Optimizing Outpatient Radiation Oncology Consult Workflow by Using Time-Driven Activity-Based Costing: Efficiency and Financial Impacts.

PURPOSE: Clinical efficiency is a key component of value-based health care. Our objective here was to identify workflow inefficiencies by using time-driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high-volume outpatient radiation oncology clinics. METHODS: Our quality improvement study was conducted with the Departments of GI, Genitourinary (GU), and Thoracic Radiation Oncology at a large academic cancer center and four community network sites. TDABC was used to create process maps and optimize workflow for outpatient consults. Patient encounter metrics were captured with a real-time status function in the electronic medical record. Time metrics were compared using Mann-Whitney U tests. RESULTS: Individual patient encounter data for 1,328 consults before the intervention and 1,234 afterward across all sections were included. The median overall cycle time was reduced by 21% in GI (19 minutes), 18% in GU (16 minutes), and 12% at the community sites (9 minutes). The median financial savings per consult were $52 in US dollars (USD) for the GI, $33 USD for GU, $30 USD for thoracic, and $42 USD for the community sites. Patient satisfaction surveys (from 127 of 228 patients) showed that 99% of patients reported that their providers spent adequate time with them and 91% reported being seen by a care provider in a timely manner. CONCLUSION: TDABC can effectively identify opportunities to improve clinical efficiency. Implementing workflow changes on the basis of our findings led to substantial reductions in overall encounter cycle times across several departments, as well as high patient satisfaction and significant financial savings.

Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer.

PURPOSE: Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications. METHODS AND MATERIALS: Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis. RESULTS: Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption. CONCLUSIONS: This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Practical Implications of the American Society for Radiation Oncology Radiation Oncology Case Rate Program Proposal for Radiation Oncologists.

The American Society for Radiation Oncology has proposed the Radiation Oncology Case Rate Program (ROCR) to advocate for fair reimbursement for radiation oncologists. ROCR would replace Medicare fee-for-service with a case rate payment for each of the 15 most common cancer types treated with external beam or stereotactic radiation therapy. This topic discussion attempts to provide a concise overview of the practical implications for radiation oncologists should the ROCR payment program be legislated by Congress and subsequently implemented by the Center for Medicare and Medicaid Services. This topic discussion covers the practical changes to billing and reimbursement, the Health Equity Achievement in Radiation Therapy payment, the Quality of Care requirement, and the available tool to calculate the effect of the ROCR based on an individual practice's case mix.

Quality/risk management system in radiotherapy: Changes afoot.

The French sanitary and regulatory context in which radiotherapy centres are comprised is evolving. Risk and quality management systems are currently adapting to these evolutions. The French nuclear safety agency (ASN) decision of July 1st 2008 on quality assurance obligations in radiotherapy has reached 10 years of age, and the French high authority of health (HAS) certification system 20 years now. Mandatory tools needed for the improvement of quality and safety in healthcare are now well known. From now on, the focus of healthcare policies is oriented towards evaluation of efficiency of these new organisations designed following ASN and HAS nationwide guidelines.

FIELDRT: an open-source platform for the assessment of target volume delineation in radiation therapy.

OBJECTIVES: Target volume delineation (TVD) has been identified as a weakness in the accuracy of radiotherapy, both within and outside of clinical trials due to the intra/interobserver variations affecting the TVD quality. Sources of variations such as poor compliance or protocol violation may have adverse effect on treatment outcomes. In this paper, we present and describe the FIELDRT software developed for the ARENA project to improve the quality of TVD through qualitative and quantitative feedbacks and individual and personalized summary of trainee"s performance. METHODS: For each site-specific clinical case included in the FIELDRT software, reference volumes, minimum and maximum "acceptable" volumes and organ at risk were derived by outlines of consultants and senior trainees. The software components currently developed include: (a) user-friendly importing interface (b) analysis toolbox to compute quantitative and qualitative (c) visualiser and (d) structured report generator for personalised feedback. The FIELDRT software was validated by comparing the performance of 63 trainees and by measuring performance over time. In addition, a trainee evaluation day was held in 2019 to collect feedback on FIELDRT. RESULTS: Results show the trainees' improvement when reoutlining a case after reviewing the feedback generated from the FIELDRT software. Comments and feedback received after evaluation day were positive and confirmed that FIELDRT can be a useful application for training purposes. CONCLUSION: We presented a new open-source software to support education in TVD and ongoing continuous professional development for clinical oncology trainees and consultants. ARENA in combination with FIELDRT implements site-specific modules with reference target and organs at risk volumes and automatically evaluates individual performance using several quantitative and qualitative feedbacks. Pilot results suggests this software could be used as an education tool to reduce variation in TVD so to guarantee high quality in radiotherapy. ADVANCES IN KNOWLEDGE: FIELDRT is a new easy and free to use software aiming at supporting education in TVD and ongoing continuous professional development. The software provides quantitative/qualitative feedback and an exportable report with an individual and personalised summary of trainee's performance.

Pilot testing and vernacular translation of a questionnaire for assessment of satisfaction in patients on radiotherapy in India.

BACKGROUND: Patient satisfaction has emerged as a yardstick to measure success of healthcare ecosystems. OUTPATSAT-35RT is a questionnaire to assess patient satisfaction on outpatient radiotherapy (RT). However, it is yet to be translated and/or validated in any of the common Indian languages. METHODS: English version of OUTPATSAT-35RT was pilot tested in 20 patients with working knowledge of English undergoing fractionated radiotherapy. Subsequently, the questionnaire was translated into two Indian vernacular languages (Hindi and Marathi) using standardized methodology. The process included forward translation into vernacular language by two professional translators independently, generating an intermediate version of the questionnaire. The intermediate questionnaire was then back-translated into English by another duo of professional translators and compared with the English version of the original OUTPATSAT-35RT questionnaire for final reconciliation. This was subsequently administered to 20 patients each (fluent in respective vernacular language) for pilot testing. All 60 patients (20 per language) underwent semi-structured interviews for reporting any difficulty encountered during filling and suggesting any corrections/modifications to the questionnaire. RESULTS: The pilot testing of the English version of OUTPATSAT-35RT in 20 Indian patients did not reveal any difficulty or suggest corrections/modifications, leading to its successful translation into Hindi and Marathi languages. Pilot testing of the translated questionnaires in 20 patients each (fluent in the respective vernacular language) did not find any major difficulty. No corrections/modifications were suggested by the respondents resulting in adoption of the reconciled vernacular questionnaires as final Hindi and Marathi versions of OUTPATSAT-35RT questionnaire. CONCLUSION: The English version of OUTPATSAT-35RT has been successfully translated into Hindi and Marathi languages using standardized methodology. Its psychometric properties are being tested for validation in a larger Indian cohort.

Aligning Requirements of Training and Assessment in Radiation Treatment Planning in the Era of Competency-Based Medical Education.

PURPOSE: Radiation treatment planning (RTP) is a unique skill that requires interdisciplinary collaboration among radiation oncologists (ROs), dosimetrists, and medical physicists (MP) to train and assess residents. With the adoption of competency-based medical education (CBME) in Canada, it is essential residency program curricula focuses on developing competencies in RTP to facilitate entrustment. Our study investigates how radiation oncology team members' perspectives on RTP education align with requirements of the CBME approach, and its implications for improving residency training. METHODS AND MATERIALS: This qualitative research study took place in the Department of Oncology at a midsize academic institution. Through convenience sampling, focus groups were conducted with radiation oncologists (n = 11), dosimetrists (n = 7), medical physicists (n = 7), and residents (n = 7). Thematic design was adopted to analyze the transcripts through open coding resulting in 3 overarching themes. RESULTS: The results identified existing strengths and weaknesses of the residency program and future opportunities to redesign the curriculum and assessment process within a CBME model. Three overarching themes emerged from the analysis: (1) the strengths of RTP in the CBME environment; (2) challenges of RTP in CBME; and (3) opportunities for change. Stakeholders were optimistic CBME will help enrich resident learning with the increased frequency and quality of competency-based assessments. Participants suggested building a library of cases and developing computer-based learning resources to provide a safe environment to develop skills in contouring, dosimetry, and plan evaluation, in accordance with CBME training. CONCLUSIONS: This study identified future opportunities to redesign the RTP curriculum and assessment process within a CBME model. The need for innovative teaching and learning strategies, including case libraries, computer-based learning, and quality assessments, were highlighted in designing an innovative RTP planning curriculum.

Radiation Oncology Quality Assessment Tool: A proposal for a new audit tool in modern radiation oncology.

INTRODUCTION: As a consequence of the development of improved treatment techniques and utilisation of digital records in radiation oncology, the RANZCR Peer Review Audit Tool has become outdated. The aim of this internal audit was to objectively evaluate the practice of our radiation oncology department to ensure that patients are being treated according to evidence-based national guidelines through the use of a new self-audit algorithm, the Radiation Oncology Quality Assessment Tool (ROQAT). METHODS: Using ROQAT, a retrospective audit was conducted of patients who received definitive treatment within the first six months (June 2017-November 2017) of opening a new radiation oncology department at the Sunshine Coast University Hospital. Data were collected from MOSAIQ® and electronic medical records. RESULTS: Two hundred and six patients were included. The median age was 65 years. Most commonly treated tumour streams included: breast (n = 62), skin (n = 31), colorectal (n = 25), genitourinary (n = 21) and head and neck (n = 21). Documentation was complete for all patients. Seventy-four per cent of patients were discussed in a multidisciplinary team meeting. Fifty-five per cent of patients were treated with inverse planning techniques. Treatment with radiation therapy was indicated in 97% of patients. Dose and fractionation were concordant with protocols in 83% of cases. Thirty-nine per cent received concurrent chemotherapy, and of these, 93% were in accordance with protocols. More than 50% were treated according to published delineation protocols. CONCLUSION: The ROQAT is a proposal for a new audit tool that reflects modern radiation therapy practice, with emphasis on compliance with evidence-based guidelines.

Towards an evidence-informed value scale for surgical and radiation oncology: a multi-stakeholder perspective.

Surgery and radiotherapy, two locoregional cancer treatments, are essential to help improve cancer outcomes, control, and palliation. The continued evolution in treatment processes, techniques, and technologies-often at substantially increased costs-demands for direction on outcomes that are most valued by patients, and the evidence that is required before clinical adoption of these practices. Three recently introduced frameworks-the European Society for Medical Oncology Magnitude of Clinical Benefit Scale, the American Society of Clinical Oncology Value Framework, and the National Comprehensive Cancer Network Blocks-which all help define the value of oncology treatments, were appraised with a focus on their methods and definition of patient benefit. In this Review, we investigate the applicability of these frameworks to surgical and radiotherapy innovations. Findings show that these frameworks are not immediately transferable to locoregional cancer treatments. Moreover, the lack of emphasis on patient perspective and the reliance on traditional, trial-based endpoints such as survival, disease-free survival, and safety, calls for a new framework that includes real-world evidence with focus on the whole spectrum of patient-centred endpoints. Such an evidence-informed value scale would safeguard against the proliferation of low-value innovation while simultaneously increasing access to treatments that show significant improvements in the outcomes of cancer care.

Gender, Professional Experiences, and Personal Characteristics of Academic Radiation Oncology Chairs: Data to Inform the Pipeline for the 21st Century.

PURPOSE: Understanding the pathways and gateways to leadership and challenges faced by individuals in such roles can inform efforts to promote diversity and equity. We sought to describe the professional experiences and personal characteristics of academic radiation oncology (RO) chairs and to evaluate whether differences exist by gender. METHODS AND MATERIALS: Anonymous surveys were distributed to 95 chairs of RO departments during the 2016 annual meeting of the Society of Chairs of Academic Radiation Oncology Programs. The surveys included 28 closed-ended questions and the Leadership Practices Inventory. Results were analyzed by gender using χ2 tests, rank-sum, and t tests (significance P < .05). RESULTS: A total of 72 chairs responded (61 male, 10 female, 1 declined to identify gender) for a response rate of 76%. There were no significant gender differences in age, academic rank, publications, or prior leadership positions held at the time of the first chair appointment, but female respondents held significantly greater total direct funding from extramural grants than their male counterparts (median, $1.89 million [interquartile range, $0.5-$5 million] vs $0.25 million [interquartile range, $0-$1.0 million]; P = .006). Women were more likely to have spouses employed outside the home at time of their first chair appointment than men were, with a trend toward women experiencing greater difficulty relocating. Men and women identified budgeting and resource allocation as their greatest professional challenges. There were no gender differences in the Leadership Practices Inventory-identified leadership domains or professional goals. CONCLUSIONS: Female RO chairs are as equally qualified as men in terms of productivity or leadership skills, but they face distinct challenges in the context of a gender-structured society. The observation of higher grant funding among women at the time of chair appointment suggests a possible need for interventions such as unconscious bias training to ensure that selection processes do not unnecessarily hold women to a higher standard.

Differences in United States Insurance Payer Policies and American Society for Radiation Oncology's (ASTRO) Model Policy on Stereotactic Body Radiation Therapy (SBRT).

PURPOSE: Insurance payers in the United States vary in the indications for which they consider stereotactic body radiation therapy (SBRT) "medically necessary." We compared changes in policies after the last update to the American Society for Radiation Oncology's (ASTRO) SBRT model policy. METHODS AND MATERIALS: We identified 77 payers with SBRT policies in 2015 from a policy aggregator, as well as 4 national benefits managers (NBMs). Of these, 65 payers and 3 NBMs had publicly available updates since 2015. For each of the indications in ASTRO's model policy, we calculated the proportion of payers that considered SBRT medically necessary. We used Fisher's exact test to compare these proportions between 2015 and now, between policies updated in the past 12 months and those updated less often, and between national and regional payers currently. RESULTS: Payers consider SBRT medically necessary most often for primary lung cancer (97%), reirradiation to the spine (91%), prostate cancer (68%), primary liver cancer (66%), and spinal metastases with radioresistant histologies (66%). Policies have become more aligned with ASTRO's model policy over time. National payers and NBMs cover indications in higher proportions than regional payers. CONCLUSIONS: Although there have been improvements over time, more work is needed to align payer policies with ASTRO's model SBRT policy, especially at the regional level.

An applicable method for PET/CT image quality assessment and comparison among three PET/CT systems with similar physical performance in cancer patients.

PURPOSE: This research proposes a method with specific procedure guideline for clinical PET/CT image quality assessment according to physicians' behavior of image interpretation and explore the relationship between image quality and image systems with similar physical performance. METHODS: Clinical PET/CT were divided according to body location: brain, chest, abdomen and pelvic cavity. We explored the lesions and suspicious regions where radiologists concerned most through eye-tracker and behavior observation study to generate an assessment checklist. Fifty-five patients who were statistically consistent in age, weight and height were studied. Thirty-seven were scanned with an experimental scanner A and control systems B or C because their clinical pathways required PET/CT examinations at short intervals, the other 18 were scanned with scanners A and C. The grade of every system's PET, CT and PET/CT image performance on the four parts was calculated by subtraction of mean value and variance between experimental and control systems. RESULTS: The scoring checklist was set for PET, CT and PET/CT images in four parts respectively, and a standard procedure guideline was formulated for assessment. Using assessment criteria, the statistical results objectively reflected certain systems' superiority on certain modalities and certain parts of the body. CONCLUSION: Our criteria for clinical PET/CT image quality assessment and comparison were efficient.

Radiation Therapists' Perceptions of Advanced Practice in Alberta.

OBJECTIVES: The purpose of this study was to describe radiation therapists' (RTs) perceptions of advanced practice (AP) and determine perceived barriers and benefits to the role. METHODS: A descriptive cross-sectional electronic survey of Albertan RTs was conducted from October to November 2016. The Canadian Association of Medical Radiation Technologists database was used to identify participants, and a modified Dillman methodology was used for survey distribution. RESULTS: The survey response rate was 29.3% (56/191). Most respondents had a Bachelor's degree (58.9%, 33/56) and 10 or more years of experience (60.7%, 34/56). Respondents included individuals in management/education positions (22.6%, 12/53) and clinical practitioners (58.5%, 31/53). Respondents reported high agreement with a number of definition components of AP, including a requirement for at least 5-year experience (90.5% ± 17.6%). Respondents viewed increased knowledge in specialty areas (97.7%, 43/44), job satisfaction (88.6%, 39/44), enhanced patient care due to collaborative practice (88.6%, 39/44), and increased continuity of care (86.4%, 38/44) as benefits. Respondents highly agreed that AP would benefit patients in Alberta (83.2% ± 23.7%); there was less personal interest in becoming advanced practitioners (58.3% ±35.7%). Insufficient directives, guidance, and training were seen as personal (93.6%, 45/47) and professional (91.3%, 42/46) barriers to AP. CONCLUSIONS: Overall, Albertan RTs agree with the components of AP proposed by the Canadian Association of Medical Radiation Technologists as well as the benefits of creating the position. There is an urgent need to provide clear guidance and directives to RTs with regard to AP practice parameters and training requirements in order for successful implementation.

Global Challenges for Cancer Imaging.

Imaging plays many essential roles in nearly all aspects of high-quality cancer care. However, challenges to the delivery of optimal cancer imaging in both developing and advanced countries are manifold. Developing countries typically face dramatic shortages of both imaging equipment and general radiologists, and efforts to improve cancer imaging in these countries are often complicated by poor infrastructure, cultural barriers, and other obstacles. In advanced countries, on the other hand, although imaging equipment and general radiologists are typically accessible, the complexity of oncologic imaging and the need for subspecialists in the field are largely unrecognized; as a result, training opportunities are lacking, and there is a shortage of radiologists with the necessary subspecialty expertise to provide optimal cancer care and participate in advanced clinical research. This article is intended to raise awareness of these challenges and catalyze further efforts to address them. Some promising strategies and ongoing efforts are reviewed, and some specific actions are proposed.