Virtual Radiation Oncology Peer Review is Associated With Decreased Engagement and Limited Case Discussion: Analysis of a Prospective Database Before and During the COVID-19 Pandemic

Provider Practices and Perceived Barriers and Facilitators in Improving Quality Practices in Radiation Oncology Peer Review

Purpose

Radiation oncology peer review evaluates case-specific qualitative treatment planning decisions. We sought to understand interdisciplinary perspectives on peer review to identify factors affecting stakeholder engagement and implementation of recommendations.

Materials and Methods

Semistructured interviews and Likert surveys (scaled, 0-10) with radiation oncology peer review participants were audio-recorded and transcribed. Two independent coders utilized a grounded theory approach to extract dominant themes.

Results

Participants included 6 academic and 3 community radiation oncologists, 2 residents, 2 medical physicists, 2 radiation therapists, 4 dosimetrists, and 1 industry representative. Thematic priorities of peer review included adherence to institutional guidelines, clinical background to inform decision-making, detection of rare errors, and education. Key facilitators included pretreatment peer review, clear planning guidelines, and feedback on peer recommendations. Barriers to recommendation adoption included resource limitations and a lack of prospective data guiding qualitative recommendations. Participants perceived benefits of peer review were assessed with Likert surveys with higher values placed on reducing practice variation (8.0) and education (7.6) and a lower value placed on the detection of medical errors (7.4) and reduction of treatment delivery incidents (6.9). When comparing Likert scores by participant role, nonphysicians rated the overall importance of peer review (mean, 9.8 vs 6.5, P = .03) and education (mean, 9.0 vs 6.7, P = .02) significantly higher than physicians.

Conclusion

Participants in radiation oncology acknowledged the importance of peer review, but there was significant variation in the perceived benefits. A higher value was placed on the alignment of clinical practice and nonphysician participant education. Future processes to improve communication and prospective plan review were identified as beneficial to peer review-mediated plan changes.

A systematic review and meta-analysis on the impact of institutional peer review in radiation oncology

BACKGROUND

Radiotherapy peer review is recognized as a key component of institutional quality assurance, though the impact is ill-defined. We conducted the first systematic review and meta-analysis to date to quantify the impact of institutional peer review on the treatment planning workflow including radiotherapy contours, prescription and dosimetry.

METHODS

We searched several medical and healthcare databases from January 1, 2000, to May 25, 2024, for papers that report on the impact of institutional radiotherapy peer review on treatment plans. We conducted random-effects meta-analyses of proportions to summarize the rates of any change recommendation and major change recommendation (suggesting re-planning or re-simulation due to safety concerns) following peer review processes. To explore differences in change recommendations dependent on location, radiotherapy intent, technique, and peer review structure characteristics, we conducted analyses of variance.

RESULTS

Of 9,487 citations, we identified 55 studies that report on 96,444 case audits in 10 countries across various disease sites. The pooled proportion of any change recommendation was 28 % (95 %CI = 21-35) and major change recommendation was 12 % (95 %CI = 7-18). Proportions of change recommendation were not impacted by any treatment characteristics. The most common reasons for change recommendation include target volume delineation (25/55; 45 %), target dose prescription (18/55; 33 %), organ at risk dose prescription (5/55; 9 %), and organ at risk volume delineation (3/55; 5 %).

CONCLUSIONS

Our review provides evidence that peer review results in treatment plan change recommendations in over one in four patients. The results suggest that some form of real-time, early peer review may be beneficial for all cases, irrespective of treatment intent or RT technique.

"If You're Talking, I Think You're Muted": Follow-up Analysis of Weekly Peer Review Discussion and Plan Changes After Transitioning From Virtual to In-Person Format

AIMS

During the COVID-19 public health emergency, we previously identified decreased rates of radiotherapy (RT) peer review (PR) discussion and plan changes in virtual versus in-person PR conferences. To expand on these findings, we continued to prospectively collect data on all PR conferences from 2021 to 2023 and performed a follow-up analysis before and after the transition back to in-person PR.

MATERIALS AND METHODS

A prospectively maintained database of weekly PR cases was queried for consecutive cases reviewed before and after the transition from virtual to in-person conferences. Rates of PR discussion and change recommendations were summarized and compared between the virtual and in-person groups. A survey was developed and administered to assess participants' perceived levels of engagement, opinions on optimal PR format, and preferences for future meetings before and 3 months after the transition back to in-person PR.

RESULTS

In total, 2,103 RT plans were reviewed: 1,590 virtually and 513 after the transition back to in-person. There was no difference in faculty attendance between groups. The proportion of cases with PR discussion increased from virtual (9.8%) to in-person (25.5%) format (p < 0.001). In the virtual group, 8.1% of cases had 1 topic and 1.7% had 2+ topics discussed. This increased to 15.8% and 9.7% during in-person PR, respectively (p < 0.001). The rate of change recommendation also increased from 1.5% (virtual) to 3.3% (in-person, p = 0.016). Among cases with at least 1 topic discussed, there was no difference in changes. Survey-reported distraction significantly decreased from virtual to in-person PR (p < 0.001).

CONCLUSION

Upon returning to in-person PR conferences, peer discussion and plan change recommendations significantly increased and returned to pre-pandemic levels, and participants' perceived levels of distraction were reduced. In an increasingly virtual world, additional efforts to develop best practices that maximize PR discussion and minimize distraction outside virtual conferences are warranted.

The Future of Safety and Quality in Radiation Oncology

The increasing complexity of radiation therapy treatment presents new potentials for error and suboptimal care. High-performing programs thus not only require adherence to, but also ongoing improvement of, key safety and quality practices. In this article, we review these practices including standardization, risk analysis, peer review, and maintenance of strong safety culture, while also describing recent innovations and promising future directions. We specifically highlight the growing role of artificial intelligence in radiation oncology, both as a tool to deliver safe, high-quality care and as a potential new source of safety challenges.

Peer Review in Radiation Oncology: Where Does the Middle East, North Africa, and Türkiye Region Stand?

PURPOSE

This study aims to assess the status of radiation oncology peer review procedures across the Middle East, North Africa, and Türkiye (MENAT) region.

METHODS

A cross-sectional electronic survey was conducted among radiotherapy centers in the MENAT region in March 2024. It assessed peer review practices, departmental demographics, perceived importance of peer review, and potential barriers.

RESULTS

Data from 177 radiation oncology centers revealed varying peer review implementation across the MENAT region. Egypt had the highest participation (16.4%) among all responders. Most centers (31%) treated 500-1,000 cases annually. The majority (77.4%) implemented peer review, with varying levels between countries and across different centers. Advanced radiotherapy techniques significantly correlated with implementation of peer review (P < .05). Peer review meetings were mostly scheduled on a weekly basis (46%) and organized by radiation oncologists (84.7%). Target volume contouring (89%) and radiotherapy prescription (82%) were frequently peer-reviewed. Respondents with peer review at their institutions significantly valued peer review for education, adherence to guidelines, improving planning protocols, and reducing variation in practice institutions without peer review (P < .05). The most frequently reported barriers to peer review were having a high number of patients (56%) and shortage of time (54%).

CONCLUSION

Peer review is essential for improving the quality of practice in radiation oncology. Despite some discrepancies, numerous obstacles, and challenges in implementation, it is instrumental in the improvement of patient care in most centers throughout the region. Raising awareness among radiation oncologists about the importance of peer review is paramount to lead to better outcomes.

Bridging the Communication Gaps: A Prospective Single-Arm Pilot Study Testing the Feasibility of Interdisciplinary Radiotherapy Planning in Locally Advanced Lung Cancer

RATIONALE AND OBJECTIVES

The treatment of locally advanced lung cancer (LALC) with radiotherapy (RT) can be challenging. Multidisciplinary collaboration between radiologists and radiation oncologists (ROs) may optimize RT planning, reduce uncertainty in follow-up imaging interpretation, and improve outcomes.

MATERIALS AND METHODS

In this prospective clinical treatment trial (clinicaltrials.gov NCT04844736), 37 patients receiving definitive RT for LALC, six attending ROs, and three thoracic radiologists were consented and enrolled across four treatment centers. Prior to RT plan finalization, representative computed tomography (CT) slices with overlaid outlines of preliminary irradiation targets were shared with the team of radiologists. The primary endpoint was to assess feasibility of receiving feedback no later than 4 business days of RT simulation on at least 50% of plans.

RESULTS

Thirty-seven patients with lung cancer were enrolled, and 35 of 37 RT plans were reviewed. Of the 35 patients reviewed, mean age was 69 years. For 27 of 37 plans (73%), feedback was received within 4 or fewer days (interquartile range 3-4 days). Thirteen of 35 cases (37%) received feedback that the delineated target potentially did not include all sites suspicious for tumor involvement. In total, changes to the RT plan were recommended for over- or undercoverage in 16 of 35 cases (46%) and implemented in all cases. Radiology review resulted in no treatment delays and substantial changes to irradiated volumes: gross tumor volume, -1.9 to +96.1%; planning target volume, -37.5 to +116.5%.

CONCLUSION

Interdisciplinary collaborative RT planning using a simplified workflow was feasible, produced no treatment delays, and prompted substantial changes in RT targets.

Head and neck radiotherapy quality assurance conference for dedicated review of delineated targets and organs at risk: results of a prospective study

Purpose

Head and neck (HN) radiotherapy (RT) is complex, involving multiple target and organ at risk (OAR) structures delineated by the radiation oncologist. Site-agnostic peer review after RT plan completion is often inadequate for thorough review of these structures. In-depth review of RT contours is critical to maintain high-quality RT and optimal patient outcomes.

Materials and Methods

In August 2020, the HN RT Quality Assurance Conference, a weekly teleconference that included at least one radiation oncology HN specialist, was activated at our institution. Targets and OARs were reviewed in detail prior to RT plan creation. A parallel implementation study recorded patient factors and outcomes of these reviews. A major change was any modification to the high-dose planning target volume (PTV) or the prescription dose/fractionation; a minor change was modification to the intermediate-dose PTV, low-dose PTV, or any OAR. We analysed the results of consecutive RT contour review in the first 20 months since its initiation.

Results

A total of 208 patients treated by 8 providers were reviewed: 86·5% from the primary tertiary care hospital and 13·5% from regional practices. A major change was recommended in 14·4% and implemented in 25 of 30 cases (83·3%). A minor change was recommended in 17·3% and implemented in 32 of 36 cases (88·9%). A survey of participants found that all (n = 11) strongly agreed or agreed that the conference was useful.

Conclusion

Dedicated review of RT targets/OARs with a HN subspecialist is associated with substantial rates of suggested and implemented modifications to the contours.