Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 6  |  Page : 1469-1473

Audit of radiation oncology practice: Lessons from a new private hospital in Delhi, India


Department of Radiation Oncology, Manipal Hospitals HCMCT, Delhi, New Delhi, India

Date of Submission14-Jan-2021
Date of Acceptance12-Aug-2021
Date of Web Publication03-Aug-2022

Correspondence Address:
Bidhu K Mohanti
KIMS Cancer Centre, Kalinga Institute of Medical Sciences, K.I.I.T. University, Bhubaneswar - 751 024, Odisha
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_87_21

Rights and Permissions
 > Abstract 


Aims: The objective of this audit was to analyze the radiotherapy (RT) practice in a newly established tertiary private hospital. With increasing radiation oncology (RO) facilities in private sector, this report is the first audit from a private health organization in India.
Subjects and Methods: The audit of all consecutively registered patients in RO has focused to extract data from the time of RT simulation planning till the completion of RT course. The patient and disease characteristics,RT-related treatment factors and compliance were analyzed in-depth.
Results: In this newly established RO department, the vendor-supplied equipment, e.g., RT planning system, treatment delivery (linear accelerator and brachytherapy), and RO information system (ROIS), are integrated with enterprise-wide hospital information system into unified paperless workflow management for the patient care records in a prospective manner. This analysis comprised consecutive 328 patients who consented for RT simulation and planning from April 20, 2018, to December 31, 2019. RT course compliance was 94.8% (311/328 patients), and treatment intent-wise: curative plus adjuvant in 60.2% and palliative RT in 36%. RT technique was conformal in all 100%, with volumetric arc radiotherapy (VMAT) delivered to 66.6% of patients. With overall median RT course duration of 29 days (range 1–81 days), the patients were delivered a median of 20 fractions.
Conclusions: Compared to the previously published audit from an academic RO department in Delhi, this audit from a private hospital has shown (i) lesser waiting time, (ii) improved treatment compliance, (iii) utilization of higher techniques, and (iv) a lower duration of RT course.

Keywords: Audit in radiation oncology, comparison in India, private hospital, public hospital, quality indicators


How to cite this article:
Mohanti BK, Munshi A, Tharmar G, Sarkar B. Audit of radiation oncology practice: Lessons from a new private hospital in Delhi, India. J Can Res Ther 2022;18:1469-73

How to cite this URL:
Mohanti BK, Munshi A, Tharmar G, Sarkar B. Audit of radiation oncology practice: Lessons from a new private hospital in Delhi, India. J Can Res Ther [serial online] 2022 [cited 2022 Dec 2];18:1469-73. Available from: https://www.cancerjournal.net/text.asp?2022/18/6/0/353342




 > Introduction and Background Top


The emphasis on quality assurance and audit in radiation oncology (RO) has evolved in the last 25 years.[1],[2] The purpose of an audit is to analyze the current process of clinical care. The IAEA document[2] has stated that “radiotherapy centers operating at a high level of competence would have the following characteristics:

  1. Be capable of delivering a sustainable radiotherapy service to international standards
  2. Be capable of serving as a model for other radiotherapy centers in the country
  3. Be capable of providing professional training for staff working in radiotherapy.”


Given a wide variety of steps and processes involved in the RO practice, it is imperative to obtain the key information through clinical audits.[3]

In 2018, for a projected population of 1.36 billion, there were 1.2 million newly diagnosed cancer cases per year in India.[4] At present documentation, India has 495 RO facilities for treating cancer patients, which can be grouped as (a) public, under central government schemes = 25; (b) public, under state governments = 104; (c) in joint public–private venture = 36; and (d) private = 330.[5]

In India, a new trend in cancer care has emerged in the last three decades, since the time of liberalization in the country's economic policies, which began in 1991. There is an unequal investment in RO, with more state-of-the-art technology for radiotherapy available in private sector compared to public hospitals.[6] In the last decade, there is sensitivity toward including quality management into the radiotherapy practice, even in countries which had not earlier paid attention.[7] The widening gap in the inequity of access to quality radiotherapy practice between private and public hospitals can create an anomalous situation. While the public academic hospitals and medical institutions show an inclination toward audit and research,[8] such a scrutiny does not prevail in the private sector in India. This audit, from a newly established RO facility in Delhi, India, has focused on certain key parameters, such as patient and tumor characteristics, treatment aspects and compliance, and radiotherapy factors. To our knowledge, this paper is the first of its kind to report a clinical audit, on certain key parameters, from a private/corporate hospital in India. The present RO audit has also been compared with a previously published audit from an academic institution in Delhi.[8]


 > Subjects and Methods Top


This new tertiary hospital, as part of a corporate chain of private hospitals, started functioning in Southwest Delhi, India, from 2018. The RO facility consists of one high-end linear accelerator, one HDR brachytherapy, and two radiotherapy treatment planning systems (TPSs). The 3-D/4-D simulation is carried out on computed tomography (CT), PET-CT, and magnetic resonance imaging with PACS and fusion software in TPS platforms. The RO workflow is managed end-to-end on paperless task management environment.

All patients are registered in RO outpatient clinic, the medical records are maintained on enterprise-wide hospital information system (HIS), and the treatment decision support is made in the multidisciplinary tumor board. Before the simulation for radiotherapy (RT), each patient provides signed consent after due counseling by doctor. Weekly intradepartmental audit is held to discuss (a) start of new patients, (b) treatment plan, (c) change in treatment course, (d) adaptive/boost plan, and (e) patients who complete planned RT course, including morbidities, noncompliance, and interruption. At the end of the planned radiotherapy course, every patient is provided a hard copy of all treatment details delivered in summary. All the records of each patient are maintained prospectively on the RO information system (ARIA, Varian Medical Systems, Palo Alto, CA, USA).

For the present report, the data were extracted and populated manually consisting of the following features: (1) patients planned for RT course; (2) patient characteristics (designated as first course of RT, i.e., those who were RT-naive); (3) treatment characteristics of all who received RT (first and subsequent courses); and (4) RT factors. Thus, the objective of this audit is to analyze the clinical component of QUATRO, IAEA, Vienna.[2]

Statistical methods

We designed this analysis on the patient data prospectively entered on the Eclipse TPS and Aria ROIS systems provided by the vendor (Varian Medical Systems, Palo Alto, USA). Our paperless workflow platform managed the data extraction. The patient characteristics on the HIS at RO outpatient consultation was further verified and confirmed on the TPS. Treatment related data entered on TPS were matched with RT course audit and treatment summary recorded on ROIS. Any missing data, at each level of workflow, were duly accounted for audit purpose. As there was no scope for any comparative analysis within the data, only range and median were derived as the values. Further, the number of patients for each parameter was assigned as proportion (percentage) to the first decimal point.


 > Results Top


The first patient, in this new RO department, started treatment on April 20, 2018. This audit analysis is based upon the data recorded prospectively on the paperless RO workflow managed and audited regularly. As this audit comprises patients in a newly established facility, the waiting time for diagnosis, simulation, and start of RT course were not features or impediments for an audit cycle.

Present report consists of all patients who signed the informed consent and were taken up for RT simulation from April 20, 2018, to December 31, 2019. Out of the consecutively registered 328 patients, 311 patients (94.8%) completed the planned RT course [Table 1]. The patient characteristics of those radiotherapy-naive patients treated for the first course of RT are shown in [Table 2]. There was a marginal male preponderance (55% vs. 45%, M:F = 1.2:1.0), with a median age of 57 years. Residential status showed that 237 (82.6%) patients were Indians, 191 from Delhi-NCR and 46 (16%) from outside Delhi, and 50 patients (17.4%) were from outside India. Tumors of head and neck, gastrointestinal, and central nervous system constituted the top three malignancies who received RT (166/287, 57.8%).
Table 1: Audit profile (n=328)

Click here to view
Table 2: Patient characteristics, registered for 1st course of radiation therapy (n=287)

Click here to view


The treatment intent consisted of curative and palliative RT in equal proportions, 38.0% and 36.0%, respectively; whereas adjuvant practices (as preoperative or postoperative RT) were delivered to 22.2% of the patients [Table 3]. The RT course was delivered to single site of body in 87.8%, whereas 12.2% required irradiation to multiple sites. RT dose planning process, from the time of simulation to the first fraction of radiotherapy, took up 2 days or less in 52.9%; it was prolonged to 5 days or more in 10.5% [Table 4]. The RT course duration was of <10 days in 20.6% and extended beyond 30 days in 49.4% of treated patients, with a median of 29 days. The volumetric arc radiation therapy (VMAT) technique was utilized for 66.6% of the patients. The median number of RT fractions and the median dose delivered in this cohort were 20 (range 1–37) fractions and 4500 (range 720–6996) cGy, respectively. Brachytherapy was delivered to 14 patients, in a total of 41 sessions (median 3 sessions per patient) during the said RT dose planning process time period [Table 4].
Table 3: Treatment characteristics

Click here to view
Table 4: Radiation therapy factors

Click here to view



 > Discussion Top


This audit gives salient information about patient care related to radiotherapy process in a private hospital of the capital region of Delhi, India. For the future academic and research purposes, the present report from a private/corporate hospital can be relevant for a comparison with an earlier published RT audit from a reputed academic institution in Delhi, i.e., in the same geographic region.[8] Since the 1990s, the increasing migration of people from rural areas to cities has resulted in a predominance of tertiary health services, including oncology, in urban regions of India. This has caused the deepening inequity in access to specialized health facilities, which affects the most vulnerable citizens of the country. Such a shift has already been recorded in Latin America.[9]

Research and audit in RO usually focus on limited domain areas in developed countries, for example, radiotherapy dosimetry and radiotherapy in rectal cancer in these two published papers,[10],[11] to improve the care pathways. At a different level, the developing countries in low- and middle-income countries (LMICs) are delivering radiotherapy to thousands of cancer patients with a mix of substandard to state-of-the-art facilities.[2],[8],[12] Country-wise survey, in LMIC, has shown that compared to an optimal radiotherapy utilization (RTU) rate of 52%, the actual RTU is 28%.[12] Despite the established role of radiotherapy in improving the disease control and survival, the heterogeneity in access and practice remains the hurdle. Hence, it is imperative that a scientific culture of audit and quality assurance needs to be implemented to improve the standards of care and outcomes.[2],[12]

The requirement of multidisciplinary cancer treatments and the complexity in RO equipment and techniques have led to an imbalance in the access and provision of care between public and private RO facilities in India. The present audit (328 patients) has shown several differences, when it is compared with a previous audit (1030 patients) from a public hospital[8] in the same city of Delhi, India:

  1. The compliance to receive the prescribed RT course was higher in the present audit compared to previous study (94.8% vs. 75%)
  2. The audit cycle showed that the waiting time from RT consultation to the start of RT course was <5 days in the present audit (in 89.5% of patients) compared to a median of 41 days in previous study
  3. The intent of radiotherapy, analyzed as curative plus adjuvant versus palliative, was similar in the two audits; 60.2% and 36% (present report) versus 60% and 30% (previous audit), respectively
  4. In the present versus previous audit, the median duration of RT courses is reported as 29 days (range 1–81 days) versus 50 days (range 5–180 days), respectively, with a median RT fractions of 20 versus 30, respectively
  5. Linear accelerator (LINAC)-based radiotherapy and conformal technique were delivered to all patients (100%) in the present audit, compared with 22% receiving LINAC-based RT and 15% treated by conformal technique in the previous report.


Brachytherapy was delivered to lower proportion of patients in the present audit, i.e., 4.5% of the treated patients [14 out of 311, [Table 1]], compared to 7% who received brachytherapy in the earlier audit.[8]

The salient findings of this audit have shown several interesting features which can impact the RO practice in the future. While the major types of cancer and the treatment intents remain similar for both public and private radiotherapy facilities, the findings from the present audit from a private hospital have shown that (a) higher treatment compliance, (b) lesser waiting time, and (c) lower duration of RT course, altogether may enhance patient satisfaction. Although conformal radiotherapy techniques and LINAC-based RO should be the standards of patient care, such practices continue to be far from satisfactory in the public institutions across India.

As regard the quality indicators of radiotherapy, five parameters are considered to be critical: use of conformal planning, use of high-energy photons, use of custom immobilization, completion of at least two follow-up visits within 1 year, and qualified radiation oncologist.[13] Hence, there are larger concerns related to the RO specialty in India which can emerge from this audit, and these may equally apply to most regions of LMIC. The facilities in private hospitals have invested in state-of-the-art equipment and have implemented IMRT and higher techniques, yet there is a reluctance to engage in audit and research. On the other side, the overburdened caseloads in public institutions in India, more so in the academic sphere, tend to compromise the required quality indicators in RO. In the process, the patients do not access the current standard of care, and the quality of training of the future generation of radiation oncologists at these higher academic institutions becomes neglected. Similar observations and concerns have been raised recently.[14] To increase the participation of private hospitals toward improving the quality indicators of RO, audit and comparative health system research should be encouraged in future.[15]


 > Conclusions Top


This audit from a private hospital, the first of such reporting from India, has shown lesser waiting time, improved treatment compliance, utilization of higher techniques, and a lower duration of RT course as compared to an audit from the public academic institution in the same city published some years ago. It is imperative to note that there is low investment going toward RO and comprehensive cancer care in the public hospitals in India. In the last 30 years, the private/corporate hospitals, both old and new setups, are steadily increasing their presence and interest in the RO specialty. Although a small percentage of cancer patients can make payments for radiotherapy, more than 70% of cancer patients in need of radiotherapy do not access the private facilities. With a population of over 1.3 billion, the cancer burden of more than 1.2 million new cases/year, and approximately 50% of cancer patients indicated for radiotherapy, the investment in RO in India requires a fair balance in both public and private sectors for its citizens and for maintaining the quality of academic higher learning in the public institutions. Public and corporate policymakers and stakeholders in RO should take note of these findings in future installations and programs related to radiation oncology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Thwaites D, Scalliet P, Leer JW, Overgaard J. Quality assurance in radiotherapy. European Society for Therapeutic Radiology and Oncology Advisory Report to the Commission of the European Union for the 'Europe Against Cancer Programme'. Radiother Oncol 1995;35:61-73.  Back to cited text no. 1
    
2.
International Atomic Energy Agency. Comprehensive Audits of Radiotherapy Practices: A Tool for Quality Improvement. Quality Assurance Team for Radiation Oncology (QUATRO). Vienna: International Atomic Energy Agency; 2007.  Back to cited text no. 2
    
3.
Torras MG, Fundowicz M, Aliste L, Asensio E, Boladeras AM, Borràs JM, et al. Improving radiation oncology through clinical audits: Introducing the IROCA project. Rep Pract Oncol Radiother 2017;22:408-14.  Back to cited text no. 3
    
4.
Smith RD, Mallath MK. History of the growing burden of cancer in India: From antiquity to the 21st century. J Glob Oncol 2019;5:1-15.  Back to cited text no. 4
    
5.
Ganesh T. RT Centres in India- collected and prepared the data from DIRAC ( https://dirac.iaea.org/Data/CountriesLight) and AERB (https://www.aerb.gov.in/images/PDF/Radiotheraphy/RSD3.pdfs); [Last accessed on 2020 May 07].  Back to cited text no. 5
    
6.
Grover S, Gudi S, Gandhi AK, Puri PM, Olson AC, Rodin D, et al. Radiation oncology in India: Challenges and opportunities. Semin Radiat Oncol 2017;27:158-63.  Back to cited text no. 6
    
7.
Bogusz-Czerniewicz M. Quality management system in radiotherapy in the light of regulations applicable in Poland. Contemp Oncol (Pozn) 2012;16:140-6.  Back to cited text no. 7
    
8.
Kaur J, Mohanti BK, Muzumder S. Clinical audit in radiation oncology: Results from one academic centre in Delhi, India. Asian Pac J Cancer Prev 2013;14:2829-34.  Back to cited text no. 8
    
9.
Rosenblatt E, Zubizarreta E, Izewska J, Binia S, Garcia-Yip F, Jimenez P. Quality audits of radiotherapy centres in Latin America: A pilot experience of the International Atomic Energy Agency. Radiat Oncol 2015;10:169.  Back to cited text no. 9
    
10.
Clark CH, Aird EG, Bolton S, Miles EA, Nisbet A, Snaith JA, et al. Radiotherapy dosimetry audit: Three decades of improving standards and accuracy in UK clinical practice and trials. Br J Radiol 2015;88:20150251.  Back to cited text no. 10
    
11.
Torras MG, Canals E, Jurado-Bruggeman D, Marín-Borras S, Macià M, Jové J, et al. Clinical audit of the radiotherapy process in rectal cancer: Clinical practice guidelines and quality certification do not avert variability in clinical practice. Transl Oncol 2018;11:794-9.  Back to cited text no. 11
    
12.
Rosenblatt E, Fidarova E, Zubizarreta EH, Barton MB, Jones GW, Mackillop WJ, et al. Radiotherapy utilization in developing countries: An IAEA study. Radiother Oncol 2018;128:400-5.  Back to cited text no. 12
    
13.
Albert JM, Das P. Quality indicators in radiation oncology. Int J Radiat Oncol Biol Phys 2013;85:904-11.  Back to cited text no. 13
    
14.
Munshi A, Ganesh T, Mohanti BK. Radiotherapy in India: History, current scenario and proposed solutions. Indian J Cancer 2019;56:359-63.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Rao KD, Arora R, Ghaffar A. Health systems research in the time of health system reform in India: A review. Health Res Policy Syst 2014;12:37.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction and...>Subjects and Methods>Results>Discussion>Conclusions>Article Tables
  In this article
>References

 Article Access Statistics
    Viewed728    
    Printed64    
    Emailed0    
    PDF Downloaded59    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]