Introduction to concept inventories for medical physics education.

Concept inventories are multiple choice exams designed with the intention to test core concepts on specific subjects and evaluate common misconceptions. These tests serve as a useful tool in the classroom to assess value added by the instructor's educational methods and to better understand how students learn. They can provide educators with a method to evaluate their current teaching strategies and to make modifications that enhance student learning and ultimately elevate the quality of medical physics education. The use of concept inventories in introductory college physics courses revealed important gaps in conceptual understanding of physics by undergraduate students and motivated a shift of physics teaching towards more effective methods, such as active learning techniques. The goal of this review is to introduce medical physicists to concept inventories as educational evaluation tools and discuss potential applications to medical physics education by development through multi-institutional collaboration.

Electronic charting of radiation therapy planning and treatment: Report of Task Group 262.

While most Radiation Oncology clinics have adopted electronic charting in one form or another, no consensus document exists that provides guidelines for safe and effective use of the Radiation Oncology electronic medical records (RO-EMR). Task Group 262 was formed to provide these guidelines as well as to provide recommendations to vendors for improving electronic charting functionality in future. Guidelines are provided in the following areas: Implementation and training for the RO-EMR, acceptance testing and quality assurance (QA) of the RO-EMR, use of the RO-EMR as an information repository, use of the RO-EMR as a workflow manager, electronic charting for brachytherapy and nonstandard treatments, and information technology (IT) considerations associated with the RO-EMR. The report was based on a literature search by the task group, an extensive survey of task group members on their respective RO-EMR practices, an AAPM membership survey on electronic charting, as well as group consensus.

Report of Task Group 201 of the American Association of Physicists in Medicine: Quality management of external beam therapy data transfer.

With the advancement of data-intensive technologies, such as image-guided radiation therapy (IGRT) and intensity-modulated radiation therapy (IMRT), the amount and complexity of data to be transferred between clinical subsystems have increased beyond the reach of manual checking. As a result, unintended treatment deviations (e.g., dose errors) may occur if the treatment system is not closely monitored by a comprehensive data transfer quality management program (QM). This report summarizes the findings and recommendations from the task group (TG) on quality assurance (QA) of external beam treatment data transfer (TG-201), with the aim to assist medical physicists in designing their own data transfer QM. As a background, a section of this report describes various models of data flow (distributed data repositories and single data base systems) and general data test characteristics (data integrity, interpretation, and consistency). Recommended tests are suggested based on the collective experience of TG-201 members. These tests are for the acceptance of, commissioning of, and upgrades to subsystems that store and/or modify clinical treatment data. As treatment complexity continues to evolve, we will need to do and know more about ensuring the quality of data transfers. The report concludes with the recommendation to move toward data transfer open standards compatibility and to develop tools that automate data transfer QA.

A service line approach: Using whiteboard analytics to improve time efficiency in radiation oncology.

The purpose of this study was to develop and implement a custom-designed electronic workflow management tool created by Medlever, Inc, in order to improve efficiency, leverage interoperability and maximize overall labor resources. Administrators and clinicians from five Banner MD Anderson Cancer Center, Department of Radiation Oncology clinics utilized Medlever, Inc. to track and analyze clinical workflow. Real-time data were collected for the duration of 3 months. Time and process data were compared month-to-month from each of the five Banner MD Anderson facilities. The data were quantified based on efficiency scores, where efficiency score was defined by measured timelines for work completion, which was defined by average measured times to complete clinical process steps. The overall average efficiency score for the clinical process steps were as follows: simulation - 66%, define target volume - 69%, creating a treatment plan - 71%, plan review - 76%, finalizing plan - 81%, physics review - 73%, IMRT QA - 72%, approving treatment plan - 69%, and therapy chart check - 66%. The combined average efficiency scores for facility A through E were approximately 72%, 77%, 82%, 66%, and 60%, respectively. Overall, the average sum of all clinical efficiency scores for the radiation oncology service line for all five facilities was approximately 73%. The results set the base line for efficiency and can be evaluated in future studies. In conclusion, a workflow management tool is an effective system to provide results for real-time data tracking, opportunities of improved efficiency, and evidence-based approaches to workflow decision making.

A consensus-based, process commissioning template for high-dose-rate gynecologic treatments.

PURPOSE: There is a lack of prescriptive, practical information for those doing the work of commissioning high-dose-rate (HDR) gynecologic (GYN) treatment equipment. The purpose of this work is to develop a vendor-neutral, consensus-based, commissioning template to improve standardization of the commissioning process. METHODS AND MATERIALS: A series of commissioning procedures and tests specific to HDR GYN treatments were compiled within one institution. The list of procedures and tests was then sent to five external reviewers at clinics engaged in HDR GYN treatments. External reviewers were asked to (1) suggest deletions, additions, and improvements/modifications to descriptions, (2) link the procedures and tests to common, severe failure modes based on their effectiveness at mitigating those failure modes, and (3) rank the procedures and tests based on perceived level of importance. RESULTS: External reviewers suggested the addition of 14 procedures and tests. The final template consists of 67 procedures and tests. "Treatment process" and "staff training" sections were identified as mitigating the highest number of commonly reported failure modes. The mean perceived importance for all procedures and tests was 4.4 of 5, and the mean for each section ranged from 3.6 to 4.8. Sections of the template that were identified as mitigating the highest number of commonly reported failure modes were not assigned the highest perceived importance. CONCLUSION: The commissioning template developed here provides a standardized approach to process and equipment commissioning. The discord between perceived importance and mitigation of the highest number of failure modes suggests that increased focus should be placed on procedures and tests in "treatment process" and "staff training" sections.

A report from the AAPM Subcommittee on Guidelines for Competency Evaluation for Clinical Medical Physicists in Radiation Oncology.

The goal of this report is to provide a framework from which an institution can develop a competency and credentialing program. It is not intended to be adopted as written, but rather as a list of suggestions from which the institution develops their program. A clear distinction should be made between the initial evaluation of the competency of new staff (credentialing) and the ongoing verification of the competency of existing staff. Furthermore, whenever new technologies are imple-mented, the entire staff would be subject to the credentialing process. Competencies involve the ongoing verification of the performance of a procedure according to the established policies and procedures at a facility. This can be done by audits of work product, direct observation of performance, self-evaluation, or testing. PACS number(s): 87.10.-e, 87.90.+y

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents.

PURPOSE: The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. METHODS AND MATERIALS: The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. RESULTS: The new curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. CONCLUSIONS: The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint.

Patterns of practice for safety-critical processes in radiation oncology in the United States from the AAPM safety profile assessment survey.

PURPOSE: The purpose of this study is to report an overview of the patterns of practice for safety-critical processes in radiation oncology clinics in the United States. METHODS AND MATERIALS: The Safety Profile Assessment (spa.aapm.org), developed by the American Association of Physicists in Medicine, was released in July 2013. It consists of 92 indicator questions designed to assess the safety and quality of radiation oncology operations. By December 2014, 114 surveys had been completed by clinics within the United States. This database was analyzed to identify those indicators of safety and quality performance with which there was the highest degree of compliance and those indicators with which there was the least. Additionally, we assessed the extent to which key clinical activities were supported by formal policies. Voluntary post assessment surveys were completed by 86 respondents (75%). RESULTS: The mean number of patients treated per day on external beam radiation therapy devices was 64 (range, 8-600) in the clinics that responded to the survey. The average overall score for the 92 SPA indicator questions was 1.45 (range, 1.00-2.78) on a 5-point scale, with 1 being the most positive. Those indicators that were associated with the highest levels of compliance are dominated by activities that are either strongly recommended, regulated, or associated with revenue generation. Surprisingly, several of those indicators for which there was the least compliance relate to activities that are known to have contributed to serious radiation therapy misadministrations in the past. Formal policies, which are widely regarded as a backbone of a safe clinical system, were reported as lacking for some safety-critical procedures. CONCLUSIONS: Although overall this analysis demonstrated reasonable performance across participating departments, several important areas for improvement were identified. The results may guide the allocation of resources both at the level of individual departments and at the professional society level.

Safety Profile Assessment: An online tool to gauge safety-critical performance in radiation oncology.

PURPOSE: It is challenging for the radiation oncology practitioner to manage and implement the plethora of recently generated recommendations on quality and safety improvement. The online Safety Profile Assessment (SPA) tool uses an easy-to-use question-and-answer format to assess safety/quality within a clinic, provide a way to benchmark against peers, and facilitate improvement. This report describes the design and development of the SPA and experience from the first year of use. METHODS: Performance indicators for the SPA were derived from 4 foundations: the Agency for Healthcare Research and Quality, a review of 7 recent authoritative documents specific to radiation oncology, a recent American Association of Physicists in Medicine report on incident learning, and the American College of Radiology-American Society for Radiation Oncology accreditation system as of 2011. After pilot testing, the free-access tool was launched through the American Association of Physicists in Medicine website (http://spa.aapm.org) in July 2013. Questionnaire data were collected to assess the experience of users. RESULTS: The SPA tool consists of 92 indicators designed to probe safety and quality. A clinic's performance is benchmarked against all other responses in the database, and aided by a downloadable log, quality/safety improvement strategies can be developed and tracked over time. At the time this paper was written, 279 individuals had registered, and 107 had completed the SPA. On average, the SPA required 1.3 hours to complete. The majority of respondents to the questionnaire (56%) completed the SPA with a multidisciplinary group of 4 people on average. Respondents noted that the SPA was easy or very easy to use (70%) and that they would definitely or very probably complete it again (63%). CONCLUSIONS: SPA provides a straightforward means of gauging a clinic's performance in key safety-critical areas and has been evaluated favorably by the first cohort of users. The tool has been qualified by the American Board of Radiology (ABR) as meeting the criteria for Practice Quality Improvement requirements of the ABR Maintenance of Certification Program.

Protection and measurement in radiation therapy.

In radiation therapy, unlike most other applications involving radiation, the intention is to deliver high doses of radiation to diseased tissue, constrained by the effects of radiation to healthy tissue. With regard to patient exposure, the radiation protection framework of justification, optimization, and limitation is a direct part of the prescription process of radiation therapy. Staff and public exposures are typically far below occupational maximum permissible exposures. However, a number of other issues arise in radiation therapy that fall into the category of radiation protection. After an historical review, this paper discusses several contemporary and emerging concerns within radiation therapy, including fetal dose, secondary malignancies, and dose to implantable devices, all of which involve accurate dose assessment outside the intended treatment volume. Other concerns include quality and safety, molecularly based disease assessment and treatment, and other novel treatment strategies. The paper ends with a discussion of the interplay between best practices and regulatory oversight.

There is a wide range of predictive dosimetric factors for I-125 and pd-103 prostate brachytherapy.

PURPOSE: We have analyzed biochemical control versus multiple dosimetric parameters for a relatively homogeneous group of low-risk patients treated with I-125 or Pd-103. METHODS AND MATERIALS: As of January 2006, 602 patients with clinical stage T1c-T2a prostate carcinoma have been randomized to treatment with either I-125 or Pd-103 brachytherapy. This report focuses on 265 patients who had CT-based dosimetry available, and have a minimum of 2 years of follow-up. Standard postimplant dosimetric parameters were calculated including the V100 and D90, as well as the V50, V75, V150, V200, V300, D50, D75, and D200. Treatment margins were calculated using the premarket Dose Calc Test Application provided by Varian BrachyTherapy. RESULTS: Almost every DVH-based dosimetric parameter was higher for patients with PSA evidence of disease control compared with those with PSA failure, regardless of isotope. Kaplan-Meier univariate analysis indicates that nearly all dosimetric parameters among patients implanted with Pd-103 were strongly predictive of biochemical control, while parameters in the I-125 group all trended to lower values for patients with biochemical failure. CONCLUSION: Our demonstration of some predictive value of nearly all dosimetric parameters is in contrast to the impression one is left with from prior reports, which explicitly or implicitly portray a unique role for D90 or V100. We think that it is important for clinical investigators to look at other dosimetric parameters as part of ongoing clinical investigations because it is likely that dosimetric guidelines can be refined to improve our ability to rate implant quality.

AAPM Task Group 128: quality assurance tests for prostate brachytherapy ultrasound systems.

While ultrasound guided prostate brachytherapy has gained wide acceptance as a primary treatment tool for prostate cancer, quality assurance of the ultrasound guidance system has received very little attention. Task Group 128 of the American Association of Physicists in Medicine was created to address quality assurance requirements specific to transrectal ultrasound used for guidance of prostate brachytherapy. Accurate imaging guidance and dosimetry calculation depend upon the quality and accuracy of the ultrasound image. Therefore, a robust quality assurance program for the ultrasound system is essential. A brief review of prostate brachytherapy and ultrasound physics is provided, followed by a recommendation for elements to be included in a comprehensive test phantom. Specific test recommendations are presented, covering grayscale visibility, depth of penetration, axial and lateral resolution, distance measurement, area measurement, volume measurement, needle template/electronic grid alignment, and geometric consistency with the treatment planning computer.

Dosimetric parameters as predictive factors for biochemical control in patients with higher risk prostate cancer treated with Pd-103 and supplemental beam radiation.

PURPOSE: To analyze the role of dosimetric quality parameters in maximizing cancer eradication in higher risk prostate cancer patients treated with palladium (Pd)-103 and supplemental beam radiation. METHODS: One-hundred-seventy-nine patients treated with Pd-103 and supplemental beam radiation, with minimum 2 years follow-up prostate-specific antigen (PSA) values and posttreatment computed tomography scans were analyzed. Dosimetric parameters included the V100 (percent of the postimplant volume covered by the prescription dose), the D90 (the minimum dose that covered 90% of the post implant volume), and the treatment margins (the radial distance between the prostatic edge and the prescription isodose). Treatment margins (TMs) were calculated using premarket software. RESULTS: Freedom from biochemical failure was 79% at 3 years, with 92 of the 179 patients (51%) followed beyond 3 years. In comparing patients who did or did not achieve biochemical control, the most striking differences were in biologic factors of pretreatment PSA and Gleason score. The V100, D90, and average TM all showed nonsignificant trends to higher values in patients with biochemical control. In multivariate analysis of each of the three dosimetric parameters against PSA and Gleason score, TM showed the strongest correlation with biochemical control (p = 0.19). CONCLUSIONS: For patients with intermediate and high-risk prostate cancer treated with Pd-103 brachytherapy and external beam radiation, biologic factors (PSA and Gleason score) were the most important determinants of cancer eradication. However, there is a trend to better outcomes among patients with higher quality implant parameters, suggesting that attention to implant quality will maximize the likelihood of cure.

Effect of post-implant edema on prostate brachytherapy treatment margins.

PURPOSE: To determine if postimplant prostate brachytherapy treatment margins calculated on Day 0 differ substantially from those calculated on Day 30. METHODS: Thirty patients with 1997 American Joint Commission on Cancer clinical stage T1-T2 prostatic carcinoma underwent prostate brachytherapy with I-125 prescribed to 144 Gy. Treatment planning methods included using loose seeds in a modified peripheral loading pattern and treatment margins (TMs) of 5-8 mm. Postimplant plain radiographs, computed tomography scans, and magnetic resonance scans were obtained 1-4 hours after implantation (Day 0). A second set of imaging studies was obtained at 30 days after implantation (Day 30) and similarly analyzed. Treatment margins were measured as the radial distance in millimeters from the prostate edge to the 100% isodose line. The TMs were measured and tabulated at 90 degrees intervals around the prostate periphery at 0.6-cm intervals. Each direction was averaged to obtain the mean anterior, posterior, left, and right margins. RESULTS: The mean overall TM increased from 2.6 mm (+/-2.3) on Day 0 to 3.5 mm (+/-2.4) on Day 30. The mean anterior margin increased from 1.2 mm on Day 0 to 1.8 mm on Day 30. The posterior margin increased from 1.2 mm on Day 0 to 2.8 mm on Day 30. The lateral treatment margins increased most over time, with mean right treatment margin increasing from 3.9 mm on Day 0 to 4.7 mm on Day 30. CONCLUSION: Treatment margins appear to be durable in the postimplant period, with a clinically insignificant increase from Day 0 to Day 30.