- Email: [email protected]
The Willingness of Dosimetrists and Radiation Therapists to Challenge Physicians as a Means of Assuring Patient Safety: Results of a Pilot Program
Proceedings of the 52nd Annual ASTRO Meeting breast (12.0%), head and neck (24.4%) cancers were most prevalent among this patient group. Over a third (39.1%) of the patients entered treatment with stage 4 cancer. Only 11.6% of the patients did not complete their treatment regimen within the prescribed number of days. Men were less likely to be adherent to their treatment in comparison to women (p\.000). No differences in adherence were observed across racial and marital status groups. Patients who were employed were more likely adhere to their treatment in comparison to patients who were unemployed or retired (p\.000). Patients receiving curative treatment and reported side effects demonstrated a higher level of adherence in comparison to those receiving palliative treatment and not reporting side effects (p\.000). Conclusions: The results indicate better adherence to radiation therapy among cancer patients who female, employed, reported side effects and receiving curative treatment. The findings suggest that targeted interventions to improve adherence to radiation therapy may be necessary to improve survival. Future studies of adherence are warranted to enhance the success of radiation treatment and extend the lives of cancer patients. Author Disclosure: D. Fyffe, None; C. Cathcart, None.
2813
Prone Hypo-fractionated Whole Breast Radiation without a Concomitant Boost: Comparative Effectiveness of Intensity Modulated Radiation Therapy (IMRT) vs. 3D-conformal Radiation Therapy (3D-CRT)
C. Min, M. E. Hardee, S. Pope, S. J. Becker, S. C. Lymberis, K. DeWyngaert, S. C. Formenti New York University School of Medicine, New York, NY Purpose/Objective(s): IMRT is substantially more expensive than its primary substitute, 3D-CRT, raising the question of whether it offers acceptable value compared to alternative uses of healthcare resources. We are reporting a dosimetry and toxicity comparison of IMRT versus 3D-CRT to treat the whole breast, when used without a concomitant boost to the tumor bed, as well as a costeffectiveness analysis of the two methods. Materials/Methods: An IRB-approved study identified a consecutive series of 73 whole breast radiotherapy plans of patients simulated in the prone position and treated with the Canadian hypo-fractionated regimen of 16 fractions of 266 cGy each, for a total of 4256 cGy. IMRT technique was used in 40 plans, while 33 patients were treated with 3D-CRT because their insurance companies denied reimbursement of IMRT. The IMRT and 3D-CRT cohorts were compared for dosimetry, toxicity, and collected payments. These values were then applied to assess cost-effectiveness based on quality-adjusted life years (QALYs). Specifically, we determined the minimum increase in QALYs that a future study should be powered to detect to justify the use of IMRT, assuming a societal willingness to pay (SWTP) of $50,000 per QALY. Results: Dosimetry and acute toxicity were found to be generally comparable among the two groups. The only significant difference was in the rate of grade 2 dermatitis, which occurred in 8% of patients in the 3D-CRT group and in none of the IMRT group. Based on Medicare reimbursement data for 2010, the average payments received for each course of treatment using IMRT was $12,657, compared to $8,099 for 3D-CRT, for a difference of $4,558. Because QALYs are calculated based on changes in either quality or quantity of life, and neither of these was detectable in our series of patients, these values were removed from the equation. Therefore, only the baseline difference in cost, $4,558, remained. We determined that IMRT would have to increase a patient’s quality-adjusted life expectancy by at least 0.1 QALYs compared to 3D-CRT in order to deliver acceptable value, assuming a SWTP of $50,000. Conclusions: This exploratory study suggests that in prone hypo-fractionated whole breast radiation, the minimal dosimetry and acute toxicity improvement achieved by IMRT compared to 3D-CRT results in an increment in cost of $4,558 per course of treatment. We thus conclude that for this particular subset of patients, IMRT is not a cost-effective approach. However, these data do not apply to a clinical setting that warrants a concomitant boost, in which IMRT assures the best dose distribution and protection of normal tissue. Author Disclosure: C. Min, None; M.E. Hardee, None; S. Pope, None; S.J. Becker, None; S.C. Lymberis, None; K. DeWyngaert, None; S.C. Formenti, None.
2814
The Willingness of Dosimetrists and Radiation Therapists to Challenge Physicians as a Means of Assuring Patient Safety: Results of a Pilot Program
R. D. Adams, R. C. Chen, J. E. Bailey, L. B. Marks Dept. of Radiation Oncology - Univ. of North Carolina, Chapel Hill, NC Purpose/Objective(s): Radiation therapy is complex, and its safe delivery requires efforts of multiple individuals (e.g. dosimetrists, therapists, nurses, physicists and physicians). The health care team’s willingness to challenge each other is an important component of the ‘‘peer review’’ to assure patient safety and treatment quality. Indeed, in one of the recently-publicized misadministrations reported in the NY Times, the radiation therapists had raised concerns to the physician. Given the hierarchical nature of the U.S. healthcare system, one might hypothesize that dosimetrists/therapists may be uncomfortable questioning physicians. We report results of a survey to assess attitudes among dosimetrists/therapists regarding their willingness to challenge physicians. The attitudes among current students who participated in a prospective educational initiative aimed, in part, to reduce barriers between dosimetrists/therapists/physicians, is highlighted. Materials/Methods: An e-mail survey was sent to alumni of our Radiation Therapy and Medical Dosimetry training programs. 16 questions assessed attitudes regarding willingness to challenge physicians (scored on a 1-5 Likert scale). Results from different subgroups were compared using chi-square. A recent student cohort participated in an initiative designed to reduce barriers between dosimetrists/therapists/physicians (i.e. daily joint patients-care conferences attended by therapy/dosimetry students/staff and physicians). Results: Overall 23/31 responded to the survey (representing 9 institutions). 3/23 (14%) and 8/23 (33%) rated as poor their ability/ willingness to confidently speak to a physician about a possible mistake or set-up error, respectively. Compared to prior graduated, the current students (in the initiative to reduce barriers) reported more satisfaction in communicating with radiation oncologists (p = .04, Chi-square), in confidence talking to radiation oncologists (p = .001) and in speaking to radiation oncologists about
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Volume 78, Number 3, Supplement, 2010
a mistake (p = .003). In each of these questions, almost all of the current students answered ‘‘very good’’ to ‘‘excellent,’’ compared to \ 20% of the prior graduates. Conclusions: There is an apparent lack of confidence/willingness among some therapists/dosimetrists to speak to physicians about potential errors/mistakes. The current students appear more willing to speak with physicians. This might reflect a positive impact of our initiative (joint patients-care conferences attended by therapy/dosimetry students/staff and physicians) to reduce communication barriers. The small sample size limits the interpretation and a larger survey would be helpful to better define the scope of the problem and the pertinent covariates. Author Disclosure: R.D. Adams, None; R.C. Chen, None; J.E. Bailey, None; L.B. Marks, None.
2815
Assessing the Feasibility of using Volumetric Modulated Arc Therapy Technology to Increase the Throughput and Quality of Radiotherapy in Developing Countries
S. Chilukuri, V. S. Subramaniam, G. Arun, S. Thirumalaiswamy, M. Kathirvel, S. Kala, J. Amit Yashoda Cancer Institute, Hyderabad, India Purpose/Objective(s): Recent studies have documented the superiority of high-precision radiotherapy techniques in reducing toxicity and improving outcomes. As a result of the economic boom in developing countries, hospitals have acquired high-end technology. However, resources are limited and due to the large patient burden most hospitals are not equipped to treat all deserving patients with IMRT. The purpose of our current study is to assess the feasibility of using RapidArc technology (RA) to increase the throughput in terms of IMRT treatments per day per machine. Materials/Methods: In this study we compared the total monitor units (MU) and the treatment delivery time for 75 patients treated per day with RA on single treatment unit (Varian 2100CD with OBI) with sliding window dynamic multi-leaf collimator IMRT (DIMRT) plans. The site of irradiation was brain (B) in 15, head and neck (H&N) in 20, thorax(T) in 13, abdomen(A) in 10 and pelvic (P) in 17 patients. A majority of RA plans consisted of 1 arc for B, T and A tumors, 2 arcs for H&N and P tumors. All cases were re-planned with DIMRT using Eclipse [V. 8.9] achieving the same treatment goals. IMRT plans consisted of 4-9 beams. The total treatment time was computed by summing positioning time [mean-3min], alignment time [mean for B- 3 minutes (min), for H&N- 4 min, for P, A and T- 5min], imaging and analysis time [mean-5min] and the beam ON time. The beam ON time for Rapid Arc treatment was measured on the first day of treatment whereas for IMRT, treatment was simulated on a phantom with planned parameters. The total treatment time was analyzed for IMRT and RA assuming time other than beam ON time to be identical. Results: The average Beam ON time and MU was lesser with RA compared to IMRT. The average MUs for RA vs. IMRT, for tumors of B, HN, T, A and P were 320.8 vs. 464.9 (p = 0.06), 459.9 vs. 1340.2 (p = 0.03), 330.4 vs. 944.2 (p = 0.037), 447.1 vs. 1204.2 (0.03) and 499.8 vs.1461 (p = 0.034) respectively. The average beam ON time for RA vs. IMRT, for tumors of B, HN, T, A and P were 1.18 min vs. 3.03 min (p = 0.056), 3.03 min vs. 8.66 min (p = 0.032), 1.32 min vs. 7.55 min (p = 0.02), 1.18 min vs. 5.51 min (p = 0.035), 2.59 min vs. 8.48 min (p = 0.04), respectively. The treatment time gain in treating 75 patients per day with RA instead of IMRT was 5.9 hrs with reduction of 51,658 MUs. Assuming same proportion of cases, only 55 patients could have been treated on IMRT per day as opposed to 75 patients on RA (working hrs- 18/day). Conclusions: The results of this study show an advantage with RA over DIMRT with a several hours gain of treatment time on the machine with reduced MUs without compromising the treatment goals. RA is an efficient technology with a significant impact in busy centers with a large load of patients being treated on high precision techniques. Author Disclosure: S. Chilukuri, None; V.S. Subramaniam, None; G. Arun, None; S. Thirumalaiswamy, None; M. Kathirvel, None; S. Kala, None; J. Amit, None.
2816
Patient Safety in Radiation Oncology: Tools for Improvement
E. C. Ford, S. Terezakis, P. Pronovost, L. Myers, R. Bell, J. Wong, D. Song, R. Zellars, T. DeWeese Johns Hopkins University, Baltimore, MD Purpose/Objective(s): Patient safety is a vital concern in radiotherapy. According to estimates based on publicly available data, the rate of serious injury during radiotherapy is approximately 1000 times higher than in industries such as commercial aviation and modern anesthesiology which are often cited as examples of complex but ultrasafe enterprises. Improvements are warranted. Here we focus on specific systems-based tools that can be used to reduce errors. Materials/Methods: Two safety improvement tools were implemented in the department of radiation oncology beginning in 2006-2007: an incident reporting system and failure mode and effects analysis (FMEA). The incident reporting system has logged over 200 reports of near-miss errors. FMEA is a prospective error prevention methodology in which failure modes are identified and scored according to severity, occurrence rate and detectability, and are combined into a risk priority number (RPN). FMEA was performed in 2006 and 2009, requiring approximately 170 staff hours each time. Individual blinded scoring of each failure mode was performed by a cross-sectional department team of 10 people to assess the statistical properties of FMEA. The results of FMEA were compared with incident reports. Results: There was a large variability in FMEA scoring between people, with standard deviations of 76% and 34% for RPN and severity, respectively. Significant bias between specialty groups was also identified with severity and RPN scores from therapists being significantly lower than those from physicists or treatment planners (p \ 0.001). Severity scores were well-correlated with risk priority number scores (Pearson r = 0.50), and increased going from consult to treatment delivery (p \ 0.001). Comparing the FMEA results to error reports over a 3-month period, only 10 of 24 (42%) reported errors were identified in the FMEA process. Conclusions: Patient safety in radiation oncology needs to be improved if it is to be brought in line with other ultra-safe practices. FMEA is a valuable tool for identifying weak points in a complex system before they become problematic. It is, however, a cumbersome and time-intensive tool and may not capture all errors actually occurring in the clinic. A streamlined approach is key to safety improvement. Given the strong correlation between severity and overall RPN score, we propose the use severity-only scoring for safety analysis.
2813
Prone Hypo-fractionated Whole Breast Radiation without a Concomitant Boost: Comparative Effectiveness of Intensity Modulated Radiation Therapy (IMRT) vs. 3D-conformal Radiation Therapy (3D-CRT)
C. Min, M. E. Hardee, S. Pope, S. J. Becker, S. C. Lymberis, K. DeWyngaert, S. C. Formenti New York University School of Medicine, New York, NY Purpose/Objective(s): IMRT is substantially more expensive than its primary substitute, 3D-CRT, raising the question of whether it offers acceptable value compared to alternative uses of healthcare resources. We are reporting a dosimetry and toxicity comparison of IMRT versus 3D-CRT to treat the whole breast, when used without a concomitant boost to the tumor bed, as well as a costeffectiveness analysis of the two methods. Materials/Methods: An IRB-approved study identified a consecutive series of 73 whole breast radiotherapy plans of patients simulated in the prone position and treated with the Canadian hypo-fractionated regimen of 16 fractions of 266 cGy each, for a total of 4256 cGy. IMRT technique was used in 40 plans, while 33 patients were treated with 3D-CRT because their insurance companies denied reimbursement of IMRT. The IMRT and 3D-CRT cohorts were compared for dosimetry, toxicity, and collected payments. These values were then applied to assess cost-effectiveness based on quality-adjusted life years (QALYs). Specifically, we determined the minimum increase in QALYs that a future study should be powered to detect to justify the use of IMRT, assuming a societal willingness to pay (SWTP) of $50,000 per QALY. Results: Dosimetry and acute toxicity were found to be generally comparable among the two groups. The only significant difference was in the rate of grade 2 dermatitis, which occurred in 8% of patients in the 3D-CRT group and in none of the IMRT group. Based on Medicare reimbursement data for 2010, the average payments received for each course of treatment using IMRT was $12,657, compared to $8,099 for 3D-CRT, for a difference of $4,558. Because QALYs are calculated based on changes in either quality or quantity of life, and neither of these was detectable in our series of patients, these values were removed from the equation. Therefore, only the baseline difference in cost, $4,558, remained. We determined that IMRT would have to increase a patient’s quality-adjusted life expectancy by at least 0.1 QALYs compared to 3D-CRT in order to deliver acceptable value, assuming a SWTP of $50,000. Conclusions: This exploratory study suggests that in prone hypo-fractionated whole breast radiation, the minimal dosimetry and acute toxicity improvement achieved by IMRT compared to 3D-CRT results in an increment in cost of $4,558 per course of treatment. We thus conclude that for this particular subset of patients, IMRT is not a cost-effective approach. However, these data do not apply to a clinical setting that warrants a concomitant boost, in which IMRT assures the best dose distribution and protection of normal tissue. Author Disclosure: C. Min, None; M.E. Hardee, None; S. Pope, None; S.J. Becker, None; S.C. Lymberis, None; K. DeWyngaert, None; S.C. Formenti, None.
2814
The Willingness of Dosimetrists and Radiation Therapists to Challenge Physicians as a Means of Assuring Patient Safety: Results of a Pilot Program
R. D. Adams, R. C. Chen, J. E. Bailey, L. B. Marks Dept. of Radiation Oncology - Univ. of North Carolina, Chapel Hill, NC Purpose/Objective(s): Radiation therapy is complex, and its safe delivery requires efforts of multiple individuals (e.g. dosimetrists, therapists, nurses, physicists and physicians). The health care team’s willingness to challenge each other is an important component of the ‘‘peer review’’ to assure patient safety and treatment quality. Indeed, in one of the recently-publicized misadministrations reported in the NY Times, the radiation therapists had raised concerns to the physician. Given the hierarchical nature of the U.S. healthcare system, one might hypothesize that dosimetrists/therapists may be uncomfortable questioning physicians. We report results of a survey to assess attitudes among dosimetrists/therapists regarding their willingness to challenge physicians. The attitudes among current students who participated in a prospective educational initiative aimed, in part, to reduce barriers between dosimetrists/therapists/physicians, is highlighted. Materials/Methods: An e-mail survey was sent to alumni of our Radiation Therapy and Medical Dosimetry training programs. 16 questions assessed attitudes regarding willingness to challenge physicians (scored on a 1-5 Likert scale). Results from different subgroups were compared using chi-square. A recent student cohort participated in an initiative designed to reduce barriers between dosimetrists/therapists/physicians (i.e. daily joint patients-care conferences attended by therapy/dosimetry students/staff and physicians). Results: Overall 23/31 responded to the survey (representing 9 institutions). 3/23 (14%) and 8/23 (33%) rated as poor their ability/ willingness to confidently speak to a physician about a possible mistake or set-up error, respectively. Compared to prior graduated, the current students (in the initiative to reduce barriers) reported more satisfaction in communicating with radiation oncologists (p = .04, Chi-square), in confidence talking to radiation oncologists (p = .001) and in speaking to radiation oncologists about
S567
I. J. Radiation Oncology d Biology d Physics
S568
Volume 78, Number 3, Supplement, 2010
a mistake (p = .003). In each of these questions, almost all of the current students answered ‘‘very good’’ to ‘‘excellent,’’ compared to \ 20% of the prior graduates. Conclusions: There is an apparent lack of confidence/willingness among some therapists/dosimetrists to speak to physicians about potential errors/mistakes. The current students appear more willing to speak with physicians. This might reflect a positive impact of our initiative (joint patients-care conferences attended by therapy/dosimetry students/staff and physicians) to reduce communication barriers. The small sample size limits the interpretation and a larger survey would be helpful to better define the scope of the problem and the pertinent covariates. Author Disclosure: R.D. Adams, None; R.C. Chen, None; J.E. Bailey, None; L.B. Marks, None.
2815
Assessing the Feasibility of using Volumetric Modulated Arc Therapy Technology to Increase the Throughput and Quality of Radiotherapy in Developing Countries
S. Chilukuri, V. S. Subramaniam, G. Arun, S. Thirumalaiswamy, M. Kathirvel, S. Kala, J. Amit Yashoda Cancer Institute, Hyderabad, India Purpose/Objective(s): Recent studies have documented the superiority of high-precision radiotherapy techniques in reducing toxicity and improving outcomes. As a result of the economic boom in developing countries, hospitals have acquired high-end technology. However, resources are limited and due to the large patient burden most hospitals are not equipped to treat all deserving patients with IMRT. The purpose of our current study is to assess the feasibility of using RapidArc technology (RA) to increase the throughput in terms of IMRT treatments per day per machine. Materials/Methods: In this study we compared the total monitor units (MU) and the treatment delivery time for 75 patients treated per day with RA on single treatment unit (Varian 2100CD with OBI) with sliding window dynamic multi-leaf collimator IMRT (DIMRT) plans. The site of irradiation was brain (B) in 15, head and neck (H&N) in 20, thorax(T) in 13, abdomen(A) in 10 and pelvic (P) in 17 patients. A majority of RA plans consisted of 1 arc for B, T and A tumors, 2 arcs for H&N and P tumors. All cases were re-planned with DIMRT using Eclipse [V. 8.9] achieving the same treatment goals. IMRT plans consisted of 4-9 beams. The total treatment time was computed by summing positioning time [mean-3min], alignment time [mean for B- 3 minutes (min), for H&N- 4 min, for P, A and T- 5min], imaging and analysis time [mean-5min] and the beam ON time. The beam ON time for Rapid Arc treatment was measured on the first day of treatment whereas for IMRT, treatment was simulated on a phantom with planned parameters. The total treatment time was analyzed for IMRT and RA assuming time other than beam ON time to be identical. Results: The average Beam ON time and MU was lesser with RA compared to IMRT. The average MUs for RA vs. IMRT, for tumors of B, HN, T, A and P were 320.8 vs. 464.9 (p = 0.06), 459.9 vs. 1340.2 (p = 0.03), 330.4 vs. 944.2 (p = 0.037), 447.1 vs. 1204.2 (0.03) and 499.8 vs.1461 (p = 0.034) respectively. The average beam ON time for RA vs. IMRT, for tumors of B, HN, T, A and P were 1.18 min vs. 3.03 min (p = 0.056), 3.03 min vs. 8.66 min (p = 0.032), 1.32 min vs. 7.55 min (p = 0.02), 1.18 min vs. 5.51 min (p = 0.035), 2.59 min vs. 8.48 min (p = 0.04), respectively. The treatment time gain in treating 75 patients per day with RA instead of IMRT was 5.9 hrs with reduction of 51,658 MUs. Assuming same proportion of cases, only 55 patients could have been treated on IMRT per day as opposed to 75 patients on RA (working hrs- 18/day). Conclusions: The results of this study show an advantage with RA over DIMRT with a several hours gain of treatment time on the machine with reduced MUs without compromising the treatment goals. RA is an efficient technology with a significant impact in busy centers with a large load of patients being treated on high precision techniques. Author Disclosure: S. Chilukuri, None; V.S. Subramaniam, None; G. Arun, None; S. Thirumalaiswamy, None; M. Kathirvel, None; S. Kala, None; J. Amit, None.
2816
Patient Safety in Radiation Oncology: Tools for Improvement
E. C. Ford, S. Terezakis, P. Pronovost, L. Myers, R. Bell, J. Wong, D. Song, R. Zellars, T. DeWeese Johns Hopkins University, Baltimore, MD Purpose/Objective(s): Patient safety is a vital concern in radiotherapy. According to estimates based on publicly available data, the rate of serious injury during radiotherapy is approximately 1000 times higher than in industries such as commercial aviation and modern anesthesiology which are often cited as examples of complex but ultrasafe enterprises. Improvements are warranted. Here we focus on specific systems-based tools that can be used to reduce errors. Materials/Methods: Two safety improvement tools were implemented in the department of radiation oncology beginning in 2006-2007: an incident reporting system and failure mode and effects analysis (FMEA). The incident reporting system has logged over 200 reports of near-miss errors. FMEA is a prospective error prevention methodology in which failure modes are identified and scored according to severity, occurrence rate and detectability, and are combined into a risk priority number (RPN). FMEA was performed in 2006 and 2009, requiring approximately 170 staff hours each time. Individual blinded scoring of each failure mode was performed by a cross-sectional department team of 10 people to assess the statistical properties of FMEA. The results of FMEA were compared with incident reports. Results: There was a large variability in FMEA scoring between people, with standard deviations of 76% and 34% for RPN and severity, respectively. Significant bias between specialty groups was also identified with severity and RPN scores from therapists being significantly lower than those from physicists or treatment planners (p \ 0.001). Severity scores were well-correlated with risk priority number scores (Pearson r = 0.50), and increased going from consult to treatment delivery (p \ 0.001). Comparing the FMEA results to error reports over a 3-month period, only 10 of 24 (42%) reported errors were identified in the FMEA process. Conclusions: Patient safety in radiation oncology needs to be improved if it is to be brought in line with other ultra-safe practices. FMEA is a valuable tool for identifying weak points in a complex system before they become problematic. It is, however, a cumbersome and time-intensive tool and may not capture all errors actually occurring in the clinic. A streamlined approach is key to safety improvement. Given the strong correlation between severity and overall RPN score, we propose the use severity-only scoring for safety analysis.