Radiotherapy contour quality improvement practices among United States radiation oncologists.
Authors: Zhang Helen , Cha Elaine , Lynch Kathleen , Gennarelli Renee L. , Sherer Michael Vincent , Brower Jeffrey W. , Golden Daniel W. , Royce Trevor Joseph , Chimonas Susan , Korenstein Deborah , Gillespie Erin F. 
Published: September 2021

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Background: The objective of this study was to assess contouring-related quality improvement practices employed by radiation oncologists in the United States (US) and to identify individual and organizational factors associated with use. Methods: We conducted a mixed methods study with a sequential explanatory design. A survey was developed with domains assessing individual and organizational demographic characteristics, clinical decision support strategies, and quality assurance and improvement processes. Study invitations were sent to a random 10% sample of practicing US radiation oncologists. After survey completion, physicians were invited to participate in a 30-minute audio-recorded semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests were used to evaluate associations between participant characteristics and survey responses. Interview data were coded using thematic content analysis. Results: The web-based survey response rate was 24% (115/482), and we completed 15 interviews. 72% of survey respondents report that contouring-related questions arise in at least half of cases in routine patient care, and the resources they access first are cooperative group guidelines and contouring atlases (e.g. RTOG/NRG) (75%) followed by consulting another radiation oncologist (60%). The most frequent barriers to optimizing quality of contours and treatment plans are time constraints (58%) and lack of access to disease site specialists (22%). About half (54%) of respondents do not have access to on-site disease site specialists. A majority of survey respondents (75%) believe having access to disease site specialists to review image-based radiation treatment-related questions would be helpful, and 40% indicated it could facilitate adoption of new radiation treatments. Seven interviewees mentioned engaging with out-of-network sub-specialists by phone, text or email. Five interviewees without access to sub-specialists mentioned a formalized system for consultation could be helpful. While almost all (97%) respondents report having a formal process for peer review, only 44% have contour-specific peer review. Academic centers/university setting and higher number of colleagues are factors associated with increased access to contour-specific peer review (p = 0.02 and p = 0.001). Clinical pathway use was reported by 18% of survey respondents, and interviews revealed concerns related to physician autonomy (i.e. ability to individualize treatment recommendations). Conclusions: This study identifies two potential opportunities to improve the radiation treatment quality from the physician’s perspective– improved access to disease site specialists and contour-specific peer review. Research is needed to test the acceptability and effectiveness of these strategies. Time and resource constraints must be considered when designing quality improvement efforts.