External audit on the clinical practice and medical decision-making at thedepartments of radiotherapy in Budapest and Vienna

Purpose: To present an example of how to study and analyze the clinical pra ctice and the quality of medical decision-making under daily routine workin g conditions in a radiotherapy department, with the aims of detecting defic iencies and improving the quality of patient care. Methods: Two departments, each with a divisional organization structure and an established internal audit system, the University Clinic of Radiotherap y and Radiobiology in Vienna (Austria), and the Department of Radiotherapy at the National Institute of Oncology in Budapest (Hungary), conducted comm on external audits. The descriptive parameters of the external audit provid ed information on the auditing (auditor and serial number of the audit), th e cohorts (diagnosis, referring institution, serial number and intention of radiotherapy) and the staff responsible for the treatment (division and ph ysician). During the ongoing external audits, the qualifying parameters wer e (1) the sound foundation of the indication of radiotherapy, (2) conformit y to the institution protocol (3), the adequacy of the choice of radiation equipment, (4) the appropriateness of the treatment plan, and the correspon dence of the latter with (5) the simulation and (6) verification films. Var ious degrees of deviation from the treatment principles were defined and sc ored on the basis of the concept of Horiot et al. (Horiot JC, Schueren van der E, Johansson KA, Bernier J, Bartelink H. The program of quality assuran ce of the EORTC radiotherapy group. A historical overview. Radiother. Oncol . 1993;29:81-84), with some modifications. The action was regarded as adequ ate (score 1) in the event of no deviation or only a small deviation with p resumably no alteration of the desired end-result of the treatment. A devia tion adversely influencing the result of the therapy was considered a major deviation (score 3). Cases involving a minor deviation (score 2) were thos e only slightly affecting the therapeutic end-results, with effects between those of cases with scores 1 and 3. Non-performance of the necessary radio therapeutic procedures was penalized by the highest score of 4. Statistical evaluation was performed with the BMDP software package, using variance an alysis. Results: Bimonthly audits (six with a duration of 4-6 h in each institution ) were carried out by three auditors from the evaluating departments; they reviewed a total of 452 cases in Department A, and 265 cases in Department B. Despite the comparable staffing and instrumental conditions, a markedly higher number (1.5 times) of new cases were treated in Department A, but wi th a lower quality of radiotherapy, as adequate values of qualifying parame ters (1-6) were more frequent for the cases treated in Department B (85.3%, 94%, 83.4%, 28.3%, 41.9% and 81.1%) than for those in Department A (67%, 8 3.4%, 87.8%, 26.1%, 33.2% and 17.7%). The responsible division (including s taff and instrumentation), the responsible physician and the type of the di sease each exerted a highly significant effect on the quality level of the treatment. Statistical analysis revealed a positive influence of the curati ve (relative to the palliative/symptomatic) intention of the treatment on t he level of quality, but the effect of the first radiotherapy (relative to the second or further one) was statistically significant in only one depart ment. At the same time, the quality parameters did not vary with the referr ing institution, the auditing person or the serial number of the audit. Conclusion: The external audit relating to the provision of radiotherapeuti c care proved feasible with the basic conformity and compliance of the staf f and resulted in valuable information to take correction measures. (C) 199 9 Elsevier Science Ireland Ltd. All rights reserved.