title: A peer review process as part of the implementation of clinical pathways in radiation oncology: Does it improve compliance?
abstract: OBJECTIVE
  Clinical pathways are patient management plans that standardize evidence-based practices to ensure high-quality and cost-effective medical care. Implementation of a pathway is a collaborative process in our network, requiring the active involvement of physicians. This approach promotes acceptance of pathway recommendations, although a peer review process is necessary to ensure compliance and to capture and approve off-pathway selections. We investigated the peer review process and factors associated with time to completion of peer review.
  
  
  METHODS
  Our cancer center implemented radiation oncology pathways for every disease site throughout a large, integrated network. Recommendations are written based upon national guidelines, published literature, and institutional experience with evidence evaluated hierarchically in order of efficacy, toxicity, and then cost. Physicians enter decisions into an online, menu-driven decision support tool that integrates with medical records. Data were collected from the support tool and included the rate of on- and off-pathway selections, peer review decisions performed by disease site directors, and time to complete peer review.
  
  
  RESULTS
  A total of 6965 treatment decisions were entered in 2015, and 605 (8.7%) were made off-pathway and were subject to peer review. The median time to peer review decision was 2 days (interquartile range, 0.2-6.8). Factors associated with time to peer review decision >48 hours on univariate analysis include disease site (P < .0001) with a trend toward significance (P = .066) for radiation therapy modality. There was no difference between recurrent and non-recurrent disease (P = .267). Multivariable analysis revealed disease site was associated with time to peer review (P < .001), with lymphoma and skin/sarcoma most strongly influencing decision time >48 hours.
  
  
  CONCLUSIONS
  Clinical pathways are an integral tool for standardizing evidence-based care throughout our large, integrated network, with 91.3% of all treatment decisions being made as per pathway. The peer review process was feasible, with <1% selections ultimately rejected, suggesting that awareness of peer review of treatment decisions encourages compliance with clinical pathway recommendations.
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: Dwight E
authors.initials: DE
authors.lastname: Heron
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: D000066491:Clinical Decision-Making / Q000379:methods; D019091:Critical Pathways / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D009369:Neoplasms / Q000532:radiotherapy*; D010380:Peer Review; D017410:Practice Guidelines as Topic; D000072378:Radiation Oncologists / Q000523:psychology*; D018787:Radiation Oncology / Q000458:organization & administration / Q000592:standards*