title: External audit of clinical practice and medical decision making in a new Asian oncology center: results and implications for both developing and developed nations.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: North Coast Cancer Institute, Coffs Harbour, Sydney, NSW, Australia. ThomasShakespeare@gmail.com
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Shakespeare
authors.forename: Michael F
authors.initials: MF
authors.lastname: Back
authors.forename: Jiade J
authors.initials: JJ
authors.lastname: Lu
authors.forename: Khai Mun
authors.initials: KM
authors.lastname: Lee
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Mukherjee
mesh_terms: D000068:Accreditation; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002173:Cancer Care Facilities / Q000592:standards*; D002568:Certification; D002648:Child; D002983:Clinical Competence; D003657:Decision Making; D019049:Developed Countries; D003906:Developing Countries; D005240:Feasibility Studies; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D009369:Neoplasms / Q000532:radiotherapy*; D010166:Palliative Care / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000592:standards; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care / Q000592:standards; D018787:Radiation Oncology / Q000592:standards*; D012846:Singapore