A Multi-institutional Survey of Attitudes and Practices Related to ...

Proceedings of the 53rd Annual ASTRO Meeting metastases, longer interval since initial NSCLC diagnosis, admission to a teaching hospital, and no history of low-income status were independently associated with the increased odds of receiving SRS. Patient age was not significantly associated with SRS use. Conclusions: The use of SRS for brain metastases in patients with NSCLC more than doubled from 2000 to 2005. In addition, there was significant variation in the utilization of SRS among SEER registries and socioeconomic quartiles. Despite randomized trials suggesting that the addition of SRS results in better control of brain metastases, national practice patterns suggest both a lack of consensus and overall limited use of the approach in this elderly cohort. Author Disclosure: L.M. Halasz: None. J.C. Weeks: None. B.A. Neville: None. N. Taback: None. R.S. Punglia: None.

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The Impact of National Health Care System Resources on Survival from Cancer 1

A. Batouli , P. Jahanshahi2, J. Yu1 1

Yale University, New Haven, CT, 2Virginia Commonwealth University, Richmond, VA

Purpose/Objective(s): Increasing per capita Gross Domestic Product (GDP) has been shown to predict improved cancer survival in European countries. Experts have proposed increased spending on radiation facilities as a cost-effective tool for battling cancer globally. We aimed to investigate the relationship between cancer survival and quantifiable measures of national health care systems (World Health Organization (WHO) overall health care system score (OHS), WHO health care system responsiveness score (RS), GDP, total health care expenditure (THE), physician density (PD), access to radiation oncology (measured by per capita total external beam devices (TEBD)) and THE per GDP). Materials/Methods: The most recent cancer incidence and mortality data (years 2005 - 2008) for 27 different cancers were obtained from the Globocan cancer registry for the 85 countries with reliable non-estimated data. Mortality per incidence for a given year was used as an inverse estimate of survival. Countries were split in half according to high (GDP.$15,000) or low-income (GDP\$15,000), and multivariate linear regression was run to compare the aforementioned markers with survival. The model controlled for rates of HIV, smoking, obesity, rural residence and ethanol consumption. Results: In low income countries, only OHS was a significant positive correlate of survival, with a 7% improvement in score corresponding to a 1% increase in overall cancer survival. PD was inversely correlated with survival in these countries, with an increase of 39 physicians per 100,000 population corresponding to a 1% decrease in survival. In high-income countries, RS, GDP, TEBD, THE, and THE per GDP were all significant correlates of survival. THE and THE per GDP were the strongest correlates, with a $400 increase in THE or a 0.8% increase in THE per GDP each corresponding to a 1% increase in overall cancer survival. For the above variables, correlations were stronger in men than in women. OHS and PD correlated poorly with survival in these countries. Conclusions: These results highlight different approaches to predicting cancer survival in low vs. high income countries. In the former, only OHS showed a significant positive correlation, showing that optimal health care system organization seemed to play a larger role in predicting cancer outcomes than radiation, physician or financial resources. In high income countries on the other hand, health care spending was the most significant predictor of survival. Although TEBD was correlated to cancer mortality, it was less significant than THE. This highlights the relative importance of overall health care spending above specific aspects of health care systems such as system organization, physician density, or radiation oncology facilities in predicting cancer survival in high income countries. Author Disclosure: A. Batouli: None. P. Jahanshahi: None. J. Yu: None.

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Learning from Our Mistakes: A Multi-institutional Survey of Attitudes and Practices Related to Voluntary Error and Near-miss Reporting

K. M. Harris1, L. Potters2, R. Sharma2, S. Mutic3, H. Gay3, J. Wright4, M. Samuels4, X. Ye1, E. Ford1, S. Terezakis1 1 Johns Hopkins, Baltimore, MD, 2North Shore-LIJ Health System, New Hyde Park, NY, 3Washington University School of Medicine, St. Louis, MO, 4University of Miami, Miami, FL

Purpose/Objective(s): Information on errors and near-miss events is essential for improving patient safety in radiation oncology, but factors affecting reporting by radiation oncology personnel are poorly understood. To better understand reporting practices and attitudes, an anonymous multi-institutional survey was distributed to clinical staff at four large academic radiation oncology centers, all of which have in-house incident reporting systems. Materials/Methods: Institutional review board approval was obtained from participating institutions for an anonymous email survey of radiation oncology department employees including attending physicians, residents, dosimetrists, physicists, radiation therapists and nurses. The survey was a 24 item questionnaire evaluating barriers to reporting, perceptions of errors and near-misses, department reporting culture and reporting practices. Participant feedback was solicited about clinical areas at highest risk for future errors and ideas for potential solutions. The distributions of responses were calculated and Chi squared tests were used to evaluate differences between proportions. Results: Responses were received from 268 participants (76.2%) with approximately equal participation by all professional groups. The vast majority of respondents (90.8%) agreed that errors and near-misses are occurring in their clinics, and most respondents agreed they had a responsibility to report these events (96.5%). Nevertheless, gaps between observed and reported events were noted across practice groups: 36.4%, 14.2%, 24.5% and 4% admitted to sometimes failing to report minor near-misses, major near-misses, minor errors and major errors, respectively. The most commonly cited barrier to reporting was concern about professional sanctions. Significant differences between the professional groups were seen in terms of concern about getting colleagues in trouble (p = 0.0084), liability (p = 0.0248) and embarrassment in front of colleagues (p = 0.0027), all of which were most frequently reported by attending physicians and residents. All groups reported that communication failures were the most common source of error in their departments. In the participant feedback section, the most frequent concerns were setup errors

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I. J. Radiation Oncology d Biology d Physics

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Volume 81, Number 2, Supplement, 2011

(n = 15), complex stereotactic treatments (n = 10) and computer-related events (n = 13). 76.7% of respondents indicated that they would participate in a national reporting system. Conclusions: Near-misses and errors are observed by all members of the radiation oncology team. Even in departments with sophisticated reporting systems, only a subset of these events are reported. Important barriers to reporting were identified and suggest targets for future patient safety initiatives. Author Disclosure: K.M. Harris: None. L. Potters: None. R. Sharma: None. S. Mutic: B. Research Grant; Varian Medical. G. Other; Shareholder in ViewRay, Fulcrum Medical. H. Gay: None. J. Wright: None. M. Samuels: None. X. Ye: None. E. Ford: None. S. Terezakis: None.

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Error-proofing in Radiation Therapy: A Quantitative Analysis of Fifteen Commonly Used Quality Control Measures

E. C. Ford, S. Terezakis, A. Souranis, K. Harris, S. Mutic Johns Hopkins University, Baltimore, MD Purpose/Objective(s): Effective quality control (QC) measures are critical to providing safe treatments in the complex environment of radiation therapy. We quantified the effectiveness of 15 commonly employed QC measures at preventing errors and nearmisses observed in the course of clinical radiotherapy operations. Materials/Methods: Near-miss incident reports were collected over a three year period at two academic medical centers by means of voluntary electronic reporting systems. Events which had a high potential severity were considered for further analysis (level 3 or greater on the French ASN scale). We determine which of these events would be detectable by 15 commonly employed QC measures including: physician plan review, physics and therapy chart checks, pre-treatment IMRT QA, port films, in vivo portal dosimetry, and onboard CT. For this analysis we assume that each QC check is functioning perfectly. Results: Of 4407 reported events, 292 had a high potential severity. Current standard QC measures detect only a minority of these events. On average, each QC measure detects only 27% of the observed high potential severity events even when functioning perfectly. Only the physics chart check could detect more than 50% of events. The least sensitive safety check is pre-treatment IMRT QA which could detect only 1% of the high potential-severity events occurring in clinic. The most sensitive QC processes (with .30% sensitivity) were: plan and chart checks by physicians, physicists, and therapists, in vivo portal dosimetry, and checklists. Though each QC check in isolation has low sensitivity, most events have more than one QC check in place. On average each event had 4.0 QC checks in place which could prevent it. Notably, however, 9% of reported events (27 events) had only one QC check in place and 3% (10 events) had no QC check in place. One limitation of this analysis is that it is based on actual reported events, the strong majority of which originate from therapists, treatment planners and physicists. Conclusions: Most individual QC measures commonly used in radiation therapy are able to prevent less than half of the errors and near-misses occurring in the clinic. A substantial number of possible high-severity errors are prevented by only a single QC check or, in some cases, no formal QC check. This analysis underscores the need for systematic analysis of clinical failure modes and design of corresponding QC measures. Further work is needed to determine if these patterns hold across multiple institutions. Author Disclosure: E.C. Ford: B. Research Grant; Pilot grant, Elekta Inc. D. Speakers Bureau/Honoraria; Users’ meeting, Elekta Inc., User’s meeting, Sun Nuclear Inc. S. Terezakis: None. A. Souranis: None. K. Harris: None. S. Mutic: None.

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The Influence of Regional Radiation Oncologist and Urologist Capacities on Treatment Choice for Prostate Cancer

S. Aneja1, C. Gross1, D. Makarov2, K. Roberts1, J. B. Yu1 1

Yale School of Medicine, New Haven, CT, 2New York University School of Medicine, New York, NY

Purpose/Objective(s): There exists significant regional variation in the management of prostate cancer. Our study investigates the influence of regional variations of radiation oncology and urology services on the treatment modality chosen for prostate cancer management. Materials/Methods: Prostate cancer treatment choice and patient data from 2004 to 2007 were obtained from the NCI Surveillance, Epidemiology, and End Results (SEER) database and combined with the health system data from the Area Resource File. The geographic units of analysis were the NCI defined Health Service Areas (HSA) within the SEER registry. The health system characteristics analyzed were radiation oncologist density, urologist density, primary care provider density, IMRT equipped hospital density, general radiation therapy equipped hospital density, and median household income. Densities were reported per 100,000 residents using 4-year population averages. Patient factors analyzed included race, marital status, and age. Separate logistic regression models were built to test the association between health system characteristics and whether patients received any form of radiation therapy (EBRT, brachytherapy, or a combination) or just surgical treatment. Results: Overall of the 108,612 patients in our sample, 43.7% received some form of radiation therapy. Patients residing in HSAs with increased radiation oncologist densities were more likely to receive some form of radiation to treat prostate cancer (OR 1.07 [SE 0.02, p\.001]). Conversely increased urologist density was associated decreased use of radiation therapy (OR .95 [SE .01, p\.001]). Presence of IMRT equipped and general radiation therapy equipped hospitals were both associated with increased use of radiation therapy (OR 1.53 [SE .05, p\.001] and OR 1.13 [SE .03, p\.001] respectively). Alternatively, 39.3% of patients in our sample received just surgical interventions. Patients residing in HSAs with increased radiation oncologist densities were less likely to receive only surgical treatment for prostate cancer (OR .91 [SE .01, p\.001]). Increased urologist density was associated with increased likelihood of only surgical treatment for prostate cancer (OR 1.09 [SE 0.01, p\.001]). Presence of IMRT equipped and general radiation therapy hospitals were both associated with decreased use of only surgical treatment for prostate cancer (OR .82 [SE .03, p\.001] and OR .82 [SE .02, p\.001] respectively). Conclusions: Radiation oncologist and urologist capacities influence the regional variations in the treatment choice for prostate cancer. There is a need for comparative effectiveness data to determine the optimal modality for effective prostate cancer management. Author Disclosure: S. Aneja: None. C. Gross: None. D. Makarov: None. K. Roberts: None. J.B. Yu: None.