233 - Peer Review Implementation: From Chart Rounds to the Bedside

C. Caraway, L. Chang, M. Duhon, D. Song, R. K. Hales, A. N. Viswanathan, and J. L. Wright; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD

Purpose/Objective(s): There are large variations in rates of plan changes after peer review programs which range from 1.8 to 23.3%. We determined the association between peer review recommendations and factors leading to implemented plan changes. Materials/

Methods: An iterative peer review checklist recorded recommendations involving clinical scenarios, radiation (RT) prescription, organs at-risk and target volumes, planning goals, and patient setup. Disease site specific review was performed in breast, head & neck (H&N), central nervous system (CNS), genitourinary (GU), gynecological (GYN), and thoracic disease sites. In the setting of pre-treatment peer review, cases could be reviewed more than once. Reviews were classified as 1) discussion (changes suggested but not required), 2) minor suggestion (implementation prior to treatment completion), or 3) major suggestion (implementation before continuing treatment). Plan changes based on discussion and suggestions were recorded. Statistical analysis utilized Student’s t-test and ANOVA.
Results: During a six-month period, 1,311 peer reviews involving 914 unique patients were recorded. The majority of reviews were discussion only (19.7%) and minor suggestion (2.0%), only one major suggestion was recorded. Review duration was dependent on disease site, with thoracic cases having the longest reviews averaging 3.44min, (IQR 1:15, 5:10, p<0.01) (Table 1). There was no difference in the average duration of peer review between patients who had plan changes after discussion as compared to patients who did not (4:01min vs 3:55min, NS). The average rate of plan changes based on peer review discussion and minor or major suggestions (18.2%) was not significantly varied across different disease sites. Not all recommended plan changes were implemented; the most frequent enacted plan changes were seen in comments regarding the planning goals, RT prescription, and target volumes (6.8%, 4.8%, and 3.9%, respectively). Patients with multiple reviews exhibited a greater proportion of completed plan changes secondary to peer recommendations (29.8% vs 8.2%, p<0.01).
Conclusion: Despite similar rates of plan change based on peer review across disease sites, treatment planning decisions including the planning goals, RT prescription, and target were most frequently changed after peer recommendations. Multiple reviews both from pre-treatment peer review and follow up after initial peer review substantively increased the implementation of suggested plan changes; however, approximately 80-90% of all discussions are not acted upon, suggesting discussions may be of educational benefit and further analysis is necessary to understand the underlying barriers of peer review mediated changes. Abstract 233 – Table 1

Disease Site	Total # Reviews	Average Review Time (min)	% Comments	% Completed Plan Changes
Breast	431	02:14	22.5	22.7
H&N/CNS	229	01:51	11.4	7.7
GU/GYN	317	02:06	17.4	14.5
Thoracic	334	03:44	34.1	19.3
All	1311	02:32	22.3	18.2