A bi-institutional multi-disciplinary failure mode and effects analysis (FMEA) for a Co-60 based total body irradiation technique.

BACKGROUND: We aim to assess the risks associated with total body irradiation (TBI) delivered using a commercial dedicated Co-60 irradiator, and to evaluate inter-institutional and inter-professional variations in the estimation of these risks. METHODS: A failure mode and effects analysis (FMEA) was generated using guidance from the AAPM TG-100 report for quantitative estimation of prospective risk metrics. Thirteen radiation oncology professionals from two institutions rated possible failure modes (FMs) for occurrence (O), severity (S), and detectability (D) indices to generate a risk priority number (RPN). The FMs were ranked by descending RPN value. Absolute gross differences (AGD) in resulting RPN values and Jaccard Index (JI; for the top 20 FMs) were calculated. The results were compared between professions and institutions. RESULTS: A total of 87 potential FMs (57, 15, 10, 3, and 2 for treatment, quality assurance, planning, simulation, and logistics respectively) were identified and ranked, with individual RPN ranging between 1-420 and mean RPN values ranging between 6 and 74. The two institutions shared 6 of their respective top 20 FMs. For various institutional and professional comparison pairs, the number of common FMs in the top 20 FMs ranged from 6 to 13, with JI values of 18-48%. For the top 20 FMs, the trend in inter-professional variability was institution-specific. The mean AGD values ranged between 12.5 and 74.5 for various comparison pairs. AGD values differed the most for medical physicists (MPs) in comparison to other specialties i.e. radiation oncologists (ROs) and radiation therapists (RTs) [MPs-vs-ROs: 36.3 (standard deviation SD = 34.1); MPs-vs-RTs: 41.2 (SD = 37.9); ROs-vs-RTs: 12.5 (SD = 10.8)]. Trends in inter-professional AGD values were similar for both institutions. CONCLUSION: This inter-institutional comparison provides prospective risk analysis for a new treatment delivery unit and illustrates the institution-specific nature of FM prioritization, primarily due to operational differences. Despite being subjective in nature, the FMEA is a valuable tool to ensure the identification of the most significant risks, particularly when implementing a novel treatment modality. The creation of a bi-institutional, multidisciplinary FMEA for this unique TBI technique has not only helped identify potential risks but also served as an opportunity to evaluate clinical and safety practices from the perspective of both multiple professional roles and different institutions.

Examining the Financial Impact of Altered Fractionation in Breast Cancer: An Analysis Using Time-Driven Activity-Based Costing.

PURPOSE: Value-based care is increasingly informing treatment decisions in radiation oncology. Although reimbursement differences have been examined for accelerated whole breast irradiation (AWBI) and conventional whole breast irradiation (CWBI), the cost of care delivery is poorly understood. This article describes our experience evaluating costs for altered fractionation in early-stage breast cancer using a time-driven activity-based costing (TDABC) model. METHODS AND MATERIALS: Process maps were developed for 2 treatment regimens, AWBI (42.5 Gy in 16 fractions + 10 Gy in 4 fractions boost) and CWBI (50 Gy in 25 fractions + 10 Gy in 5 fractions boost). Cost was determined based on aggregate cost of personnel, materials, equipment, space, and utilities per unit time and based on the relative proportion of capacity used. The total reimbursement for each regimen was calculated as the aggregate of all billable events during a course of radiation therapy, based on the 2019 Centers for Medicare & Medicaid Services physician fee schedule database. RESULTS: The total cost of delivering courses of AWBI and CWBI was $6965 and $9267, respectively, a difference of $2302 (25%). Eighty-six percent of this difference was related to a lower cost of delivering daily treatments. The total reimbursement for AWBI or CWBI was $9665 or $12,908, respectively, a difference of $3243 (25%). Overall, 55% to 60% of total costs were related to personnel, with the remainder related to materials, utilities, space, and equipment. CONCLUSIONS: This analysis shows how TDABC can be used to evaluate resource requirements for different radiation therapy fractionation schedules. We found a substantially lower cost for AWBI compared with CWBI, primarily resulting from fewer daily treatments. As the emphasis in health care shifts toward value-based care, TDABC can help identify opportunities to reduce costs and increase clinical efficiency.

WBC Associates with Readmission Following Cystectomy.

Background: Radical cystectomy is associated with perioperative complication rates exceeding 50% in some series. Readmission rates are increasingly used as a surgical quality metric. White blood cell count is a crude surrogate for physiologic processes which may reflect postoperative complications leading to readmission. Objective: We assessed the association between final white blood cell count at discharge and risk of readmission following radical cystectomy. Methods: Records on 477 patients undergoing radical cystectomy from 2006-2013 were reviewed. Final white blood cell count was defined as the last documented value during index admission. Univariate analysis was performed using Fisher's exact, Wilcoxon rank sum test, and Spearman's coefficient tests where appropriate. Multivariable logistic regression models were used to test the associations between final white blood cell count and readmission. Results: 34% of patients were readmitted within 90 days of surgery. Amongst this cohort, a cutoff final white blood cell count of 9000/mm3 was identified, with a significantly higher proportion of patients with values >9000/mm3 experiencing readmission than those with values≤9000/mm3 (42% vs 28%, p = 0.004). Other perioperative variables associated with an increased readmission rate included initial hospital length of stay≤10 days, and receipt of a continent diversion. Following adjustment, final white blood cell count >9000/mm3 was associated with increased risk of readmission (OR 2.09, 95% CI 1.23-3.53, p = 0.006). Conclusions: Final white blood cell count is associated with hospital readmission following radical cystectomy. This metric may provide important guidance in discharge algorithms.

Sports-related concussion testing.

Due to the recent focus on concussion in sports, a number of tests have been developed to diagnose and manage concussion. While each test measures different brain functions, no single test has been shown to quickly and reliably assess concussion in all cases. In addition, most of the current concussion tests have not been validated by scientific investigation. This review identifies the pros and cons of the most commonly used noninvasive tests for concussion in order to provide a more complete picture of the resources that are available for concussion testing. The potential utility of research tools such as the head impact telemetry system, advanced magnetic resonance imaging protocols, and biomarkers are discussed in the context of the currently employed tools.

The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort.

OBJECTIVE: Concussion, defined as an impulse blow to the head or body resulting in transient neurologic signs or symptoms, has received increasing attention in sports at all levels. The King-Devick (K-D) test is based on the time to perform rapid number naming and captures eye movements and other correlates of suboptimal brain function. In a study of boxers and mixed martial arts (MMA) fighters, the K-D test was shown to have high degrees of test-retest and inter-rater reliability and to be an accurate method for rapidly identifying boxers and mixed martial arts fighters with concussion. We performed a study of the K-D test as a rapid sideline screening tool in collegiate athletes to determine the effect of concussion on K-D scores compared to a pre-season baseline. METHODS: In this longitudinal study, athletes from the University of Pennsylvania varsity football, sprint football, and women's and men's soccer and basketball teams underwent baseline K-D testing prior to the start of the 2010-11 playing season. Post-season testing was also performed. For athletes who had concussions during the season, K-D testing was administered immediately on the sidelines and changes in score from baseline were determined. RESULTS: Among 219 athletes tested at baseline, post-season K-D scores were lower (better) than the best pre-season scores (35.1 vs. 37.9s, P=0.03, Wilcoxon signed-rank test), reflecting mild learning effects in the absence of concussion. For the 10 athletes who had concussions, K-D testing on the sidelines showed significant worsening from baseline (46.9 vs. 37.0s, P=0.009), with all except one athlete demonstrating worsening from baseline (median 5.9s). CONCLUSION: This study of collegiate athletes provides initial evidence in support of the K-D test as a strong candidate rapid sideline visual screening tool for concussion. Data show worsening of scores following concussion, and ongoing follow-up in this study with additional concussion events and different athlete populations will further examine the effectiveness of the K-D test.