scores by provider, non-physicians rated overall importance of peer review (mean: 9.8 vs 6.5, p=0.03) and education (9.0 vs 6.7, p=0.02) significantly higher than physicians. There was no significant difference in Likert scores by academic vs community practice. Conclusions: All participants agreed peer review is an important process in radiation oncology quality assurance that may catch rare errors. However, there was significant variation in the perceived benefits of peer review, and a higher value was placed on alignment of clinical practice and non-physician participant education. Future processes to improve communication between multi-disciplinary teams was identified as beneficial to peer review discussions.

Artificial Intelligence-Assisted Peer Review in Radiation Oncology

<h3>Purpose/Objective(s)</h3> Peer review is reflective of the entire patient treatment process with clinical information, therapeutic parameters and potential treatment variations. Our hypothesis is that using artificial intelligence (AI), we can enhance the efficacy of the peer review process by screening cases with a potential for treatment interruption. <h3>Materials/Methods</h3> From 3,899 radiotherapy patients (7,168 plans) treated from 2014-2021 in our department, 36 features of clinical and therapeutic parameters were used as input for two AI models: multivariable least absolute shrinkage and selection operator (LASSO) logistic regression model and pattern recognition feed forward neural network (NN). LASSO is a shrinkage regularization method that assigns coefficients to significantly useful features. NN passes input features through multiple hidden nodes to assign weights and biases for feature selection. Each method results in continuous probability of treatment interruption. Performance metrics of accuracy, sensitivity and specificity were calculated for evaluations. <h3>Results</h3> Overall, 8.1% of all cases had treatment interruptions, most commonly in head and neck (18.8%) compared to other sites (19% vs 7-9%, p<0.01). For LASSO model, testing set sensitivity, specificity and accuracy ranged from 65-89%, 31-53% and 35-54%, respectively, with higher sensitivity than specificity. Spine/Extremity and Brain sites had the highest accuracy (54%). Higher sensitivity than specificity indicated that the model was more able to predict true positives. For NN model, testing set sensitivity, specificity and accuracy ranged from 23-62%, 66-90% and 64-86%, respectively. Higher specificity than sensitivity was observed. The Brain site had highest accuracy (86%). Accuracy of NN was higher than LASSO for all treatment sites (68% vs. 50%), which is particularly true for the brain (86% vs. 54%) and the pelvis/prostate (77% vs. 35%). This result indicates that the linear hyperplane of LASSO was insufficient to classify the underlying complex clinical dataset accurately. Including more input features is expected to improve the accuracy for both models. <h3>Conclusion</h3> Our results provide proof-of-concept that AI can be used as a screening tool to aid the peer review process. It can help to predict treatment interruptions, which include replanning or treatment cessation. Early identification of patients at risk of radiotherapy interruptions using this method may potentially translate into higher treatment completion rates. The study is being continued at our institution to further explore the capabilities of AI in the peer review process.

Virtual Radiation Oncology Peer Review is Associated With Decreased Engagement and Limited Case Discussion: Analysis of a Prospective Database Before and During the COVID-19 Pandemic

Radiotherapy (RT) plan peer review (PR) is critical to maintain safety and quality of care in radiation oncology. During the ongoing COVID-19 pandemic, in-person activities have been limited to minimize the risk of exposure in the workplace. We aimed to determine whether the transition from an in-person to virtual format impacts the efficacy and engagement of PR conference. We analyzed a prospectively maintained database of RT plans reviewed in routine PR between 2019-2021. Plans were categorized as in-person or virtual based on our department's transition to virtual meetings in March 2020. The rate of identified deviations and the rate and type of discussion topics per case were compared between groups. A total of 3,372 RT plans were analyzed, 1,120 in-person and 2,252 virtually. Deviations were identified in 4.1% of the cohort, significantly less for the virtual group (2.5%) compared with the in-person group (7.3%, p<0.001). PR discussion was reduced in the virtual group: 90.3% of cases had no discussion versus 72.8% in the in-person group (p<0.001). Significant decreases discussion rates for multiple topics were observed after the transition from in-person conferences to virtual PR meetings: treatment intent (2.1% to 0.7%), RT dose/prescription/technique (14.0% to 4.0%), documentation/nomenclature (4.1% to 1.3%), and target/organ at risk considerations (12.9% to 5.0%). There were no observed differences in the rates of deviations identified among cases that were discussed (26.7% in-person v. 23.9% virtual). Virtual radiation oncology peer review is associated with a significant decline in identified deviations and a decrease in the frequency and breadth of discussion. Similar rates of deviations among discussed patients in either group suggest the observed change in deviation rate is potentially related to reduced physician engagement. Further evaluation of the promises and pitfalls of virtual RT plan PR is imperative.

Radiation oncology peer review in Australia and New Zealand.

Peer review is a part of high quality care within radiation oncology, designed to achieve the best outcomes for patients. We discuss the importance of and evidence for peer review in clinical practice. The Royal Australia and New Zealand College of Radiologists (RANZCR) has evolved a Peer Review Assessment Tool (PRAT) since 1999. We report the results of a RANZCR faculty survey conducted in radiation oncology facilities across Australia and New Zealand to guide the 2019 PRAT revision process, and discuss the development and implementation of the 2019 PRAT. Peer-review processes are now mandated as a component of Australian and International Quality Standards. Several practical recommendations might address challenges for effective implementation of peer review process in routine clinical practice. This includes prioritising tumour sites and treatment techniques for peer review within the time and resources constraints of each institution, improving resource allocation, ensuring optimal timing and duration for peer review meetings, and adopting multi-centre virtual peer review meeting where necessary.

PD-0866 100% Peer Review in Radiation Oncology. Is it feasible?

PD-0866 100% Peer Review in Radiation Oncology. Is it feasible?

A Comprehensive Analysis of a Prospective Multidisciplinary Peer Review Process Before Radiation Therapy Simulation

PurposeAlthough peer review in radiation oncology (RO) has been recommended to improve quality of care, an analysis of modifications resulting from an RO multidisciplinary presimulation standardized review process has yet to be empirically demonstrated. Methods and MaterialsA standardized simulation directive was used for patients undergoing simulation for external beam radiation therapy at a single tertiary care institution. The simulation directives were presented, and all aspects were reviewed by representatives from key RO disciplines. Modifications to the original directives were prospectively captured in a quality improvement registry. Association between key variables and the incidence of modifications were performed using Fisher exact test and t test. ResultsA registry of 500 consecutive simulations for patients undergoing radiation therapy was reviewed. A median of 105 simulations occurred per month. All simulation directives were entered by a physician a median of 3 days before simulation (range, 1-76 days). The treatment intent was curative for 269 patients (53.8%), palliative for 203 patients (40.6%), and benign for 3 patients (0.6%). Twenty-five (5%) patients did not have a treatment intent selected. Based on RO multidisciplinary review, 105 directives (21%) were modified from the original intent, with 29 (5.8%) requiring more than 1 modification. A total of 149 modifications were made and categorized as changes to patient positioning and immobilization (n = 100, 20%), treatment site and care path (n = 34, 6.8%), simulation coordination activities (n = 6, 1.2%), and treatment technique and planning instructions (n = 9, 1.8%). A higher proportion of modifications occurred at the time of multidisciplinary review in patients receiving more complex treatments (intensity modulated radiation therapy/stereotactic radiosurgery/stereotactic body radiation therapy [IMRT/SRS/SBRT] vs 3-dimensional radiation therapy [3DCRT] radiation therapy, 25% vs 16%, P < .025). ConclusionsGiven the complexity of radiation therapy simulation, standardization of directives with prospective RO multidisciplinary presimulation peer review is critical to optimizing department processes and reducing errors. Approximately 1 in 5 patients benefits from this peer review process, especially patients treated with IMRT/SRS/SBRT.

Three discipline collaborative radiation therapy (3DCRT) special debate: Peer review in radiation oncology is more effective today than 20 years ago.

Three discipline collaborative radiation therapy (3DCRT) special debate: Peer review in radiation oncology is more effective today than 20 years ago.

PO-1290: 100% peer review in radiation oncology. Is it feasible?

PO-1290: 100% peer review in radiation oncology. Is it feasible?

100% peer review in radiation oncology: is it feasible?

PurposePeer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. Despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. Our purpose is to analyze peer-review process at our institution.Methods and materialsBased on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. Prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. Items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. Cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session.ResultsOver a period of 4 weeks, 148 cases were reviewed. Median of attendants was six physicians, three in-training-physicians and one physicist. Median time per session was 38 (4–72) minutes. 59.5% of cases presented in 1–4 min, 32.4% in 5–9 min and 8.1% in ≥ 10 min. 79.1% of cases were accepted without changes, 11.5% with minor changes, 6% with major changes and 3.4% were rejected with indication of new presentation. Most frequent reason of change was contouring corrections (53.8%) followed by dose or fractionation (26.9%).ConclusionEveryday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. This model is feasible within the normal operation of every radiation oncology Department.

Radiation Oncology Peer Review in a Community Setting

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.

Analysis of a real time group consensus peer review process in radiation oncology: an evaluation of effectiveness and feasibility

BackgroundPeer review systems within radiation oncology are important to ensure quality radiation care. Several individualized methods for radiation oncology peer review have been described. However, despite the importance of peer review in radiation oncology barriers may exist to its effective implementation in practice. The purpose of this study was to quantify the rate of plan changes based on our group peer review process as well as the quantify amount of time and resources needed for this process.MethodsData on cases presented in our institutional group consensus peer review conference were prospectively collected. Cases were then retrospectively analyzed to determine the rate of major change (plan rejection) and any change in plans after presentation as well as the median time of presentation. Univariable logistic regression was used to determine factors associated with major change and any change.ResultsThere were 73 cases reviewed over a period of 11 weeks. The rate of major change was 8.2% and the rate of any change was 23.3%. The majority of plans (53.4%) were presented in 6–10 min. Overall, the mean time of presentation was 8 min. On univariable logistic regression, volumetric modulated arc therapy plans were less likely to undergo a plan change but otherwise there were no factors significantly associated with major plan change or any type of change.ConclusionGroup consensus peer review allows for a large amount of informative clinical and technical data to be presented per case prior to the initiation of radiation treatment in a thorough yet efficient manner to ensure plan quality and patient safety.

Group consensus peer review in radiation oncology: commitment to quality

BackgroundPeer review, especially prospective peer review, has been supported by professional organizations as an important element in optimal Radiation Oncology practice based on its demonstration of efficacy at detecting and preventing errors prior to patient treatment. Implementation of peer review is not without barriers, but solutions do exist to mitigate or eliminate some of those barriers.MethodsPeer review practice at our institution involves three key elements: new patient conference, treatment planning conference, and chart rounds. The treatment planning conference is an adaptation of the group consensus peer review model from radiology which utilizes a group of peers reviewing each treatment plan prior to implementation. The peer group in radiation oncology includes Radiation Oncologists, Physician Residents, Medical Physicists, Dosimetrists, and Therapists. Thus, technical and clinical aspects of each plan are evaluated simultaneously.ResultsThough peer review is held in high regard in Radiation Oncology, many barriers commonly exist preventing optimal implementation such as time intensiveness, repetition, and distraction from clinic time with patients. Through the use of automated review tools and commitment by individuals and administration in regards to staffing, scheduling, and responsibilities, these barriers have been mitigated to implement this Group Consensus Peer Review model into a Radiation Oncology Clinic.ConclusionA Group Consensus Peer Review model has been implemented with strategies to address common barriers to effective and efficient peer review.

Pre-treatment peer-review: enhancing value through increased efficiency and effectiveness of radiation oncology peer review

The purposes of this study are to enhance our quality assurance process with the introduction of pre-treatment peer review within a large academic group practice and to document how this commitment impacts the delivery of safe and effective plans. We supplemented our chart-rounds-based peer review process with the addition of pre-treatment peer review rounds in August 2014. Chart rounds consisted of weekly meetings where all patients on treatment were reviewed within their first five fractions of treatment, regardless of treatment intent. Pre-treatment peer review consisted of all stereotactic radiotherapy cases (SBRT/SRS) or cases with increased complexity, or questions about appropriateness or technique, and was conducted separately from chart rounds. Treatment teams participating in quality assurance conferences included radiation oncologists (at least one other than the primary physician), residents, physician assistant, and physics and dosimetry teams. Components of peer review discussed were treatment intent, appropriateness of radiation therapy, organ at risk/target delineation, and proposed dose/fractionation. Changes were stratified into major and minor changes. Major changes included wrong use of radiotherapy (RT), change in RT modality, > 1 cm field change, > 4 Gy total dose change or adding chemotherapy or surgical evaluation. Minor changes included ≤ 1 cm field change, ≤ 4 Gy total dose change, or additional physical exam, imaging or pathology clarification to assist in target volume delineation. Since August 2014, there have been 1439 patients presented at our peer review conferences. A total of 8% of patients had changes recommended. Importantly, the frequency of change was 10 to 15 times higher for cases that were reviewed prior to treatment start, as compared to those reviewed during on-treatment chart rounds (22% for pre-treatment SBRT/SRS patients, 44% for pre-treatment non-SBRT/SRS patients and 3% for patients presented at chart rounds. Most of the changes were minor (62%), but 38% of all changes were major and thought to be of a magnitude that could potentially affect therapeutic outcome or normal tissue toxicity. The addition of comprehensive pre-treatment peer review proved valuable and effective. The introduction of pre-treatment peer review resulted in an almost 50% reduction in on-treatment chart round changes. This reduction provides value in both patient safety and clinical efficiency.

The Impact of a Detailed Checklist on Physician Peer Review in Radiation Oncology: A Prospective Study

The Impact of a Detailed Checklist on Physician Peer Review in Radiation Oncology: A Prospective Study

Implementing a Program of Radiation Oncology Peer Review Across Multiple Cancer Centers in Ontario: A Quantitative and Qualitative Analysis

Implementing a Program of Radiation Oncology Peer Review Across Multiple Cancer Centers in Ontario: A Quantitative and Qualitative Analysis

Prospective Analysis of Radiation Oncology Peer Review for Head and Neck Cancer

Prospective Analysis of Radiation Oncology Peer Review for Head and Neck Cancer

Analysis of an inter-centre, web-based radiation oncology peer-review case conference

AbstractPurposePeer-review programmes in radiation oncology are used to facilitate the process and evaluation of clinical decision-making. However, web-based peer-review methods are still uncommon. This study analysed an inter-centre, web-based peer-review case conference as a method of facilitating the decision-making process in radiation oncology.MethodologyA benchmark form was designed based on the American Society for Radiation Oncology targets for radiation oncology peer review. This was used for evaluating the contents of the peer-review case presentations on 40 cases, selected from three participating radiation oncology centres. A scoring system was used for comparison of data, and a survey was conducted to analyse the experiences of radiation oncology professionals who attended the web-based peer-review meetings in order to identify priorities for improvement.ResultsThe mean scores for the evaluations were 82·7, 84·5, 86·3 and 87·3% for cervical, prostate, breast and head and neck presentations, respectively. The survey showed that radiation oncology professionals were confident about the role of web-based peer-reviews in facilitating sharing of good practice, stimulating professionalism and promoting professional growth. The participants were satisfied with the quality of the audio and visual aspects of the web-based meeting.ConclusionThe results of this study suggest that simple inter-centre web-based peer-review case conferences are a feasible technique for peer review in radiation oncology. Limitations such as data security and confidentiality can be overcome by the use of appropriate structure and technology. To drive the issues of quality and safety a step further, small radiotherapy departments may need to consider web-based peer-review case conference as part of their routine quality assurance practices.

Peer review in radiotherapy (RT): A national quality improvement initiative.

221 Background: Peer review (PR) in Radiation Oncology has been shown to be effective in improving quality of treatment by detecting and correcting deficiencies in proposed treatment plans prior to treatment. PR is also effective in: guiding departmental treatment planning policies and processes; reducing variation in practice; providing a venue for multi-disciplinary communication, and increasing staff and trainee awareness of evolving treatment processes. The importance of PR is reflected in the inclusion of 3 PR-specific quality indicators in the Canadian Partnership for Quality Radiotherapy QA Guidelines for Radiation Oncology programs. Given this endorsement, we aim to enhance PR implementation across all Canadian cancer centres using a knowledge-translation and implementation framework. Methods: This project will facilitate increased uptake of PR in Canadian RT programs by implementing the top-down model used with success in Ontario. This model has several key components, including: a) engaging the leadership of provincial cancer agencies to promote PR at every Provincial cancer centre; b) providing modest financial support for the acquisition of the required hardware and/or staff time for coordinating PR activities; c) systematic collection of each centre’s baseline PR activities, perceived barriers and potential facilitators of PR at each centre; d) creation of a continuous quality improvement cycle by monitoring PR quality indicators over time; e) systematic knowledge and information sharing regarding effective PR processes. Results: Funding for this initiative was obtained from the Canadian Partnership against Cancer (CPAC) in April 2014. A steering committee consisting of stakeholders from across Canada has been struck and provincial launches, based on the tenets used in Ontario, have commenced in 7 of 13 provinces with others expressing interest. A national survey to obtain baseline data relating to PR activities, perceived barriers, and facilitators is underway and will be reported. Conclusions: Preliminary evidence suggests a “snowball effect” of increasing PR uptake across Canada. The implementation model could be applied in other jurisdictions interested in increasing PR in radiation oncology.