The ABR - Radiation Oncology

Type 1 projects build on common practice components to engage the physician in continuous quality improvement. Critical descriptors include a project that is relevant to clinical practice (a specific feature of practice chosen by the individual with quantifiable endpoints) and inclusion of both assessment by the individual and an improvement or action plan. Type 1 projects can reflect departmental or institutional quality improvement programs, adapted by the individual to include their personal assessment and improvement/action plan. The following are examples of hypothetical Type 1 projects that summarize some of the practice components we believe would be appropriate for PQI.

Proposed Type 1 project-National Protocol Enrollment. A Type 1 project is envisioned for physicians enrolling patients on national protocols in which central quality assessment of radiotherapy includes feedback to the individual or department. A physician would identify a given interval during which a series of consecutive cases have been entered, for which quality assessment reports have indicated cases as fully evaluable or show deviations in data submitted or technique or therapy as delivered. The individual would complete a database form defining and documenting elements such as those listed in Table 1. The ABR and specialty-related organizations will provide templates such as this that can be used by the individual to complete the PQI project, essentially providing their data related to each critical element, along with self-assessment and an action plan.

Table 1. Protocol enrollment as Practice Quality Improvement project

Critical element	Protocol enrollment
Relevance to patient care	Therapeutic protocols provide opportunity to assess agreed on parameters of "ideal" management in selected cancer settings
Relevance to individual's practice	Documents understanding of radiation oncology parameters; individual's interpretation and performance of target localization, treatment planning and delivery; departmental/system-based submission of required data; response to central quality assurance center if required
Metrics	Fully evaluable cases; specific deficits in treatment planning or delivery or in data submission (completeness, timeliness of required data); goal, 100% compliance
Results	Number of fully evaluable cases among five or more sequential case entries; specific reasons for partially or nonevaluable cases
Assessment	Performance of individual based on goal of 100% fully evaluable cases with which further knowledge or difference in practice can address identified deviations; departmental or institutional processes or procedures for which further physician input/oversight may eliminate deviations
Improvement/action plan to include reassessment	Individual educational efforts; changes in practice to better adhere to protocol requirements; interaction with departmental/institutional infrastructure to ensure full compliance with data submission; plan to reassess evaluability of enrolled patients within given interval (e.g., 6, 12, or 18 months later) months later)

Proposed Type 1 project-Prostate Implants: Postimplant Dosimteric Assessment. A second Type 1 PQI example has been suggested by the American Brachytherapy Society (ABS) related to permanent source prostate brachytherapy (Table 2). The ABS, along with other organizations, has recommended that a postimplant dosimetric assessment be performed in all cases (14). Evidence is growing that dosimetric quantifiers (DQs) that can be easily generated after prostate brachytherapy are associated with the likelihood of cancer cure (15-19). DQs derived from multi-institutional cooperative group trials are now available that allow for normative comparisons (20). The ABS has proposed that individual practitioners choose one of the DQ benchmarks and compare the results of the practitioner's last 25 cases with the normative results in the peer-reviewed publications. If the DQs are not consistent with the results of the peers, an action plan outlining possible technical improvements (use of stranded sources, intraoperative dosimetry) would be required. Even if the DQs are consistent with published standards, an action plan would be required. The ABS expects the prostate model to be a template for future proposals in breast and gynecologic brachytherapy.

Table 2. Self-review of prostate implants: postimplant dosimetric assessment

Critical element	Prostate implants: postimplant dosimetric assessment
Relevance to patient care	Physician expertise and technical factors in implantation influence postimplant dosimetry
Relevance to individual's practice	Results of postimplant dosimetry have been correlated with disease-free survival after prostate brachytherapy
Metrics	Dosimetric quantifiers, including V₁₀₀ or D₉₀
Results	Median V₁₀₀ or D₉₀ and particularly percentage of cases at less than threshold value (e.g., V₁₀₀ <80% or D₉₀ <90% prescription dose)
Assessment	Comparison of practitioner's results with recent published data (peer comparison)
Improvement/action plan to include reassessment	Individual educational efforts; changes in technique to ensure that most of prostate is encompassed by prescription dose (e.g., use of stranded sources, intraoperative planning); plan to reassess dosimetric quantifiers after action plan implemented

Abbreviations: V₁₀₀ = percentage of prostate volume receiving 100% of prescribed minimal peripheral dose; D₉₀ = minimal dose received by 90% of target volume.

Proposed Type 1 project-retrospective review. A third Type 1 project might focus on a retrospective review of treatment policies and/or outcomes related to a practitioner's practice in a specific disease setting (Table 3). As an example, practitioners could evaluate their treatment policies for postmastectomy irradiation, comparing their own treatment policies with the American College of Radiology (ACR) appropriateness criteria for postmastectomy irradiation (21). Implicit is that a reasonable proportion of the cases reviewed in a given department or institution reflect the individual's clinical practice and/or systems developed by, or with, the practitioner.

Table 3. Individual participant's participation in academic retrospective review relevant to individual practice or role in determining departmental/institutional policies and practice

Critical element	Postmastectomy radiotherapy policies
Relevance to patient care	Evaluation of specific patient-related treatment in radiation management of breast cancer after mastectomy
Relevance to individual's practice	Identifies whether practitioner's treatment policies in postmastectomy irradiation are in accordance with published ACR appropriateness criteria
Metrics	What percentage agreement with ACR appropriateness criteria is apparent in series or practitioner's component thereof
Results	What percentage of >=10 consecutive cases within defined interval (within <=3 y) are in accordance with guidelines outlined in ACR appropriateness criteria for postmastectomy irradiation (17)
Assessment	Goal is 100% compliance with appropriateness criteria with respect to indications for treatment, radiation volume, dose, fractionation, use of bolus, and other technical factors
Improvement/action plan to include reassessment	Individual educational efforts; changes in policy as may be indicated; in areas of noncompliance, individual will read appropriate published reports and modify practice pattern; physician should reassess within 3 years, using an additional sample to demonstrate improvement in compliance with appropriateness criteria

Abbreviations: ACR = American College of Radiology.

Type 1 projects can link directly to departmental or institutional quality improvement programs. Required would be physician-specific data that might be benchmarked (compared within the department or the institution or with the national data when available), the individual's assessment of their own results, and an improvement or action plan with subsequent planned follow-up assessment. Examples include detailed departmental quality improvement programs related to the ACR standards for chart rounds with associated peer review; institutional quality improvement programs related to patient safety, medical documentation, and/or communication; multidisciplinary quality improvement programs related to patient care and management compared with accepted consensus-or evidence-based practice. Generic templates for such projects will be available through the ABR and/or specialty-related societies.

The diplomate will indicate the title of the PQI project, the date of initial completion, and the timeframe to document improvement or completion of the action plan on their Internet-based personal ABR repository; as with other aspects of MOC, the completed documentation will be subject to audit by the Board on a random basis.

Type 2 projects

Type 2 initiatives differ from Type 1 in that they are society or organization initiated and are reported through the sponsoring organization. Type 2 initiatives must meet the fundamental elements of any practice quality improvement program. Furthermore, the program must have predetermined measurable endpoints, in which the measured baseline parameters are compared with evidence-based guidelines, consensus statements, or peer comparisons (21, 22). An action plan outlining how the diplomate will improve performance should be in place, as well as a follow-up plan to assess the effect of the improvement plan within the 3-year PQI project interval. Type 2 initiatives must be submitted by the sponsoring society or organization to the ABR for qualification.

Sponsoring societies or organizations interested in developing Type 2 initiatives should have at least a 3-year history of an established infrastructure and 10 members who are diplomates of the ABR. Societies are encouraged to develop programs in which the data collected can be organized into large anonymous aggregate databases that can serve to further establish national standards. These databases will provide future metrics and benchmarks of quality standards in radiation oncology.

To date, two societies, the ACR and the American Society for Therapeutic Radiology and Oncology (ASTRO), have submitted Type 2 programs for qualification by the ABR. The ACR's RO-PEER program and the American Society for Therapeutic Radiology and Oncology's Performance Assessment for the Advancement of Radiation Oncology Treatment (PAAROT) are both chart-based reviews in which specific parameters are measured at baseline and compared with predetermined standards. The features of the two programs yet in development are summarized in Table 4.

Currently, these two programs evaluate the diplomate's practice at a fixed point in time, but incorporate an improvement plan and method for reassessment of the improvement plan. It is anticipated that the Type 2 initiatives will provide an opportunity for reassessment over an approximate 3-year cycle. Such data will be a valuable resource to the diplomate, documenting improvements in the individual's practice, as well as improvements in overall quality of care.

Critical element	ACR RO-PEER	ASTRO PAAROT
Relevance to patient care	Evaluation of direct patient care through chart review as component of ACR facility review or independent review of diplomate's submitted cohort of consecutive patient records	Evaluation of direct patient care through chart review of 10-15 randomly selected charts
Relevance to individual's practice	Sample of individual practitioner's charts reviewed for adherence to established standards	Sample of individual practitioner's charts reviewed for adherence to established standards
Metrics	Metrics from ACR's practice guidelines and standards for radiation oncology evaluated in each chart; evaluation conducted by independent peer radiation oncologists; professional/patient satisfaction survey included	Recognized parameters evaluated by individual practitioner by responding to specific questions for each chart; Internet-based program includes individual's distribution of professional/patient satisfaction surveys
Results	Goal is 100% compliance with practice guidelines and standards and to benchmark to aggregate peer data from ACR practice accreditation program and the Patterns of Care studies	Practitioner's answers and survey results will be compared with ideal answers and, ultimately, to aggregate peer data compiled through this process
Assessment	Individual will be scored for compliance in selected areas	Based on how practitioner varies from ideal answers, areas for improvement will be identified
Improvement/action plan to include reassessment	Areas of noncompliance will be identified and practitioner will develop plan for improvement; future consideration of time-specific reassessment will document improvement in areas of noncompliance over time	Practitioner will formulate plan for improvement, and repeat measurement will occur at fixed interval from initial assessment

Abbreviations: ACR = American College of Radiology

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