<h3>Purpose/Objective(s)</h3> Quality assurance (QA) is critical to the successful delivery of radiation therapy (RT) for cancer patients and also impacts outcomes. The present study reports the longitudinal results of a prospective peer review evaluation system (PES) implemented at a major academic health system as an integral part of RT QA. <h3>Materials/Methods</h3> All patient cases treated with RT by one of 32 physicians at 14 treatment locations within our radiation oncology department undergo prospective peer review in daily rounds. Each case is assigned a grade (A, B, C) based on the following criteria: clinical suitability for RT, prescription, contours, and treatment plan, where applicable. "A" cases require no changes, "B's" require minor modification, and "C's" require major modification with re-review prior to treatment planning. The present study is a longitudinal analysis of grade trends over time by hospital, plan type, and physician. The Wilcoxon-signed-ranked test was used to compare grades during the baseline PES period (2013-2016) to the follow-up period (2017-2021). A p-value below 0.05 is considered significant. <h3>Results</h3> A total of 20,069 cases for 14,300 patients were reviewed from September 2013 to November 2021. Of the total cases, 15,659 (78%) were curative and were included in the present analysis; 5,868 from the baseline period and 9,791 in the follow-up period. The fraction of A cases decreased from 74.8% (baseline) to 64.5% (follow-up), while the fraction of B's increased from 19.4% (baseline) to 35.4% (follow-up), and the fraction of C's decreased from 5.8% (baseline) to 0.1% (follow-up). The main hospital site contributed 54.8% of all cases and 48.1% of all B grades. IMRT plans accounted for 55.4% of all plans and 68.2% of all B scores, while 3D-conformal plans accounted for 24.4% of cases and 15.4% of all B scores. When normalized by total department A/B/C scores, there were no statistically significant changes in percent A/B/C scores over the time period studied (p-value> 0.05). However, for the 13 physicians with cases throughout the study period, there was a statistically significant increase in the fraction of B scores (p value = 0.01) and decrease in the fraction of C scores (p value < 0.01) between the two time periods when individual physician grades were normalized to their individual caseload. <h3>Conclusion</h3> PES improves the identification of quality-related factors that can impact downstream radiation treatment plan quality. The diminishing fraction of C grades over time indicates amelioration of ‘major failures,' which were addressed in the startup years of PES. The proportional increase in B's, at the cost of fewer putative A's, suggests increased scrutiny of cases, as well as findings-based improvements in contouring and planning, over time. Peer review rounds upstream of treatment planning provides valuable RT QA and should be considered by other departments to enhance the quality and consistency of RT.
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