2679 - Improving Breast Cancer Quality Metrics with Early Radiation Oncology Internal Referral Model

R. Goldsberry¹, D. A. Hamstra², J. Wong³, P. M. Jhaveri², M. S. Ludwig², A. Echeverria², S. S. Desai², C. H. Chapman², J. Nangia⁴, C. Hsu⁵, E. Silberfein⁵, S. Martinez Garcia², C. E. Duncan⁶, M. Binu⁵, T. Saunders⁷, T. Patel⁸, and S. Sharma²; ¹Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, ²Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, ³Harris Health, Houston, TX, ⁴Department of Medical Oncology, Baylor College of Medicine, Houston, TX, ⁵Baylor College of Medicine, Houston, TX, ⁶San Antonio Military Medical Center, San Antonio, TX, ⁷UT Health, Houston, TX, ⁸MD Anderson, Houston, TX

Purpose/Objective(s): This project aims to ensure compliance with Commission on Cancer (CoC) Standard 7.1 by focusing on timely delivery of breast-conserving surgery (BCS) radiation treatment (BCSRT) for patients under 70, acknowledging the impact of delays on patient outcomes. Materials/

Methods: Utilizing the Institute for Healthcare Improvement (IHI) model, a systematic approach was employed to address delays in initiating radiation therapy (RT) post-breast cancer diagnosis in patients undergoing BCS. Delays were identified through regular BCSRT reports, indicating a significant dead time of almost three weeks after surgery until Radiation referrals. Interventions:

1. Modification of health care software radiation referral forms for efficient triage.
2. Adjustment of the interdisciplinary referral workflow to initiate radiation oncology referrals at or before surgery.
3. Establishment of points of contact from medical, radiation, and surgical oncology disciplines for streamlined communication.
4. Integration of internal and external checks to enhance workflow from surgery to radiation, including modifications to the Quality Checklist (QCL) in Moasiq for improved chemotherapy sequencing coordination.

Outcome Measures: BCSRT rate ensuring the time from breast cancer diagnosis to RT initiation is <365 days in =90% of BCSRT patients at the end of one year. Process measure: Percentage of referrals made to radiation oncology before surgery (PreSRef), tracking trends in pre-intervention referrals compared to post-intervention.

Results: Pre-intervention, the median BCSRT rate was 78.24%. Following the first PDSA cycle, PreSRef increased from 20% to 32%. After the second cycle, it improved to 34.4%. Subsequent to the third PDSA cycle, the outcome measure surpassed the goal, achieving a new median BCSRT rate of 100% and BCSRT Mean= 93.08% Limitations: Notably, a lack of communication with rotating clinical medical oncology fellows was identified during the first PDSA cycle, prompting the initiation of biweekly email alerts for early referrals as an additional intervention. Limitations encountered during subsequent cycles included cases where patients proceeded directly to surgery, necessitating surgeons to initiate radiation referrals for these individuals.

Conclusion: Enhanced referral processes and interdisciplinary collaboration significantly improved BCSRT rates, surpassing goals. Establishing early radiation oncology referrals as a permanent workflow is crucial for our institution. Future plans involve medical oncologists initiating referrals for neoadjuvant therapy, and surgeons for those proceeding directly to surgery. Triple-negative patients with longer chemotherapy durations face additional delays. Institution-specific prediction models will identify at-risk patients based on clinical and social characteristics.