Evaluation of a Prospective Radiation Oncology Departmental Peer Review Process using Standardized Simulation Directives

ABSTRACT

The primary objective of this study is to evaluate the utility and value of an institutional, multi-disciplinary peer review process prior to radiotherapy simulation. Over a period of 3 months and through an iterative process, a standardized simulation requisition directive (SSRD) was developed, piloted, modified, and subsequently implemented for all patients treated with external beam radiotherapy at a single tertiary care institution from January to December 2020. The SSRDs were reviewed at a daily multi-disciplinary peer review conference ("morning huddle");modifications in the simulation process consequential to the review were prospectively recorded in a quality database. Descriptive statistics were used to identify characteristics associated with modifications. Independent sample t test and Chi-square test were used to compare continuous and categorical variables. A total of 1500 consecutive SSRDs were prospectively reviewed and met inclusion criteria for this study. The median time between the physician SSRD order and date of simulation was 4 days (Range 0-97 days), and the majority of patients were treated with curative intent (n = 872, 58%). A total of 369 modifications on 269 (17.9%) simulation directives were recorded and parsed into 17 categories. The most common modifications resulted from omission of pregnancy testing orders (n = 92, 24.9%), immobilization device changes (n = 88, 23.8%), changes in the radiotherapy care path (n = 56, 15.1%), and arm positioning (n = 43, 11.6%). Modifications were less likely to occur if the directives were entered within 1 week of simulation (15.6% vs. 21.7%, P = 0.0028). Significant differences were also observed across tumor sites (P = 0.0091) with the highest modification rates observed for stomach, esophagus, and pelvis sites (40%, 30%, and 26.9% modified, respectively). A significant change in department workflow and clinic visits occurred in March 2020 as a result of COVID-19, with transition to virtual platforms. An increased rate of simulation directive modifications was also observed for patients simulated after these changes were implemented (April – December 2020 19.3% vs. Jan – March 2020 13.5%, P = 0.013). No differences in modification rates were observed by modality, i.e., photon or proton therapy (P = 0.20). Overall, with this prospective peer review process, only 14 patients (0.9%) needed re-simulation during the entire study period. Prospective peer review prior to simulation in radiotherapy identifies actionable change in approximately 18% of procedures, and results in an extremely low, < 1% rate of re-simulation. SSRDs ordered > 1 week before from simulation and gastrointestinal and pelvic sites were at higher risk of requiring modifications during peer review. As departmental processes transition to virtual meeting platforms, more thorough attention is needed to identify patients at higher risk of simulation modifications. [ABSTRACT FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)