A comparison of Royal Australian and New Zealand College Radiologists (RANZCR) and Singapore-designed radiation oncology practice audit instruments: how does reproducibility affect future approaches to revalidation?
Radiotherapy Centre, The Cancer Institute, National University Hospital, Singapore.Australasian Radiology (Impact Factor: 0.51). 06/2004; 48(2):195-203. DOI: 10.1111/j.1440-1673.2004.01296.x
Physician competency assessment requires the use of validated methods and instruments. The Royal Australian and New Zealand College of Radiologists (RANZCR) developed a draft audit form to be evaluated as a competency assessment instrument for radiation oncologists (ROs) in Australasia. We evaluated the reliability of the RANZCR instrument as well as a separate The Cancer Institute (TCI) Singapore-designed instrument by having two ROs perform an independent chart review of 80 randomly selected patients seen at The Cancer Institute (TCI), Singapore. Both RANZCR and TCI Singapore instruments were used to score each chart. Inter- and intra-observer reliability for both audit instruments were compared using misclassification rates as the primary end-point. Overall, for inter-observer reproducibility, 2.3% of TCI Singapore items were misclassified compared to 22.3% of RANZCR items (P < 0.0001, 100.00% confidence that TCI instrument has less inter-observer misclassification). For intra-observer reproducibility, 2.4% of TCI Singapore items were misclassified compared to 13.6% of RANZCR items (P < 0.0001, 100.00% confidence that TCI instrument has less intra-observer misclassification). The proposed RANZCR RO revalidation audit instrument requires further refinement to improve validity. Several items require modification or removal because of lack of reliability, whereas inclusion of other important and reproducible items can be incorporated as demonstrated by the TCI Singapore instrument. The TCI Singapore instrument also has the advantage of incorporating a simple scoring system and criticality index to allow discrimination between ROs and comparisons against future College standards.
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ABSTRACT: Meta-analyses demonstrate audit with feedback (AWF) is effective continuing medical education (CME). However, efficacy varies between specialties, with little published radiation oncologist (RO)-specific evidence. We evaluated an AWF CME intervention for ROs determining efficacy, cost-effectiveness, and participant satisfaction. CME program: The CME incorporated fortnightly random patient chart audit, scoring management adequacy via a checklist. Scores were presented at a same-day institutional meeting, and case management discussed. Senior peers provided individualized, educational feedback. Changes in behavior and performance were evaluated by chart review of new patients seen by ROs in the 2 months before commencement of AWF (T0), and at months 13-14 of the program (T1). Behavior and performance were evaluated with a validated, reproducible, 19-item instrument. Criteria for each case audited included 10 targeted and 3 nontargeted behavior items and 6 performance items; each scored 1 point if deemed adequate (maximum score 19). Cost-effectiveness was reported as cost to the institution per item point gained. The mean score (out of 5) of a 14-item questionnaire evaluated program perception. A total of 113 and 118 charts were evaluated at T0 and T1, respectively. Mean score of targeted behavior improved between T0 and T1 (from 8.7 to 9.2 out of 10, P = .0001), with no significant improvement of nontargeted behavior/performance items. Annual costs and cost-per-point gained were US 7,897 dollars and 15 dollars. Participant satisfaction was positive, increasing after efficacy result distribution (P = .0001). Audit with comparative, individualized, educational feedback is cost-effective and positively perceived CME, significantly improving targeted RO behavior. Oncologists' CME design and evaluation require further research.
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ABSTRACT: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making. Clinical documentation/quality assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p = 0.007), overall performance (p = 0.003), and optimal treatment rates (p = 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.
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ABSTRACT: There has been little radiation oncologist (RO)-specific research in continuing medical education (CME) or quality improvement (QI) program efficacy. Our aim was to evaluate a CME/QI program for changes in RO behavior, performance, and adherence to department protocols/studies over the first 12 months of the program. The CME/QI program combined chart audit with feedback (C-AWF), simulation review AWF (SR-AWF), reminder checklists, and targeted CME tutorials. Between April 2003 and March 2004, management of 75 patients was evaluated by chart audit with feedback (C-AWF) and 178 patients via simulation review audit (SR-AWF) using a validated instrument. Scores were presented, and case management was discussed with individualized educational feedback. RO behavior and performance was compared over the first year of the program. Comparing the first and second 6 months, there was a significant improvement in mean behavior (12.7-13.6 of 14, p = 0.0005) and RO performance (7.6-7.9 of 8, p = 0.018) scores. Protocol/study adherence significantly improved from 90.3% to 96.6% (p = 0.005). A total of 50 actions were generated, including the identification of learning needs to direct CME tutorials, the systematic change of suboptimal RO practice, and the alteration of deficient management of 3% of patients audited during the program. An integrated CME/QI program combining C-AWF, SR-AWF, QI reminders, and targeted CME tutorials effectively improved targeted RO behavior and performance over a 12-month period. There was a corresponding increase in departmental protocol and study adherence.
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