title: Impact of dynamic changes to a bone metastases pathway in a large, integrated, National Cancer Institute-designated comprehensive cancer center network.
abstract: OBJECTIVE
  Studies suggest equivalent pain relief from bone metastases after radiation therapy with >10-fraction regimens and shorter courses. Although American Society for Radiation Oncology evidence-based guidelines and the Choosing Wisely campaign endorse single-fraction treatments and caution against the use of extended courses, publications report single-fraction utilization rates below 5%. We evaluated the impact of our bone metastasis clinical pathway on the adoption of short-course palliative radiation in a large, integrated radiation oncology network.
  
  
  METHODS
  We implemented a clinical pathway for the management of bone metastases in 2003 that required the entry of management decisions into an online tool that subjected off-pathway choices to peer review beginning in 2009. In 2014, the pathway was modified to encourage single-fraction treatments, and the use of >10 fractions was considered off pathway. Data were obtained from 16 integrated sites (4 academic, 12 community) from 2003 through 2014. Multivariate logistic regression was conducted to establish factors associated with treatment with a single fraction and with >10 fractions.
  
  
  RESULTS
  In this study, 12,678 unique courses were delivered. From 2003 to 2008, the single-fraction utilization rate was 7.6%. This increased to 10.9% from 2009 to 2013 and to 15.8% in 2014. The odds ratios for single-fraction use were 1.59 (95% confidence interval [CI], 1.39-1.81) and 2.58 (95% CI, 2.11-3.15) for 2009-2013 and 2014, respectively. Academic physicians were more likely to treat with a single fraction (odds ratio, 5.00; 95% CI, 4.38-5.71). Use of >10-fraction regimens significantly decreased from 18.6% in 2003-2008 to 15.2% in 2009-2013 and 9.7% in 2014.
  
  
  CONCLUSIONS
  Although our single-fraction utilization rate was initially in line with national rates (7.6%), the adoption rate increased to >15%. The use of >10-fraction regimens decreased significantly, predominantly among community practices. By 2014, >90% of courses were delivered with <10 fractions. This study demonstrates that provider-driven clinical pathways are able to standardize practice patterns and promote change consistent with evidence-based guidelines.
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Gebhardt
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Malolan S
authors.initials: MS
authors.lastname: Rajagopalan
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Beant S
authors.initials: BS
authors.lastname: Gill
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Dwight E
authors.initials: DE
authors.lastname: Heron
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Rakfal
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
authors.forename: John C
authors.initials: JC
authors.lastname: Flickinger
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. Electronic address: beriwals@upmc.edu.
authors.forename: Sushil
authors.initials: S
authors.lastname: Beriwal
mesh_terms: D001859:Bone Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D019091:Critical Pathways / Q000458:organization & administration* / Q000592:standards; D020000:Decision Support Systems, Clinical; D006801:Humans; D054547:National Cancer Institute (U.S.); D059408:Pain Management / Q000379:methods; D010166:Palliative Care; D010380:Peer Review / Q000379:methods*; D010818:Practice Patterns, Physicians'; D018787:Radiation Oncology / Q000458:organization & administration*; D011879:Radiotherapy Dosage; D014481:United States