Robert Olson

Background: Evidence-based, clinical practice guidelines (CPGs) provide a framework for prescribing practices and patient management. A gap between CPGs and clinical practice often exists and may result in substandard patient care. Clinical audit and feedback (CA&F) is a demonstrated successful knowledge translation (KT) method that can positively impact change in practice in numerous clinical scenarios including adherence to CPGs. However, there has been low implementation of CA&F in oncology, and specifically in radiotherapy (RT) prescribing practices. We sought to identify the impact of a simple CA&F intervention on the proportion of recommended prescription use across six cancer centres in British Columbia (BC) by investigating five breast cancer clinical scenarios. Methods: Thirty-five radiation oncologists (ROs) were randomized to either be audited with feedback or audited alone (control). Patient data was obtained retrospectively for patients treated before and after intervention. The effect of feedback was measured by identifying the proportion of patients who received the recommended prescription before vs. after the feedback intervention, and a logistic regression model was used to predict odds ratio of using the recommended prescription as a result of CA&F.Results: A total of 8713 unique cases were identified, and the recommended prescription was used 75% of the time. Odds ratio of using the recommended prescription across five clinical scenarios was 0.78 (p=0.57), 0.87 (p=0.77), 0.90 (p=0.85), 0.93 (p=0.58), and 0.28 (p=0.36) respectively. Conclusion: There was no significant change in odds of utilizing the more evidence-based prescription, suggesting our simple CA&F intervention was not effective in changing prescribing practices. Further, ROs may have already been well informed of their prescribing patterns. A more complex CA&F intervention may be necessary in future quality assurance efforts to achieve a greater impact on radiotherapy prescribing practices.

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Patient-reported outcomes (PROs) are defined as any report coming directly from the patient about a health condition and its treatment using a self-reported measure. The Prospective Outcomes and Support Initiative (POSI) is an initiative of BC Cancer that drives the provincial coordination of PRO data collection to create system improvements in clinical care processes. This study focuses on the influence of POSI on the role of the radiation therapist (RT) in clinical practice.Fifteen (15) RTs were recruited through POSI team leadership from 6 different BC Cancer sites. Semi-structured telephone interviews were the primary method of data collection, and interviews were audio-recorded and transcribed verbatim. The data obtained were analyzed using the software NVIVO and guided by constant comparative methods.Three overarching themes described RT's perspectives on the ways in which POSI influenced their role as a healthcare provider. The first theme that emerged was that RT’s did not perceive POSI as influencing their radiation therapist role. The second theme described how POSI influenced the RT’s caring role through communication. Specifically, POSI enhanced the patient-provider relationship, provided a process through which to educate and advise patients, and the opportunity to address patient questions and/or priorities that they would not otherwise. The third theme portrayed ways in which POSI impeded the RTs ability to perform their usual work by creating extra workload. While the first theme suggests that POSI had minimal influence, the other two themes indicate that POSI influenced the RT-Patient interaction and hence, the overall patient experience during their cancer radiation treatments.POSI can both positively and negatively influence the RT's role in clinical practice. Nonetheless, maximizing the benefits of POSI so as to improve patient care will require concerted efforts to reduce the barriers to administration. Furthermore, creating opportunities for RTs to interact regularly with patients through POSI administration, has the potential to greatly improve the caring role of the RT in clinical practice.

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Background and Purpose: Recent literature has suggested that higher volumes of practice areassociated with better survival outcomes for head and neck cancer (HNC) patients. However,these studies are limited by looking at the volume of practice on a cancer centre level (i.e. notprovider level), and include jurisdictions without central coordination and specialized HNCtumor group support. The objective of this thesis was to evaluate the effect of treatment centre onthe overall survival (OS) and cancer-specific survival (CSS) of HNC patients in BritishColumbia in a provincially coordinated program.Methods: The BC Cancer Registry (BCCR), a population-based provincial database, was used toidentify all patients in BC diagnosed for the first time with a primary non-thyroid HNC andtreated with radiotherapy between 2006 and 2011. Patients were categorized as residing in large,small and rural local health authorities (LHAs) using BC Stats and BC Ministry of Healthinformation. Physician case frequency was defined as low (0-14 cases per year), medium (15-29cases per year) and high (>30 cases per year). There was no effect on OS or head and neck CSSwhen physician case frequency was treated as a continuous variable.Results: 2,330 HNC patients were included in the study. On multivariable analysis, aftercontrolling for age, gender, cancer stage, anatomical site, treatment and physician casefrequency, neither head and neck CSS (HNCSS) (HR range=0.86-1.03; p=0.54-0.99) nor OS(HR range=0.91-1.05; p=0.60-0.88) was significantly different by centre. OS was also notsignificantly different for patients treated by physicians with low case frequency (HR=0.96;0.81-1.13; p=0.60) and medium case frequency (HR=1.12; 0.84-1.49; p=0.43) in reference tohigh case frequency. Conclusions: There was no significant difference in survival among BC cancer centres aftercontrolling for differences in rurality, physician case volume and other potential confoundingvariables. This lack of difference may be in large part due to the centrally coordinatedpopulation-run program where radiation oncologists subspecialize, follow provincial guidelines,attend multidisciplinary rounds, have access to radiotherapy quality assurance, and are supportedby a HNC tumor group.

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