Leveraging Academic Community Collaboration to Improve Rural Outcomes in RT Planning and Use of NCCN Guidelines

Purpose: As a small rural hospital with a single radiation oncology provider, we lack resources for peer review, which is an important part of quality outcomes. We created a peer review process through a partnership with an academic institution along with other community single-provider facilities to help review contouring, adherence to NCCN guidelines, and other quality metrics. We review the impact of this prospective peer review program on several outcomes over a 10-year period.

Methodology: We created core group of providers of radiation therapy in a large region rurally in eastern North Carolina, including 7 solo providers and 1 academic cancer program. We met three times weekly to present 95% of curative cases prospectively with the intent to help rural providers and standardize care regionally. We presented critical elements of RT planning before the start of therapy, including contouring, co-registration of diagnostic imaging, doses and techniques, review of OAR’s and overall plans using commonly agreed templates for RT planning based on site treated and Evidence based guidelines. A group consensus was reached on cases before RT was started. We review results from this programmatic approach since 2014.

Results: 7 facilities and 12 providers participated in this prospective peer review process over a ten year period. 1000 cases were reviewed on average annually with a consensus in RT dose and techniques achieved in all cases over time. Evidence based guideline use became the norm in all facilities with NCCN guidelines now followed consistently in each practice. Solo providers in particular benefited from this model of collaboration with expert guidance provided by academia, helping with recommended therapy, and influencing in order: 1) contour and anatomical volume changes , 2) changes in dose and dose per fraction, and 3) adoption of hypofractionation techniques regionally. Overall this model has improved conformity of radiation in a mostly rural 29-county service region within our state.

Conclusions: Peer review is a critical part of any quality program in radiation oncology. Solo providers lack the ability to obtain feedback on contours, planning volumes, doses, techniques and many other metrics that are critical in RT delivery. Our model of peer review has resulted in over 95% of successful prospective peer review, with outcomes following NCCN guidelines within a large geography in our state.

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