Strategic investment and new technology in radiation oncology

Authors:

Details:

*Dept Radiation Oncology, Liverpool Hospital  Liverpool, NSW
**Centre for Clinical Governance Research, University of NSW, Sydney, NSW
***Dept of Radiation Oncology, Royal Prince Alfred Hospital, Sydney, NSW
****Collaboration for Cancer Outcomes Research and Evaluation, Liverpool Hospital Liverpool, NSW


Introduction

Radiation oncology is considered high-cost because of the high initial capital expenditure and the recurrent funding necessary to maintain full function of the department. Therefore, there is great interest in ensuring that this expenditure is used in as most effective a fashion as possible. In fact, relative to its usefulness, the overall cost of radiation oncology, relative to its usefulness, is less than other forms of cancer treatment1-8. The equipment can be used to treat patients over many years and therefore the capital costs are spread out over long periods of time. Over the lifetime of the machinery the most significant cost has been identified as labour and not capital9-11. Irrespective of the cost-efficiency of radiation oncology, it is imperative that any costs are justified and radiation oncology treatment delivery is evidence-based.

Strategic investment in radiation oncology in Australia is required to improve the delivery of service that is currently troubled by long waiting lists and old equipment, and may ultimately lead to sub-optimal patient care. The broad areas that may be considered for investment in radiation oncology include improvements in:

  • treatment quality by either reducing toxicity (eg improved and more efficient shielding technology, conformal radiotherapy, intensity modulated radiotherapy) or increasing local control (eg concurrent chemotherapy, conformal radiotherapy with dose escalation, altered fractionation, clinical trials);
  • quality assurance methods, particularly in response to increased automation of treatment;
  • planning and treatment efficiency (this includes optimising staffing levels, investigating more efficient methods of treatment and planning, ensuring appropriate fractionation, improved staff education/training);
  • “client” satisfaction (the “clients” are the patients, patients’ families, referring doctors and the staff);
  • service delivery (reduce waiting lists for treatment, maintain adequate resources, optimise utilisation of resources, ensure rural access, machine reliability, have contingencies for periods of inadequate service, ensure better education about radiotherapy efficacy so that appropriate patients are referred for treatment, co-ordination of services including specialised techniques); and
  • modern treatment techniques and new technologies (machine replacement criteria, forward automatic replacement rather than reactive replacement of old equipment when it finally breaks down, purchase of new technology), and by establishing:
  • standard minimum guidelines for staff and equipment resources between departments to allow quality care, and for these guidelines to be reviewed regularly to keep up with technology changes;
  • standard treatment guidelines and systematised care plans;
  • knowledge-sharing rather than departments re-inventing the wheel (eg common commissioning protocols for new linear accelerators);
  • efficient, networked information systems;
  • efficient outcome evaluation; and
  • adequate investment in research and development.

Though there are many areas where strategic investment may help improve radiation oncology delivery, this paper will concentrate on the new technologies and how these might be considered for investment.

Validating new technologies

As methods of improving the therapeutic ratio of local tumour control over toxicity are developed, the complexity of such treatment has grown enormously3,12-19. Innovative techniques will always require investment of money and resources, outcome evaluation and perhaps changes in the organisation of clinical practice15,17,18,20. In addition, the pressure on radiation oncology resources is likely to grow with a significant shift in the age of the population, and the increasing utility of radiation oncology in the management of cancer12. It is estimated that approximately 50% of cancer patients should receive radiation during the course of their illness12,21, yet in most areas of NSW this referral rate has not been achieved. At the same time as growth in radiation utilisation is necessary, the purchasers of cancer services are exerting significant pressures to reduce costs and improve efficiencies22

Areas in which new technologies have already been appropriately validated in radiation oncology include the use of conformal radiotherapy17,18,20,23, the replacement of fixed shielding blocks with multi-leaf collimation24,25, three-dimensional planning systems24, computer controlled treatment delivery 26-28 and co-registration of diagnostic images and CT planning images19, just to name a few. However, one of the frustrations in radiation oncology is that despite evidence existing for some of these technologies, very few have been implemented on a large scale in Australia and New Zealand. A recent national survey of Australian resources showed that 32% of linear accelerators have multi-leaf collimation and 27% have electronic portal imaging despite the evidence supporting their widespread use29. Electronic data systems reduce error in transfer of treatment data, yet 22% of linear accelerators do not have this technology29.

It should not be assumed that all improvements come at huge costs. There are some instances where technology advances have led to significant savings and/or patient benefits. Studies have identified improved better local tumour control and lower toxicity associated with investments in technology17,19. Multi-leaf collimation studies have identified a reduction in unit cost, an improvement in efficiency as well as obvious occupational health and safety improvements associated with replacing the manufacture and use of heavy shielding blocks for treatment with multi-leaf collimators17,18,23-25. Radiation oncology information systems allow a more automated data collection, reducing data handling, which could potentially lead to administrative savings. These systems should provide greater availability of outcome data including data on service provision, patient satisfaction, quality of life, as well as the more common oncology outcomes of survival and local tumour control.

Given that there will always be a need to consider strategic investment into new technology, it is also responsible management to not adopt technology without adequate evidence that it may improve outcome or efficiency3. Research and development of some of these new technologies with appropriate assessment of efficacy and economics must also be encouraged, both philosophically and financially. However in Australia, the adoption of new technologies occurs in a relatively haphazard and not necessarily evidence-based way. It is often difficult to obtain funds for the appropriate installation of new technologies, despite the existence of evidence to support widespread implementation. In addition, the automatic replacement of outdated equipment or its upgrading is not coordinated and often under-funded.

When considering investments in technology it would be appropriate to follow these steps:
1. determine the appropriateness of a new procedure consistent with the overall health strategic plan;
2. determine safety, efficacy, and cost-effectiveness;
3. discriminate between appropriate and inappropriate indications for the new technology;
4. devise quality improvement methods and health care service delivery considerations to optimise the use of new technology;
5. facilitate change across radiation oncology departments to ensure widespread access; and
6. evaluate outcomes such as local control, survival, quality of life, as well as evaluating health service delivery such as the proportion of a population of patients receiving appropriate treatment, treatment efficiency statistics, etc.

However, if this process is formalised, there needs to be acceptance by budget holders that once a technology is validated as improving care (improved patient outcomes, improved efficiency of staff, etc) then appropriate funding needs to be made available in as short a time as possible to maximise access for patients. Currently the process is slow and poorly coordinated, leading to poorer quality of care.

Benchmarking: The development of appropriate measures

It is important to consider the way that productivity benchmark statistics are collected when issues of new technology and increasing complexity of treatment arise. If fields per time, or patients per time, continue to be used as benchmark productivity statistics, pressure may be exerted on departments to increase their fields per hour and forego the complexity of treatments. This has the potential to restrict measures that may have been introduced into clinical practice to improve the therapeutic ratio. This will have particular impact on departments with a complex case-mix. It is therefore imperative that not only should we have measures that consider complexity, but we also must continue to review treatment outcomes and treatment quality.

In Australia and New Zealand, the Basic Treatment Equivalent (BTE) has been developed in an attempt to measure linear accelerator throughput with some consideration of complexity33. It has been validated in departments of radiation oncology in Australia and New Zealand34 and confirmed that traditional consideration of fields per hour and patients per hour are poor at reflecting throughput. It is important that a measure that considers complexity is used to measure throughput, otherwise the continually evolving complexity increases used to treat patients will not be reflected in output measurements. It is also clear that the main measures to be considered need to be tied to outcome (ie improved survival, local tumour control, patient satisfaction, quality of life and quality of treatment).

Other considerations

Investment in new technologies should not be considered in isolation. Consideration of investment for initiatives to improve the evidence base for radiation oncology and evidence-based treatment guidelines 35-36, access to radiation oncology for rural patients, research into better therapies, appropriate data collection and outcome measurements should also occur when deciding upon appropriate strategic investment. However, the new technologies may facilitate the development of some of these other initiatives as well..

Staff profiles also need consideration when investing in technology. The implementation of new technologies may require new expertise within a department and this will need to be factored into budgets and business plans. For example, there may be savings made in administration for automating some of administrative services but at a cost of increasing the need for specialists in electronic information management.

Recommendations

The broad recommendations regarding strategic investment are:

  • Develop a detailed strategic plan including issues regarding service delivery, investment in new technologies, staffing levels, criteria for machine and information and planning software replacement.
  • Create a central committee with appropriate representation to ensure enactment and adequate funding of the strategic plan and to provide ongoing review.
  • Develop guidelines for acceptable minimum equipment standards and the maximum acceptable age of equipment before automatic replacement.
  • Upgrade equipment automatically, according to set criteria.
  • Maintain up-to-date staff profiles with regular review, to reflect changes in technological complexity.
  • Ensure appropriate use of benchmarking measures that include consideration of complexity.
  • Co-ordinate implementation of radiation oncology services, including specialised techniques.
  • Validate new technology.
  • Review and invest in cutting edge technology and research.

The current focus on the inadequacies in radiation oncology services across Australia and New Zealand provides an opportunity to create an improved model. The success or failure of the initiatives listed above will depend upon both the radiation oncology providers and the policy-makers accepting responsibility and working co-operatively for the good of the whole community.

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