Quality Research In Radiation Oncology Research Articles

Impact of sociodemographic factors on the radiotherapeutic management of lung cancer: Results of a Quality Research in Radiation Oncology Survey

Purpose: The objective of this study is to describe the impact of sociodemographic (SOC) factors on the management of lung cancer patients treated at radiation therapy facilities participating in the Quality Research in Radiation Oncology survey.Methods and materials: A 2-stage stratified random sample of lung cancer patients treated in 2006 to 2007 at 45 facilities yielded 340 stage I-III non-small cell lung cancer (NSCLC) and 144 limited-stage small cell lung cancer (LS-SCLC) cases. Five SOC variables based on data from the 2000 US Census were analyzed for association with the following clinical factors: patients living in urban versus rural settings (U/R); median household income (AHI); % below poverty level (PPV); % unemployed (PUE); and % with college education (PCE).Results: The 340 NSCLC patients were stage I, 16%; stage II, 11%; stage III, 62%; stage unknown, 11%. Histologic subtypes were adenocarcinoma, 31.8%; squamous cell carcinoma, 35.3%; large cell carcinoma, 3.2%; and NSCLC NOS, 27.7%. The median age was 66 years. Median Karnofsky performance status (KPS) was 80. The 144 LS-SCLC had a median age of 63; 73 were male (50.7%). Median KPS was 80. Stereotactic body radiation therapy (SBRT) and modern imaging utilization was associated with treatment at facilities located in higher SOC regions. SBRT was employed in 46.8% stage I NSCLC patients treated in centers where %PUE was below median versus 14.8% in centers where %PUE was above median (P = .02). Four-dimensional computed tomography was utilized in 14.2% of patients treated in centers located in regions with %PPV below median versus 3.7% in centers located in regions with %PPV above median (P < .01). SCLC patients were more likely to receive all of their planned RT when treated at centers located in regions with lower PPV (95.0% vs 79.1%; P = .04).Conclusions: SOC factors may impact use of modern treatment planning and delivery and multidisciplinary management of NSCLC and SCLC. These results may suggest an impact of these SOC factors on access to health care.

Radiation Oncology Peer Review: Measuring Quality

I’m with you when you’re right, Governor. But not when you’re wrong. –David M. Kleck, public relations counsel You stupid sonofabitch. I don’t need you when I’m right. –Earl Long, Louisiana governor [1] In a 1992 article, Cosio and Taylor [2] summarized the US Department of Defense experience with a very specific type of military nonbattle trauma: soda pop vending machine injuries. A total of 64 reported events had contributed to 15 deaths and 13 cases of multiple trauma, including 49 fractures. Although one unfortunate man was killed by a machine tipped over by colleagues just as he left his room, the remaining cases were triggered by people trying to retrieve sodas that had not descended (n 33), trying to get free sodas (n 7), trying to clean under the machines (n 3), or trying to retrieve change (n 2). The mean age of the victims was 19.8 years (range, 5-39 years). Because it is unlikely that any of the injured intended to be crushed by a vending machine, we easily may believe the statement of one victim: “It came down faster than I thought . . . it was too heavy” [3]. This is a glaring example of how we can fatally miscalculate our competence in some arenas. In a seminal 1999 article, Kruger and Dunning [4] described the results of experiments in which participants scoring in the bottom quartile on tests of humor, logic, and grammar drastically and reproducibly overestimated their true capabilities. These people considered themselves to be well above average: from the true median of their cohort at the 12th percentile, they thought they had performed at the 62nd. The authors further demonstrated that once these bottomquartile performers were taught in the subject of that incompetence, (1) their performance levels rose, and (2) their self-analysis became more accurate. In other words, we do not well recognize our own lack of competence in areas in which it exists, and the best way to remedy such poor competence calibration is to be taught more in those areas. This phenomenon is extraordinarily apt in the area of quality in radiation oncology as well. Practice accreditation as provided by the ACR [5] or clinical review from Quality Research in Radiation Oncology [6] provides an organization with the benefit of a comparison of institutional metrics and clinical outcomes with national benchmarks. At the individual level, peer review, performed in a collegial and administratively confidential manner, provides essential opportunities for physicians to “sharpen” one another in terms of clinical care and plan review [7]. The American Board of Medical Specialties requires within the Maintenance of Certification construct that Practice Quality Improvement projects provide individual assessments using national norms [8]; such projects serve as critical adjuncts to ongoing local peer review. As a discipline, radiation oncology takes insufficient advantage of these processes. In 2013, it is an uncomfortable fact that many of our peer-review and Practice Quality Improvement projects are merely administrative. Until now, the pre-

Penetration of Recommended Procedures for Lung Cancer Staging and Management in the United States Over 10 Years: A Quality Research in Radiation Oncology Survey

To document the penetration of clinical trial results, practice guidelines, and appropriateness criteria into national practice, we compared the use of components of staging and treatment for lung cancer among patients treated in 2006-2007 with those used in patients treated in 1998-1999. Patient, staging work-up, and treatment characteristics were extracted from the process survey database of the Quality Research in Radiation Oncology (QRRO), consisting of records of 340 patients with locally advanced non-small cell lung cancer (LA-NSCLC) at 44 institutions and of 144 patients with limited-stage small cell lung cancer (LS-SCLC) at 39 institutions. Data were compared for patients treated in 2006-2007 versus those for patients treated in 1998-1999. Use of all recommended procedures for staging and treatment was more common in 2006-2007. Specifically, disease was staged with brain imaging (magnetic resonance imaging or computed tomography) and whole-body imaging (positron emission tomography or bone scanning) in 66% of patients with LA-NSCLC in 2006-2007 (vs 42% in 1998-1999, P=.0001) and in 84% of patients with LS-SCLC in 2006-2007 (vs 58.3% in 1998-1999, P=.0011). Concurrent chemoradiation was used for 77% of LA-NSCLC patients (vs 45% in 1998-1999, P<.0001) and for 90% of LS-SCLC patients (vs 62.5% in 1998-1999, P<.0001). Use of the recommended radiation dose (59-74 Gy for NSCLC and 60-70 Gy as once-daily therapy for SCLC) did not change appreciably, being 88% for NSCLC in both periods and 51% (2006-2007) versus 43% (1998-1999) for SCLC. Twice-daily radiation for SCLC was used for 21% of patients in 2006-2007 versus 8% in 1998-1999. Finally, 49% of patients with LS-SCLC received prophylactic cranial irradiation (PCI) in 2006-2007 (vs 21% in 1998-1999). Although adherence to all quality indicators improved over time, brain imaging and recommended radiation doses for stage III NSCLC were used in <90% of cases. Use of full thoracic doses and PCI for LS-SCLC also requires improvement.

Results from the Quality Research in Radiation Oncology (QRRO) survey: Evaluation of dosimetric outcomes for low-dose-rate prostate brachytherapy

We report on quality of dose delivery to target and normal tissues from low-dose-rate prostate brachytherapy using postimplantation dosimetric evaluations from a random sample of U.S. patients. Nonmetastatic prostate cancer patients treated with external beam radiotherapy or brachytherapy in 2007 were randomly sampled from radiation oncology facilities nationwide. Of 414 prostate cancer cases from 45 institutions, 86 received low-dose-rate brachytherapy. We collected the 30-day postimplantation CT images of these patients and 10 test cases from two other institutions. Scans were downloaded into a treatment planning system and prostate/rectal contours were redrawn. Dosimetric outcomes were reanalyzed and compared with calculated outcomes from treating institutions. Median prostate volume was 33.4cm(3). Reevaluated median V(100), D(90), and V(150) were 91.1% (range, 45.5-99.8%), 101.7% (range, 59.6-145.9%), and 53.9% (range, 15.7-88.4%), respectively. Low gland coverage included 27 patients (39%) with a D(90) lower than 100% of the prescription dose (PD), 12 of whom (17% of the entire group) had a D(90) lower than 80% of PD. There was no correlation between D(90) coverage and prostate volume, number of seeds, or implanted activity. The median V(100) for the rectum was 0.3cm(3) (range, 0-4.3cm(3)). No outcome differences were observed according to the institutional strata. Concordance between reported and reevaluated D(90) values (defined as within ±10%) was observed in 44 of 69 cases. Central review of postimplantation CT scans to assess the quality of prostate brachytherapy is feasible. Most patients achieved excellent dosimetric outcomes, yet 17% had less than optimal target coverage by the PD. There was concordance between submitted target-coverage parameters and central dosimetric review in 64% of implants. These findings will require further validation in a larger cohort of patients.

Evaluation of adherence to quality measures for prostate cancer radiotherapy in the United States: Results from the Quality Research in Radiation Oncology (QRRO) Survey

PurposeThe purpose of this survey was to test the feasibility of using proposed quality indicators to assess radiotherapy quality in prostate cancer management based on a 2007 stratified random survey of treating academic and nonacademic US institutions. Methods and MaterialsA total of 414 patients with clinically localized prostate cancer treated with external beam radiotherapy (EBRT) or brachytherapy were selected from 45 institutions. Indicators used as specific measurable clinical performance measures to represent surrogates for quality of radiotherapy delivery included established measures such as the use of prescription doses ≥75 Gy for intermediate- and high-risk EBRT patients and androgen-deprivation therapy (ADT) in conjunction with EBRT for patients with high-risk disease, and emerging measures, including daily target localization (image-guidance) to correct for organ motion for EBRT patients. ResultsAmong the 354 patients treated with EBRT, the beam energy was recorded in 353 patients. One hundred sixty-seven patients (47%) were treated with 6 MV photons, 31 (9%) were treated with 10 MV, 65 (18%) received 15 MV, and the remaining 90 (26%) 16-23 MV. For intermediate- plus high-risk patients (n = 181), 78% were treated to ≥75 Gy. Among favorable-risk patients, 72% were treated to ≥75 Gy. Among high-risk EBRT patients, 60 (87%) were treated with ADT in conjunction with EBRT and 13% (n = 9) with radiotherapy alone. Among low- and intermediate-risk patients, 10% and 42%, respectively, were treated with ADT plus EBRT. For 24% of EBRT patients (85 of 354), weekly electronic portal imaging was obtained as verification films without daily target localization, and the remaining 76% were treated with daily localization of the target using various methods. ConclusionsAdherence to defined quality indicators was observed in a majority of patients. Approximately 90% of high-risk patients were treated with ADT plus EBRT and ≈80% of intermediate- and high-risk patients received prescription doses ≥75 Gy, consistent with the published results of randomized trials.

Results from the Quality Research in Radiation Oncology (QRRO) Survey: Evaluation of Dosimetric Outcomes for Low Dose Rate Prostate Brachytherapy

Results from the Quality Research in Radiation Oncology (QRRO) Survey: Evaluation of Dosimetric Outcomes for Low Dose Rate Prostate Brachytherapy

Impact of Co-morbidities on Practice Patterns in the Management of Gastric Cancer: Findings from the Quality Research in Radiation Oncology (QRRO) GI Committee Process Survey

The presence of co-morbidities may result in selection bias in cancer management because of the concern that patients will not tolerate definitive therapy. Hence, the specific aim of this ACR QRRO-based retrospective survey was to determine the impact of patient co-morbid illness on national patterns of practice in patients treated for Stage IB-IV (non-metastatic) gastric cancer.

Co-morbidities Affect Cancer Treatment Strategies And Outcome In Patients With Locally Advanced Non-small Cell Lung Cancer (NSCLC): Report Of Quality Research In Radiation Oncology (QRRO) Data For Stage III NSCLC Patients

To investigate the association of the prevalence of co-morbidities with treatment decisions and variations in compliance with recommended disease management guidelines for patients with Stage III NSCLC. The National Cancer Institute (NCI) is striving for the goal of personalized cancer prevention, diagnosis, treatment, and survivorship.

Secure Web-based Remote Quality Assessment of Prostate Brachytherapy Treatment Plans for a Multi-institutional Patterns of Care/QRRO Survey: A Proof of Principle Study

The Quality Research in Radiation Oncology (QRRO) GU and eData committees established a task group to prospectively demonstrate remote de-identification and common aggregation of prostate brachytherapy treatment plans for comparative quality assessment from a representative cross section of United States radiation oncology facilities.

Patterns of radiotherapy practice in the management of gastric cancer: Preliminary findings from the Quality Research in Radiation Oncology (QRRO) GI Committee process surveys.

77 Background: The specific aim of the ACR QRRO survey was to determine the national patterns of radiotherapy (RT) practice in patients (pts) treated for stage IB–IV (non-metastatic) gastric cancer (GC). Methods: A National Process Survey was conducted from randomly selected U.S. RT facilities to assess demographics, staging, geographic region, practice setting, and treatment through retrospective on-site record review of eligible GC cases treated from 2005-2007. Three clinical performance measures (CPMs): 1) use of CT-based treatment planning; 2) use of dose volume histograms (DVHs) to evaluate RT dose to the kidneys and liver; 3) completion of RT within the prescribed time frame were assessed. Three emerging quality indicators: 1) use of intensity modulated RT (IMRT); 2) use of image-guided tools (IGRT), other than CT, for RT target delineation; 3) use of preop RT were also assessed. Results: CPMs were computed on data collected through Aug, 2010 for 250 eligible pts at 45 institutions. Median age was 62 years; 66% male; 60% Caucasian. 13% were AJCC 2002 stage I, 29% II, 32% IIIA, 10% IIIB and 12% IV. Most pts (43%) were treated at academic centers with 32% at large non-academic centers and 25% medium-small facilities. Almost all (99.5%) pts underwent CT-based planning and 75% had DVHs to evaluate normal tissue doses to the kidneys and liver. 70% completed RT within the prescribed time frame. IMRT and IGRT were used in 22% and 17% of pts, respectively. IGRT techniques included: PET (n = 20), MRI (n = 1), respiratory gating and/or 4D-CT (n = 22) and on-board imaging (n = 10). 19% of pts received preop RT. Conclusions: Preliminary findings from QRRO's analysis of radiation practice patterns for non-metastatic gastric cancer indicate widespread adoption of CT-based planning with the use of DVHs to evaluate normal tissue doses. Moreover, most pts completed adjuvant RT in the prescribed time frame. Emerging RT techniques such as IMRT and IGRT were not routinely incorporated into clinical practice during the evaluated time period. These data will serve as a benchmark for future QRRO gastric cancer surveys. No significant financial relationships to disclose.

Shifting the Focus to Practice Quality Improvement in Radiation Oncology

To demonstrate how the American College of Radiology, Quality Research in Radiation Oncology (QRRO) process survey database can serve as an evidence base for assessing quality of care in radiation oncology. QRRO has drawn a stratified random sample of radiation oncology facilities in the USA and invited those facilities to participate in a Process Survey. Information from a prior QRRO Facilities Survey has been used along with data collected under the current National Process Survey to calculate national averages and make statistically valid inferences for national process measures for selected cancers in which radiation therapy plays a major role. These measures affect outcomes important to patients and providers and measure quality of care. QRRO's survey data provides national benchmark data for numerous quality indicators. The Process Survey is "fully qualified" as a Practice Quality Improvement project by the American Board of Radiology under its Maintenance of Certification requirements for radiation oncology and radiation physics.

Shifting the Focus to Practice Quality Improvement in Radiation Oncology

To demonstrate how the American College of Radiology, Quality Research in Radiation Oncology (QRRO) process survey database can serve as an evidence base for assessing quality of care in radiation oncology. QRRO has drawn a stratified random sample of radiation oncology facilities in the USA and invited those facilities to participate in a Process Survey. Information from a prior QRRO Facilities Survey has been used along with data collected under the current National Process Survey to calculate national averages and make statistically valid inferences for national process measures for selected cancers in which radiation therapy plays a major role. These measures affect outcomes important to patients and providers and measure quality of care. QRRO's survey data provides national benchmark data for numerous quality indicators. The Process Survey is “fully qualified” as a Practice Quality Improvement project by the American Board of Radiology under its Maintenance of Certification requirements for radiation oncology and radiation physics.

Assessment of Emerging Technologies Used in Adjuvant Radiotherapy for Gastric Cancer: Preliminary Findings from the Quality Research in Radiation Oncology (QRRO) GI Committee Process Surveys

Radiotherapy for Gastric Cancer: Preliminary Findings from the Quality Research in Radiation Oncology (QRRO) GI Committee Process Surveys Karyn A. Goodman, M.D.1; Najma Khalid, M.S.2; Bruce D. Minsky, M.D.3; Lisa A. Kachnic, M.D.4; Cheryl L. Crozier, R.N.2; Jean B. Owen, Ph.D.2; Charles R. Thomas, Jr., M.D.5 1Memorial Sloan-Kettering Cancer Center, New York, NY; 2American College of Radiology, Philadelphia, PA Boston, MA; 3University of Chicago, Chicago, IL; 4Massachusetts General Hospital Cancer Center, 5Knight Cancer Institute, Oregon Health and Science University, Portland, OR

Quality Research in Radiation Oncology (QRRO): A Patterns of Care Analysis of Clinical Performance Measures in the Management of Gastric Cancer (GC)

The ACR Quality Research in Radiation Oncology (QRRO) project is conducting a study of quality and patterns of care for patients (pts) receiving radiation therapy (RT) for GC with the goal of determining factors associated with compliance of evidence-based clinical standards. The specific aim of this analysis is to evaluate penetrance of level one clinical trial results establishing adjuvant chemoradiation (CRT) as a validated, evidence-based standard-of-care in North America for resectable GC.

Report of Quality Research in Radiation Oncology (QRRO) Survey for Lung Cancer Patients Treated in the USA between 2006 and 2007

Quality of Radiation Oncology practice was recently criticized (NY Times 2010). We sought to demonstrate the feasibility of measuring quality indicators (QIs) in RO for lung cancer patients and estimate national benchmarks.

Results from the Quality Research in Radiation Oncology (QRRO) Survey Evaluating Adherence to Quality Measures for Prostate Cancer Radiotherapy

Results from the Quality Research in Radiation Oncology (QRRO) Survey Evaluating Adherence to Quality Measures for Prostate Cancer Radiotherapy

QRRO: Estimating National Benchmarks for Quality Indicators for Non–small Cell Lung Cancer (NSCLC)

To demonstrate the feasibility of measuring quality indicators (QIs) in radiation oncology (rad onc) for NSCLC from the Quality Research in Radiation Oncology (QRRO) national patterns of care database with the objective of estimating national benchmarks.

Using QRRO™ Survey Data to Assess Compliance With Quality Indicators for Breast and Prostate Cancer

Quality Research in Radiation Oncology (QRRO) has embarked on a new national process survey to provide benchmark data that will allow radiation oncologists to assess the quality of care in their own practices by measuring quality indicators (QIs) and comparing individual with national practice. Investigators at QRRO developed QIs on the basis of nationally recognized, evidence-based guidelines such as those of the National Comprehensive Cancer Network, as well as additional emerging QIs for processes involving rapidly emerging technology. They specifically defined the QIs as clinical performance measures. Published results of the national survey database for patients treated in 1998 and 1999 were reviewed and additional analyses conducted to assess data adequacy to measure compliance with these clinical performance measures. Examples of workup QIs for breast cancer patients showed that 97% underwent diagnostic bilateral mammography, 96% underwent pathology reviews, 83% underwent the determination of estrogen receptor status, 81% underwent the determination of progesterone receptor status, and 31% underwent the determination of human epidermal growth factor receptor 2 status. Compliance with treatment QIs for field recommendations on the basis of nodal findings can be measured. Of patients with prostate cancer, 90% underwent digital rectal examinations, 99% underwent prostate-specific antigen tests, and 99% had their Gleason scores determined. Compliance with QIs on the basis of prognostic group can also be measured. Benchmarking utilization patterns provides a foundation for assessing the appropriateness of cancer care in the future. The QRRO database is a rich data source, and the new survey will provide contemporary benchmark data for these measures.

Evolutionary Phases in Quality Research in Radiation Oncology over the Last 35 Years

Evolutionary Phases in Quality Research in Radiation Oncology over the Last 35 Years

Improving quality of care: Challenges to implementing quality indicators

16030 Background: To assess the overall quality of cancer care, efforts seek consensus quality indicators that crosscut health services. Although pilot programs have collected and analyzed relevant clinical data, they have been unable to collect radiation oncology (RO) data detailed enough to assess the quality of services or to inform key decision makers. Quality Research in Radiation Oncology (QRRO) conducted retrospective surveys of national practice since 1973 with major positive impact on the quality of practice through recursive processes. Methods: From Donabedian’s model of quality assessment, QRRO analyzes crucial quality components by conducting Facilities, Process, and Outcomes Surveys. Survey design allows calculation of national averages for patients treated with RO and comparisons by key factors. Evolving data collection methods allow assessment of modern technologies. Methods start with definition and measurement of evidence-based quality indicators but allow greater detail and specification than most other quality measurement efforts. Results: QRRO showed that radiation dose affected outcomes for prostate cancer patients. Higher radiation doses were associated with improved local tumor control rates and treatment techniques affected toxicity rates. These results, presented widely in numerous venues, stimulated dose escalation clinical trials. Trials conducted in the USA all used QRRO results as critical data, providing the major impetus to test new directions in dose escalation and new methods to target delivery more precisely. National practice shifted to higher doses and use of conformal techniques. The dataset is unique in providing cross-sectional information on practice patterns with a wide variety of treatment approaches from many institutions and sufficient details of treatment delivery to allow examination of questions about quality and effects of techniques. Conclusions: Mounting societal demands for improvement in the quality of care, ever increasing complexity of radiation therapy, and escalating use of multi-modality treatment make continuing to measure, report, and improve quality of care in RO crucial to patients and the profession. Methods must keep pace with new technologies and techniques in radiation therapy. [Supported by NCI grant CA 65435]. No significant financial relationships to disclose.