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.