Daily Peer Review Reduces Replanning and Activity-Based Costs in a Network of Community Radiation Oncology Centers

BACKGROUND AND OBJECTIVES: Peer review of radiation therapy plans is an essential quality assurance process; however, when performed after the initial treatment plan has already been created, it can lead to avoidable replanning, delays, and increased resource utilization. In this study, we implemented a quality improvement initiative to reduce the rate of replanning and utilize time-driven activity-based costing (TDABC) to measure its impact. METHODS: Plan-Do-Study-Act was utilized to move peer review from after treatment planning to before treatment planning at a network of freestanding cancer centers. Chart rounds were shifted from once-weekly retrospective plan review to daily prospective peer review of physician contours and prescriptions before dosimetric planning, immediately followed by a structured multidisciplinary clinical huddle (including physicians, nurses, dosimetrists, physicists, therapists, patient schedulers, medical assistants, and benefit representatives) to address care coordination. The rate of monthly dosimetry replans and their causes were abstracted from the electronic medical record system for 1 year before and after the initiative. TDABC was calculated for the cost of the replanning workflow, for the cost of the baseline once-weekly chart rounds, and for the cost of daily chart rounds. RESULTS: Four thousand five hundred seventy-two new treatment starts were observed over the 25-month period (average of 175.9 per month), of which 393 (8.6%) were replans. Before the change in peer review, the average monthly replan rate was 11.1%, which declined rapidly to 6.9% after the intervention. The most common reasons for replans included volume segmentation (33%), imaging and closer inspection (30%), and change in tumor (13%). Average fully loaded TDABC cost per replan occurrence was $908; weekly cost of once-weekly chart rounds was $3249; and weekly cost of daily chart rounds (4 days per week) was $4300. The reduction in replans translated to $118,996 in saved costs during the 14-month period ($8499 per month), with a net TDABC savings of $4294 to the practice per month or $60,124 for the 14-month postintervention timeframe. CONCLUSIONS: Physician-related peer review of contours and medical decision-making in the context of a daily chart rounds can lead to a reduction in the number of replans and reduction in resource utilization. With the movement towards value-based care, an understanding of both outcomes and sources of costs to the provider is essential.