The Impact of Transitioning to Prospective Contouring and Planning Rounds as Peer Review

Abstract

Purpose: Our peer-review program previously consisted of weekly chart rounds performed before the end of the first week of treatment. In order to perform peer review before the start of treatment when possible, we implemented daily prospective contouring and planning rounds (CPR).

Methods and materials: At the time of computed tomography simulation, patients were categorized by the treating physician into 5 treatment groups based on urgency and complexity (ie, standard, urgent, palliative nonemergent, emergent, and special procedures). A scoring system was developed to record the outcome of case presentations, and the results of the CPR case presentations were compared with the time period 2.5 years before CPR implementation, for which peer review was performed retrospectively.

Results: CPR was implemented on October 1, 2015, and a total of 4759 patients presented for care through May 31, 2018. The majority were in the standard care path (n = 3154; 66.3%). Among the remainder of the charts, 358 (7.5%), 430 (9.0%), and 179 (3.8%) cases were in the urgent, nonemergent palliative, and emergent care paths, respectively. The remaining patients were in the special procedures group, representing brachytherapy and stereotactic radiosurgery. A total of 125 patients (2.6%) required major changes and were re-presented after the suggested modifications, 102 patients (2.1%) had minor recommendations that did not require a repeat presentation, and 247 cases (5.2%) had minor documentation-related recommendations that did not require editing of the contours. In the 2.5 years before the implementation, records of a total of 1623 patients were reviewed, and only 9 patients (0.6%) had minor recommendation for change. The remainder was noted as complete agreement.

Conclusions: Contouring and planning rounds were successfully implemented at our clinic. Pretreatment and, most often, preplanning review of contours and directives allows for a more detailed review and changes to be made early on in the treatment planning process. When compared with historical case presentations, the CPR method made our peer review more thorough and improved standardization.

Figure 1

(A) Standard care path for patients undergoing treatment that could start ≥5 days after computed tomography simulation. Contours are reviewed at rounds before the start of planning. (B) Urgent care path for patients who need to start treatment ≤4 days after simulation. Planning begins immediately to avoid delay, but contours and directives are reviewed before the start of treatment.

Figure 2

(A) Palliative nonemergent care path for patients who require relatively simple planning with anticipated start ≤4 days after simulation. Fields are reviewed at rounds before the start of treatment. (B) Emergent care path for patients who must start treatment before the next contouring and planning rounds. Patients are reviewed retrospectively after the start of treatment.

Figure 3

(A) Special procedures care path for patients receiving special procedures, such as stereotactic radiosurgery or brachytherapy. Patients are reviewed before treatment when possible; however, most present retrospectively after the first treatment. (B) Time from computed tomography simulation to initiation of treatment between May 2015 and March 2017. Contouring and planning rounds were implemented in October 2015.