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Peer Review Quality Assurance for Radiation Therapy

Key findings

Peer review is an important quality assurance tool in healthcare. While peer review is being done among radiation oncologists across Ontario, variation in the rates of peer review has been reported by Regional Cancer Programs (RCPs). The overall Ontario average of curative cases being peer reviewed is 88%, which exceeds the target of 75% for fiscal year 2016/2017.

Measure:  Percentage of radical courses peer reviewed by a radiation oncologist

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing upwards in a green box. This indicates that there has been an increase in performance over the previous periods identified and this action is exceeding or meeting targets.

What is peer review?

  • Peer review is a valuable tool that is central to quality assurance programs in healthcare. Peer review is loosely defined as the evaluation of creative work or performance by other people in the same field to enhance the quality of work or the performance of colleagues [1].
  • In the context of quality radiation treatment practice, the Cancer Care Ontario Radiation Treatment Program has defined peer review as the evaluation of components of the attending radiation oncologist’s treatment plan by a second radiation oncologist, ideally with multidisciplinary input from physicists and radiation therapists [2]. For more information, see Cancer Care Ontario’s Radiation Oncology Peer Review Guidance Document.
  • Widely endorsed among radiation oncologists, peer review has several dimensions [3]. These include case conference review of treatment decision-making, peer-to-peer review of planning contours, and team meetings where representatives from multiple disciplines (e.g., nurses, physicians, physicists and therapists) review proposed treatment plans. This team review includes parameters such as prescribed dose, volumes to be covered, technique or patient set-up. It is sometimes referred to as “chart rounds” [1].
  • Multidisciplinary cancer conferences (MCCs) are a second form of peer review common in many centres, although case presentation in MCCs is not included in the statistics that report radiation oncology peer review rates. At MCCs, physicians from multiple disciplines and other members of the healthcare team discuss new patients or cases, reviewing decision points to help decide on the appropriate means of treatment (e.g., whether a patient should receive radiation treatment or if concurrent chemotherapy should be used).
  • This approach contrasts with peer review in radiation treatment, which concentrates on ensuring that treatment plans associated with the delivery of radiation (which are created after the decision has been made to treat with radiotherapy) are both safe and effective [2].

Figure 1. Percentage of completed radical courses peer reviewed by radiation oncologists, fiscal year 2015/2016 and fiscal year 2016/2017, by Regional Cancer Program (RCP) of treatment

More information regarding the methodology is available.

Report date: December 2017

Data source: ALR

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Fiscal years 2015/2016 and 2016/2017 data is based on the Activity Level Reporting (ALR) data cut in December 2017.
  2. Please refer to technical documentation.

 

Data Table 1. Percentage of completed radical courses peer reviewed by radiation oncologists, fiscal year 2015/2016 and fiscal year 2016/2017, by Regional Cancer Program (RCP) of treatment

RCP Percentage of peer reviewed radical completed courses fiscal year 2015/2016 Number of peer reviewed radical completed courses fiscal year 2015/2016 Total number of radical completed courses fiscal year 2015/2016 Lower confidence interval fiscal year 2015/2016 Upper confidence interval fiscal year 2015/2016 Percentage of peer reviewed radical completed courses fiscal year 2016/2017 Number of peer reviewed radical completed courses fiscal year 2016/2017 Total number of radical completed courses fiscal year 2016/2017 Lower confidence interval fiscal year 2016/2017 Upper confidence interval fiscal year 2016/2017
Ontario 76.9 27,443 35,684 76.5 77.3 87.8 32,736 37,293 87.4 88.1
Erie St. Clair 68.9 798 1,158 66.2 71.6 84.2 1,059 1,257 82.2 86.3
South West 74.0 2,573 3,479 72.5 75.4 80.9 2,678 3,309 79.6 82.3
Waterloo Wellington 70.4 1,044 1,483 68.0 72.8 84.6 1,351 1,597 82.8 86.4
Hmltn-Ngr-Hldmnd-Brnt 72.4 2,711 3,742 71.0 73.9 81.7 3,345 4,093 80.5 82.9
Mississauga Halton/Central West 99.9 2,560 2,562 99.8 100.0 99.6 2,880 2,891 99.4 99.9
Toronto Central South 84.5 6,216 7,358 83.6 85.3 90.0 6,952 7,725 89.3 90.7
Toronto Central North 62.8 3,173 5,049 61.5 64.2 93.5 4,979 5,326 92.8 94.2
Central 93.3 1,091 1,169 91.9 94.8 96.8 1,218 1,258 95.8 97.8
Central East 68.7 1,359 1,977 66.7 70.8 77.9 1,575 2,023 76.0 79.7
South East 90.6 1,093 1,206 88.9 92.3 92.3 1,172 1,270 90.8 93.8
Champlain 62.8 2,251 3,584 61.2 64.4 79.2 2,754 3,479 77.8 80.5
North Simcoe Muskoka 96.8 826 853 95.6 98.1 95.2 1,032 1,084 93.9 96.5
North East 87.7 1,344 1,533 86.0 89.3 90.0 1,258 1,398 88.4 91.6
North West 76.1 404 531 72.4 79.8 82.8 483 583 79.7 86.0

Report date: December 2017

Data source: ALR

Prepared by: Analytics and Informatics, Cancer Care Ontario

Note:

  1. Fiscal years 2015/2016 and 2016/2017 data is based on the Activity Level Reporting (ALR) data cut in December 2017.
  2. Please refer to technical documentation.

 

What do the results show?

Peer review in radiation therapy has improved significantly in Ontario.

  • The overall Ontario average of curative cases being peer reviewed has risen significantly, up from 77% for fiscal year 2015/2016 to 88% for fiscal year 2016/2017. All regions exceeded the fiscal year 2016/2017 target of 75%.
  • Mississauga Halton/Central West (99.6%), Central (96.8%) and North Simcoe Muskoka (95.2%) have the highest rates of peer review among the RCPs.
  • Recent surveys of professional practice in Ontario show that the importance of peer review is strongly endorsed by all Regional Cancer Centres (RCCs). Implementing efficient peer review practices has proven to be a challenge, however, particularly in older centres with well-established protocols and significant case volumes across all cancer types. Due to the use of targeted strategies last year, RCCs are exceeding the peer review target rate of 75%.
  • Palliative peer review quality assurance for radiation treatment is a priority for the Radiation Treatment Program and starting in April 2017, a target of 30% for each individual centre by the end of the year was agreed to. By March 2017, 28% of palliative courses were peer reviewed in Ontario (data not shown).

Why is this important to Ontarians?

Quality assurance is vital to successful treatment outcomes.

  • The Canadian Partnership for Quality Radiotherapy (CPQR) issued a policy statement that recommends increased peer review within the radiation therapy treatment process and among members of the radiation oncology team in order to increase quality assurance and safety [2].

Peer review encourages continuous professional improvement.

  • A recent meta-analysis of randomized controlled trials assessing the effects of peer review (audit and feedback) on objective professional practices or health outcomes found that audits and feedback can be effective in improving professional practice [4].
  • Embracing a culture of peer review provides benefits beyond explicit peer review decisions. Members of the healthcare team involved in peer review may feel empowered to increase their sphere of influence, making them more likely to suggest improvements in activities that benefit everyone [2].
  • Several radiation oncology professional associations have expressed support for the implementation of peer review as a regular part of practice. In its “Quality Assurance Guidance for Canadian Radiation Treatment Programs,” the CPQR recommends that all radiation treatment plans administered with adjuvant or curative intent undergo oncology peer review of volumes and dosimetry, ideally before the start of treatment [5]. This is also the case for other plans that have a significant potential for adverse patient outcomes if tumour targets and/or normal structures are treated inappropriately.
  • The Canadian Partnership Against Cancer and Cancer Care Ontario have supported the expansion of peer review activities in Ontario that document the frequency of changes made due to peer reviews and the associated disease sites. This new information will help determine the value of peer review processes in improving the quality of care.
  • The Radiation Treatment Program is currently working towards setting disease site-specific guidance for peer review to improve the overall quality of care in Ontario. Guidance is required because the key components of a plan that require peer review differ across cancer sites. It will thus provide clarity around the following questions.
    • What constitutes peer review? This may currently be contributing to the observed variation between RCCs.
    • What are the minimum requirements for peer review best practice? This will increase the quality of peer review for each disease site.

Find out more

Notes

  1. Peer Review Definition [Internet]. Linux Information Project; c2005 [cited 2015 Mar 10]. Available from here.
  2. Marks LB, Adams RD, Pawlicki T, Blumberg AL, Hoopes D, Brundage MD, et al. Enhancing the role of case oriented peer review to improve quality and safety in radiation oncology. Pract Radiat Oncol. 2013;3(3):149–156.
  3. Brundage M, Foxcroft S, McGowan T, Gutierrez E, Sharpe M, Warde P. A survey of radiation treatment planning peer-review activities in a provincial radiation oncology programme: current practice and future directions. BMJ Open. 2013;3:e003241.
  4. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2006;CD000259.
  5. Quality Assurance Guidance for Canadian Radiation Treatment Programs [Internet]. Canadian Partnership for Quality Radiotherapy; c2018 [cited 2014 Jan 16]. Available from here.
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