Analysis of clinical decision-making in multi-disciplinary cancer teams

The impact of Clinical Nurse Specialists on the decision making process in cancer multidisciplinary team meetings: A qualitative study

PURPOSE

There are well-documented barriers to nurse participation in cancer multidisciplinary team (MDT) meetings. This paper aims to identify the approaches used by Clinical Nurse Specialists (CNSs) in this setting to contribute during discussion, and to consider the impact of these approaches on the decision making process. In doing so it aims to highlight ways that CNSs can increase their influence, and enhance multidisciplinary engagement.

METHODS

This study is based on analysis of observation data from 122 MDT meetings in gynaecology, haematology and skin cancer MDTs. Field notes were reviewed, identifying 58 cases where CNSs contributed to MDT discussion. Audio recordings of the relevant sections were then transcribed and analysed thematically.

RESULTS

Five approaches were used by CNSs to contribute in MDT meetings: sharing information, asking questions, providing practical suggestions, framing and using humour. These approaches influenced three key intermediary processes identified during the analysis ('successful contributions'): prompting discussion, influencing a treatment plan and facilitating teamwork. CNSs contributed successfully in cases where medical factors (such as relapsed disease or complex comorbidities) or non-medical factors (such as strong patient preference), had the potential to impact on the ability of teams to deliver treatment.

CONCLUSIONS

CNSs have an important role in cancer MDT meetings. By focusing on a subset of cases where CNSs contributed during MDT discussion, this study has provided an insight into approaches that can be adopted by CNSs to increase their influence on the decision making process, enabling teams to capitalise on their knowledge and expertise in MDT meetings.

Analysis of management decisions and outcomes of a weekly multidisciplinary pediatric tumor board meeting in Uganda

Aim:

To evaluate the efficacy of a pediatric multidisciplinary tumor board (MTB) in Uganda.

Patients & methods:

We documented the discussion of cases presented at a pediatric MTB and subsequently, though retrospective chart review, determined the degree to which decision were implemented.

Results:

95 patients were discussed. In total, 129 of 226 (57%) distinct management decisions reached during the MTBs were implemented. Of these, 15 resulted in changes in diagnosis and 53 were classified as major changes in management. Decisions on chemotherapy were the most likely to be successfully enacted (51/58), followed by radiotherapy (18/30) and surgery (12/21). Labs/consults were less likely to be implemented.

Conclusion:

Key improvements, specifically in the documentation and implementation of management decisions, are needed to improve the MTB's efficacy.

Tumor board meetings, which are standard of care for cancer management and well-studied in high income settings, have not been appropriately evaluated in low-income settings. Therefore, we undertook a review of a weekly pediatric tumor board meeting in Uganda, in which we documented the patients discussed and management decisions reached. We found that many diverse patients were discussed in tumor board meetings, with important implications in diagnosis and management. However, many of the decisions reached in the meetings were not subsequently implemented, underscoring the need to improve the effectiveness of the tumor board meeting.

Educational Value of Surgical Multidisciplinary Team Meetings for Learning Non-Technical Skills - A Pilot Survey of Trainees From Two UK Deaneries

OBJECTIVE

This prospective survey study aimed to identify trainee surgeons' views on the educational potential of multi-disciplinary team (MDT) meetings for learning non-technical skills and relevant issues around using MDT meetings as an educational instrument.

DESIGN

An online survey questionnaire containing eight closed and three open-ended questions; was developed based on established educational theories. Responses were anonymous.

SETTING

This survey study was designed as professional project for masters in medical education degree at Warwick University. The study received ethical approval from the Biomedical Science Research and Ethics Committee of Warwick University.

PARTICIPANTS

Trainee surgeons and non-trainee junior surgical doctors within two regions (Health Education Kent Surrey and Sussex, Health Education Wessex) in the UK were invited through an email to take the survey with the help of regional heads of surgery and coordinators.

RESULTS

Twenty eight (28) out of 420 invitees completed the survey. High internal consistency was observed for questionnaire (Cronbach's α = 0.924). 71.42% (20/28) respondents attended MDT at least once a week. 75.9% of participants indicated the importance of attendance to MDT meetings with any level of involvement; passive attendance considered the least important (5/28, 17.9%, p=0.005). Trainees felt included in the team by attendance to MDT meetings (Median score 5, p=0.027). MDT meetings were considered important for learning all domains of non-technical skills for surgeons taxonomy (cumulative mean score 2.4, p=001). Respondents considered MDT as a valuable tool for learning non-technical skills for surgeons on Miller's pyramid for learning (Cumulative mean 5.6, p=0.025). Free text answers indicated agreement to the learning opportunity provided by MDT meetings. Consistent suggestions of increasing trainee participation were obtained.

CONCLUSION

Results indicate consistently positive views from trainees about the educational value of MDT meeting in general and for non-technical skills. Trainee participation, in the form of case-preparation, presentation, and discussion are recommended by respondents.

Function, information, and contributions: An evaluation of national multidisciplinary team meetings for rare cancers

National virtual multidisciplinary team meetings have been established in Swedish cancer care in response to centralized treatment of rare cancers. Though national meetings grant access to a large multidisciplinary network, we hypothesized that video-based meetings may challenge participants’ contributions to the case discussions. We investigated participants’ views and used observational tools to assess contributions from various health professionals during the multidisciplinary team meetings. Data on participants’ views were collected using an electronic survey distributed to participants in six national multidisciplinary team meetings for rare cancers. Data from observations were obtained from the multidisciplinary team meetings for penile cancer, anal cancer, and vulvar cancer using the standardized observational tools Meeting Observational Tool and Metric of Decision-Making that assess multidisciplinary team meeting functionality and participants’ contributions to the case discussions. Participants overall rated the multidisciplinary team meetings favorably with high scores for development of individual competence and team competence. Lower scores applied to multidisciplinary team meeting technology, principles for communicating treatment recommendations, and guidelines for evaluating the meetings. Observational assessment resulted in high scores for case histories, leadership, and teamwork, whereas patient-centered care and involvement of care professionals received low scores. National virtual multidisciplinary team meetings are feasible and receive positive ratings by the participants. Case discussions cover medical perspectives well, whereas patient-centered aspects achieve less attention. Based on these findings, we discuss factors to consider to further improve treatment recommendations from national multidisciplinary team meetings.

It's how we communicate! Exploring face-to-face versus electronic communication networks in multidisciplinary teams

BACKGROUND

Previous research suggests that multidisciplinary team communication networks enhance knowledge exchange, learning, and quality of care in health organizations. However, little is known about team members' reliance on face-to-face versus electronic-based communication networks for information and knowledge exchange.

PURPOSE

The aim of the study was to describe patterns of face-to-face versus electronic-based communication networks in a multidisciplinary team and to explore the relationships between team communication networks and performance, measured as promptness of treatment implementation.

METHODOLOGY

We collected data on work-based communication among members of a multidisciplinary tumor board (MDT) in a large Italian research hospital. A social network survey was administered in 2016 to all board members to gather network data on face-to-face interaction and the use of electronically based communication channels (e-mail, text messages, and WhatsApp) for sharing clinical knowledge. Twenty physicians (71%) completed the survey. Archival data were accessed to obtain detailed information about 222 clinical cases discussed over a 1-year period during weekly MDT meetings. Minutes of board meetings were used to link all discussed cases to team members. We used the multiple regression quadratic assignment procedure (MR-QAP) to study associations between team member characteristics and communication networks. Negative binomial regression was employed to test relationships between team communication networks and performance.

RESULTS

MDT members relied on different communication channels for knowledge sharing. The geographical proximity of team members positively predicted the frequency of face-to-face interaction. Physicians' seniority was related to the use of WhatsApp as a communication channel; greater interaction of this type was observed between team members of different seniority. Performance was related positively to face-to-face communication networks but negatively to communication via WhatsApp.

PRACTICE IMPLICATIONS

Although team communication networks are important for knowledge exchange, health administrators must pay attention to the increasing propensity of team members to rely on electronic-based communication. The use of these easy-to-use tools can hinder the quality of group discussion and debate.

Patient participation in multidisciplinary tumour conferences in breast cancer care (PINTU): a mixed-methods study protocol

INTRODUCTION

A central instrument of multidisciplinary care is the multidisciplinary tumour conference (MTC). In MTCs, diagnosis and treatment of cancer patients are discussed, and therapy recommendations are worked out. As we found previously, patients participate in MTCs in some breast cancer centres in the state of North Rhine-Westphalia, Germany. However, studies on risks and benefits of patient participation have not provided substantiated findings. Therefore, the study's objective is to analyse differences between MTCs with and without patient participation.

METHODS AND ANALYSIS

This is an exploratory mixed-methods study. MTCs in six breast and gynaecological cancer centres in North Rhine-Westphalia, Germany, are examined. MTCs will be conducted with and without patient participation. First, interviews with providers concentrating on the feasibility of patient participation and quality of decision-making will be carried out, transcribed and analysed by means of content analysis. Second, videotaped or audiotaped participatory observations in MTCs will be executed. Video data or transcribed audio data from video and audio recordings will be coded using the established "Observational Assessment Rating Scale" for MTCs and analysed by comparing centres with and without patient participation. Third, all patients will fill out a questionnaire before and after MTC, including questions on psychosocial situation, decision-making and expectations before and experiences after MTC. The questionnaire data will be analysed by means of descriptive and multivariate statistics and pre-post-differences within and between groups.

ETHICS AND DISSEMINATION

Consultation and a positive vote from the ethics committee of the Medical Faculty of the University of Cologne have been obtained. For all collected data, relevant data protection regulations will be adhered to. All personal identifiers from patients and providers will be pseudonymised, except video recordings. Dissemination strategies include a discussion with patients and providers in workshops about topics such as feasibility, risks and benefits of patient participation in MTCs.

TRIAL REGISTRATION NUMBER

DRKS00012552.

Patient perspectives on a national multidisciplinary team meeting for a rare cancer

Multidisciplinary team meetings (MDTM) provide a regular forum for cancer teams to convene and discuss the diagnostic and treatment aspects of patient care. For some rare cancers, MDTMs may also occur at national level to pool expertise and to ensure more consistent decision-making. One such national MDTM exists in the UK for patients with a diagnosis of Ewing's sarcoma of the bone-the National Ewing's MDT (NEMDT). This study explored the patient perspective of this rare cancer national MDTM using focus group and survey methodology. Study participants used their experience to provide several recommendations: that their views should always inform the decision-making process, these views should be presented by someone who has met them such as a specialist nurse, MDT recommendations should be provided to them in plain English, and tools to improve patient choice and enhance communication should be implemented. These patient-centred recommendations will be used to improve the NEMDT but may be valid to inform quality improvement processes for other similar national panels.

Cross-sectional increase of adherence to multidisciplinary tumor board decisions

BACKGROUND

Cancer research has made great progress in the recent years. With the increasing number of options in diagnosis and therapy the implementation of tumorboards (TUBs) has become standard procedure in the treatment of cancer patients. Adherence tests on tumor board decisions are intended to enable quality assurance and enhancement for work in tumor boards in order to continuously optimize treatment options for cancer patients.

METHODS

Subject of this study was the adherence of the recommendations made in three of 14 tumorboards, which take place weekly in the Center for Integrated Oncology (CIO) at the University Hospital Bonn. In total, therapy recommendations of 3815 patient cases were checked on their implementation. A classification into four groups has been made according to the degree of implementation. A second classification followed regarding the reasons for differences between the recommendation and the therapy which the patient actually received.

RESULTS

The study showed that 80.1% of all recommendations in the three TUBs were implemented. 8.3% of all recommendations showed a deviance. Most important reasons for the deviances were patient wish (36.5%), patient death (26%) and doctoral decision, due to the patient's comorbidities or side effects of the treatment (24.1%).Interestingly, deviance in all three tumor boards in total significantly decreased over time.

CONCLUSIONS

Aim of the study was to clarify the use of tumor boards and find approaches to make them more efficient. Based on the results efficiency might be optimized by increased consideration of patients` preferences, improved presentation of patient-related data, more detailed documentation and further structuring of the tumor board meetings.

Will the presence of the patient at multidisciplinary meetings influence the decision in head and neck oncology management?

OBJECTIVES

Multidisciplinary team meetings (MTM) are essential in the choice of a therapeutic strategy in head and neck cancer. In many centres patients attend MTMs and are examined by the team. The aim of this study was to assess the influence of the patient's presence on therapeutic decisions.

STUDY DESIGN

Prospective study of 119 consecutive patients.

METHODS

Two therapeutic situations were compared: the therapeutic decision taken following discussion of the patient's file in the MTM (D1) and the therapeutic decision taken after examination of the patient during MTMs (D2). Concordance between the two situations was measured.

RESULTS

Concordance between D1 and D2 was 97%. No factors likely to decrease concordance were identified. Decisions taken during MTMs were acted upon for 97% of the patients.

CONCLUSION

The presence of the patient during MTMs is not essential if the files are thoroughly presented and discussed.

Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: an overview and synthesis of the available literature

In many health care systems globally, cancer care is driven by multidisciplinary cancer teams (MDTs). A large number of studies in the past few years and across different literature have been performed to better understand how these teams work and how they manage patient care. The aim of our literature review is to synthesize current scientific and clinical understanding on cancer MDTs and their organization; this, in turn, should provide an up-to-date summary of the current knowledge that those planning or leading cancer services can use as a guide for service implementation or improvement. We describe the characteristics of an effective MDT and factors that influence how these teams work. A range of factors pertaining to teamwork, availability of patient information, leadership, team and meeting management, and workload can affect how well MDTs are implemented within patient care. We also review how to assess and improve these teams. We present a range of instruments designed to be used with cancer MDTs - including observational tools, self-assessments, and checklists. We conclude with a practical outline of what appears to be the best practices to implement (Dos) and practices to avoid (Don'ts) when setting up MDT-driven cancer care.

Availability and feasibility of structured, routine collection of comorbidity data in a colorectal cancer multi-disciplinary team (MDT) setting

PURPOSE

Availability of comorbidity assessment at multi-disciplinary team (MDT) discussions is cornerstone in making the MDT process more robust and decisive in optimising treatment and improving quality of survivorship. Comorbidity assessments using tools, such as the ACE-27 questionnaire would aid in optimising the decision-making process at MDTs so that treatment decisions can be made without delay. This study determined the availability of comorbidity data in a CRC MDT and the feasibility of routine comorbidity data collection using the validated ACE-27 questionnaire. Secondary aims determined the optimal time and method of collecting comorbidity data.

METHODS

A retrospective mapping exercise (phase I; 6-months) examined the availability of comorbidity data within the MDT. Phase II prospectively collected comorbidity data using ACE-27 for a 3-month period following a short pilot.

RESULTS

In phase I, 73/135 (54%) patients had comorbidity data readily available informing the MDT discussion; 62 patients lacked this information. After a review of the patient records, it was clear that 41 of these 62 also had comorbidities and 21 out of the 135 had ≥ 2 major system disorders. Common referral sources to the MDT were surgical outpatient clinics (42%) and the endoscopy unit (13%). The average lead-time from referral to MDT discussion was 14 days. In phase II, an ACE-27 questionnaire was prospectively administered in 50 patients, mean age 54 years (range 20-84). Male: female ratio 26:24. Average time to administer ACE-27 was 4.8 min (range 1-15).

CONCLUSIONS

The phase I study confirmed the widely acknowledged view of poor comorbidity data availability within a CRC MDT. Phase II demonstrated the feasibility of routinely collecting comorbidity data using ACE-27.

The TRIO Framework: Conceptual insights into family caregiver involvement and influence throughout cancer treatment decision-making

OBJECTIVE

Family caregivers are regularly involved in cancer consultations and treatment decision-making (DM). Yet there is limited conceptual description of caregiver influence/involvement in DM. To address this, an empirically-grounded conceptual framework of triadic DM (TRIO Framework) and corresponding graphical aid (TRIO Triangle) were developed.

METHODS

Jabareen's model for conceptual framework development informed multiple phases of development/validation, incorporation of empirical research and theory, and iterative revisions by an expert advisory group.

RESULTS

Findings coalesced into six empirically-grounded conceptual insights: i) Caregiver influence over a decision is variable amongst different groups; ii) Caregiver influence is variable within the one triad over time; iii) Caregivers are involved in various ways in the wider DM process; iv) DM is not only amongst three, but can occur among wider social networks; v) Many factors may affect the form and extent of caregiver involvement in DM; vi) Caregiver influence over, and involvement in, DM is linked to their everyday involvement in illness care/management.

CONCLUSION

The TRIO Framework/Triangle may serve as a useful guide for future empirical, ethical and/or theoretical work.

PRACTICE IMPLICATIONS

This Framework can deepen clinicians's and researcher's understanding of the diverse and varying scope of caregiver involvement and influence in DM.

A nurse-led multidisciplinary team approach in urology-oncology: Addressing the new cancer strategy

Objectives:

The urology-oncology service in NHS Ayrshire and Arran (AA) is nurse-led, with a multidisciplinary team (MDT) process at its core. Here, we assess the efficacy of this nurse-led service against similar services and consider it in the context of the new NHS cancer strategy.

Materials and methods:

Audit data regarding the management of patients with urological malignancies published by the West of Scotland Cancer Network (WoSCAN) were compared against pre-determined quality performance indicators. These data were used to assess the efficacy of the NHS AA service against the other WoSCAN centres.

Results:

All parameters analysed were comparable, except for the following performance indicators for which the NHS AA data appeared to show significant improvement compared with the other WoSCAN centres: the number of patients with bladder cancer with recorded TNM clinical staging ( p = 0.012); the proportion of patients with prostate cancer who underwent transrectal ultrasound-guided prostate biopsy for histological diagnosis where a minimum of 10 cores are received by pathology ( p = 0.043); and the number of patients with metastatic prostate cancer who underwent immediate hormone therapy ( p = 0.031).

Conclusion:

Our analysis demonstrates that the NHS AA urology-oncology nurse-led MDT-based service is a highly efficient and well-functioning structure.

It Takes a Village: The Importance of Multidisciplinary Care

This article explores the evolving world of cancer care that requires increasing collaboration and is focused on value, quality, and efficiency, while placing the utmost importance on patient autonomy and individualized care plans. The expanding membership of the multidisciplinary team and the role of integrated patient care units are reviewed in the context of care for the patient with head and neck cancer.

Retrospective Analysis of Treatment Outcomes and Geriatric Assessment in Elderly Malignant Lymphoma Patients

In recent years, the Comprehensive Geriatric Assessment (CGA), which is used in gerontology to assess functioning in elderly individuals, has been said to be useful in geriatric oncology. Therefore, we examined whether items in the CGA were associated with survival time in elderly patients with non-Hodgkin lymphoma (NHL). We conducted the CGA for 93 patients aged ≥ 65 years who had undergone treatment for NHL retrospectively. The CGA includes activities of daily living, instrumental activities of daily living, mood, cognition, nutrition, and the Charlson comorbidity index. For each category, we divided subjects into a "good" group and a "poor" group. In regard to the Charlson comorbidity index, patients were divided into two groups using different cutoffs to divide the groups; the two groups were established according to the division with the largest significant difference in survival time. Multivariate analysis was then performed with the following prognostic factors affecting survival: all CGA items, NHL classification, stage, performance status, and doxorubicin use/non-use. We also performed similar analysis for 43 diffuse large B-cell lymphoma (DLBCL) patients who had undergone anthracycline treatment. Results are factors affecting survival in NHL cases included comorbidity score ≥ 6 (P < 0.0001), doxorubicin non-use (P = 0.005), and cognitive impairment (P = 0.0488). In cases of DLBCL, survival was affected by comorbidity score ≥ 5 (P = 0.0016). High comorbidity score was strongly associated with survival in both NHL and DLBCL.

Utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study

BACKGROUND & OBJECTIVES

Multidisciplinary tumor boards (MDTBs) are frequently employed in cancer centers but their value has been debated. We reviewed the decision-making process and resource utilization of our MDTB to assess its utility in the management of pancreatic and upper gastrointestinal tract conditions.

METHODS

A prospectively-collected database was reviewed over a 12-month period. The primary outcome was change in management plan as a result of case discussion. Secondary outcomes included resources required to hold MDTB, survival, and adherence to treatment guidelines.

RESULTS

Four hundred seventy cases were reviewed. MDTB resulted in a change in the proposed plan of management in 101 of 402 evaluable cases (25.1%). New plans favored obtaining additional diagnostic workup. No recorded variables were associated with a change in plan. For newly-diagnosed cases of pancreatic ductal adenocarcinoma (n = 33), survival time was not impacted by MDTB (p = .154) and adherence to National Comprehensive Cancer Network guidelines was 100%. The estimated cost of physician time per case reviewed was $190.

CONCLUSIONS

Our MDTB influences treatment decisions in a sizeable number of cases with excellent adherence to national guidelines. However, this requires significant time expenditure and may not impact outcomes. Regular assessments of the effectiveness of MDTBs should be undertaken.

Review at a multidisciplinary tumor board impacts critical management decisions of pediatric patients with cancer

BACKGROUND

Optimal cancer care requires a multidisciplinary approach. The purpose of the current study was to evaluate the impact of a multidisciplinary tumor board on the treatment plans of children with solid tumors.

PROCEDURES

The records of 158 consecutive patients discussed at a formal multidisciplinary pediatric tumor board between July 2012 and April 2014 were reviewed. Treatment plans were based on clinical practice guidelines and on current Children's Oncology Group protocols. Alterations in radiologic, pathologic, surgical, and medical interpretations were analyzed to determine the impact on changes in recommendations for clinical management.

RESULTS

Overall, 55 of 158 children (35%) had alterations in radiologic, pathologic, medical, or surgical interpretation of clinical data following multidisciplinary discussion. Of these, 64% had changes to the initial recommendation for clinical management. Review of imaging studies resulted in interpretation changes in 30 of 158 patients studied (19%), with 12 clinical management changes. Six of 158 patients (3.9%) had changes in pathologic interpretation, with four patients (2.5%) requiring treatment changes. In eight patients (5%), a change in medical management was recommended, while in 11 patients (7%) there were changes in surgical management that were based solely on discussion and not on interpretation of imaging or pathology.

CONCLUSIONS

Formal multidisciplinary review led to alterations in interpretation of clinical data in 35% of patients, and the majority led to changes in recommendations for treatment. Comprehensive multidisciplinary tumor board incorporated into the care of children with cancer provides additional perspectives for families and care providers when delineating optimal treatment plans.

The impact of contemporary multidisciplinary meetings on workload at a tertiary level hospital

BACKGROUND

In recent years, multidisciplinary meetings (MDMs) have become the standard of patient care in oncologic and other speciality care pathways. The number, complexity, and diverse source of imaging studies presented continue to expand rapidly. True multidisciplinary input requires parallel support from other colleagues and diagnostic services. It is now recognised that this is the appropriate forum for key decision making and education in care algorithms, though service plans make little or no accommodation of their expanding role in addition to existing services.

AIMS

We tried to objectively quantify one element of this burgeoning service.

METHODS

Data were retrospectively gathered over a 6 month period, and a 5 week prospective study was then performed to examine the workload in further detail.

RESULTS

Retrospectively, 199 meetings were held with 2253 clinical cases reviewed over 26 weeks. Prospectively, 52 meetings were held over 5 weeks for 13 clinical specialty areas. There were 1038 clinical case discussions. There were a total of 2122 documented individual imaging studies reviewed. Specialist registrar preparation time was 55 h (11 per week). Consultant preparation time was 67.75 h (13.55 per week). Delivery time was 57.25 h (11.45 per week).

CONCLUSION

The complexity and range of cases at MDMs continue to expand, serving local and national needs, though service plans do not acknowledge their role in the working day. Our study shows just one element that clearly signals a need to take account of the new methods of delivering modern healthcare.

International metal-on-metal multidisciplinary teams: do we manage patients with metal-on-metal hip arthroplasty in the same way? An analysis from the International Specialist Centre Collaboration on MOM Hips (ISCCoMH)

AIMS

There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries.

METHODS

Six international tertiary referral orthopaedic centres were invited to participate by organising a multi-disciplinary team (MDT) meeting, consisting of two or more revision hip arthroplasty surgeons and a musculoskeletal radiologist. A full clinical dataset including history, blood tests and imaging for ten patients was sent to each unit, for discussion and treatment planning. Differences in the interpretation of findings, management decisions and rationale for decisions were compared using quantitative and qualitative methods.

RESULTS

Overall agreement between the orthopaedic centres and the recommended treatment plans for the ten patients with MOM hip implants was moderate (kappa = 0.6). Full agreement was seen in a third of cases, however split decisions were also seen in a third of cases. Units differed in their interpretation of the significance of the investigation findings and put varying emphasis on serial changes, in the presence of symptoms.

DISCUSSION

In conclusion, the management of raised or rising blood metal ions, cystic pseudotumours and peri-acetabular osteolysis led to inconsistency in the agreement between centres. Coordinated international guidance and MDT panel discussions are recommended to improve consensus in decision making.

TAKE HOME MESSAGE

A lack of evidence and the subsequent variation in regulator guidance leads to differences in opinions, the clinical impact of which can be reduced through a multi-disciplinary team approach to managing patients with MOM hip implants. Cite this article: Bone Joint J 2016;98-B:179-86.

Development and testing of the cancer multidisciplinary team meeting observational tool (MDT-MOT)

OBJECTIVE

To develop a tool for independent observational assessment of cancer multidisciplinary team meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance.

DESIGN

Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs.

SETTING

Study 2 included 10 cancer MDMs in England.

PARTICIPANTS

Testing was undertaken by 13 health service staff and a clinical and non-clinical observer.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Tool development, validity, reliability/agreement and variability in MDT performance.

RESULTS

Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance (P ≤ 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (≥80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed well in 6-7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P ≤ 0.01).

CONCLUSIONS

MDT-MOT demonstrated good criterion validity. Agreement between clinical and non-clinical observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.

Is there a Benefit of Multidisciplinary Cancer Team Meetings for Patients with Gastrointestinal Malignancies?

Background

Multidisciplinary cancer team meetings are intended to optimize the diagnosis of a patient with a malignancy. The aim of this study was to assess the number of correct diagnoses formulated by the multidisciplinary team (MDT) and whether MDT decisions were implemented.

Methods

In a prospective study, data of consecutive patients discussed at gastrointestinal oncology MDT meetings were studied, and MDT diagnoses were validated with pathology or follow-up. Factors of influence on the correct diagnosis were identified by use of a Poisson regression model. Electronic patient records were used to assess whether MDT decisions were implemented, and reasons to deviate from these decisions were hand-searched within these records.

Results

In 74 MDT meetings, 551 patients were discussed a total of 691 times. The MDTs formulated a correct diagnosis for 515/551 patients (93.4 %), and for 120/551 (21.8 %) patients the MDT changed the referral diagnosis. Of the MDT diagnoses, 451/515 (87.6 %) were validated with pathology. Patients presented to the MDT by their treating physician were 20 % more likely to receive a correct diagnosis [relative risk (RR) 1.2, 95 % confidence interval (CI) 1.1–1.5], while the number of patients discussed or the duration of the meeting had no influence on this (RR 1.0, 95 % CI 0.99–1.0; RR 1.0, 95 % CI 0.9–1.1; resp.). MDT decisions were implemented in 94.4 % of cases. Deviations of MDT decisions occurred when a patient’s wishes or physical condition were not taken into account.

Conclusions

MDTs rectify 20 % of the referral diagnoses. The presence of the treating physician is the most important factor to ensure a correct diagnosis and adherence to the treatment plan.

An Association of Cancer Physicians' strategy for improving services and outcomes for cancer patients

The Association of Cancer Physicians in the United Kingdom has developed a strategy to improve outcomes for cancer patients and identified the goals and commitments of the Association and its members.

The Role of Cancer Boards in the Treatment Decisions Regarding Chemotherapy

Objective The influence of cancer boards with respect to the treatment decisions regarding chemotherapy remains to be elucidated. In the present study, we investigated the cases that presented at our institutional cancer boards, to assess the effect of cancer boards on the treatment decisions regarding chemotherapy. Methods Data from the cancer boards at Yamagata University Hospital, Yamagata, Japan, were collected. Along with data from the clinical records, the details of the discussions and the chosen plan of treatment of the cancer boards were analyzed. Results From February 2010 to February 2014, 1,541 cases were discussed at our cancer boards. Of these, 811 cases (52.6%) involved discussions about chemotherapy. Of those 811 cases, recommendations were made to alter the treatment plans for 189 cases (23.3%). The reasons for discouraging chemotherapy varied; however, 29/45 (64.4%) cases involved discouragement for the following reasons: old age, a comorbid condition, the physical (performance) status, or insufficient evidence to administer chemotherapy. Eighty-six patients were referred to the medical oncology department through the cancer boards. Conclusion Our results showed that cancer boards have a great influence on the treatment decisions regarding chemotherapy and the prompt referral of cases to medical oncologists as necessary. In terms of future research, we will evaluate the effect of cancer boards on the prognosis and outcomes of cases using the institutional cancer registry.

Cancer treatment decision-making processes for older patients with complex needs: a qualitative study

OBJECTIVES

Although older people can experience complex health and social care needs alongside a primary cancer diagnosis, little is understood about how cancer treatment decisions are made for this population. This study aimed to investigate how cancer treatment decisions are formulated for older people with complex health and social care needs and the factors that shape these processes.

DESIGN

Qualitative study involving semistructured interviews and non-participant observations. Framework approach used for data analysis.

SETTING

Breast and colorectal cancer services in five English NHS hospital trusts.

PARTICIPANTS

Interviews: purposive sample of 22 clinicians directly involved in a face-to-face clinical role with patients regarding cancer treatment and care, maximising variation across clinical roles, tumour types and trusts.

OBSERVATIONS

purposive sample of five cancer multidisciplinary meetings, maximising variation across location, team size and tumour type.

RESULTS

The initial stages of cancer treatment decision-making are team-based, medically dominated and focused on the cancer. For patients with complex health and social care needs that extend beyond cancer pathology, later and less visible stages in the decision-making process are more haphazard and may result in less effective and workable treatment plans, as individual clinicians struggle to devise and deliver these plans without breaching time-based targets.

CONCLUSIONS

Service targets that focus resources solely on the presenting disease can disadvantage older patients with complex health and social care needs that extend beyond this primary diagnosis. Care should be taken to ensure time-based targets do not disincentivise thorough and timely assessment that can lead to the formulation of treatment plans tailored to individual needs and circumstances.

In Absentia: An Exploratory Study of How Patients Are Considered in Multidisciplinary Cancer Team Meetings

Background

Multidisciplinary team meetings and shared decision-making are potential means of delivering patient-centred care. Not much is known about how those two paradigms fit together in cancer care. This study aimed to investigate how decisions are made in multidisciplinary team meetings and whether patient perspectives are incorporated in these decisions.

Materials and Methods

A qualitative study was conducted using non-participant observation at multidisciplinary team meetings (also called tumor boards) at the University Cancer Center Hamburg-Eppendorf, Germany. Two researchers recorded structured field notes from a total of N = 15 multidisciplinary team meetings. Data were analyzed using content analysis and descriptive statistics.

Results

Physicians mainly exchanged medical information and based their decision-making on this information. Individual patient characteristics or their treatment preferences were rarely considered or discussed. In the few cases where patient preferences were raised as a topic, this information did not seem to be taken into account in decision-making processes about treatment recommendations.

Conclusion

The processes in multidisciplinary team meetings we observed did not exhibit shared decision-making. Patient perspectives were absent. If multidisciplinary team meetings wish to become more patient-centred they will have to modify their processes and find a way to include patient preferences into the decision-making process.

Use of a formal consensus development technique to produce recommendations for improving the effectiveness of adult mental health multidisciplinary team meetings

BACKGROUND

Multidisciplinary team (MDT) meetings are the core mechanism for delivering mental health care but it is unclear which models improve care quality. The aim of the study was to agree recommendations for improving the effectiveness of adult mental health MDT meetings, based on national guidance, research evidence and experiential insights from mental health and other medical specialties.

METHODS

We established an expert panel of 16 health care professionals, policy-makers and patient representatives. Five panellists had experience in a range of adult mental health services, five in heart failure services and six in cancer services. Panellists privately rated 68 potential recommendations on a scale of one to nine, and re-rated them after panel discussion using the RAND/UCLA Appropriateness Method to determine consensus.

RESULTS

We obtained agreement (median ≥ 7) and low variation in extent of agreement (Mean Absolute Deviation from Median of ≤1.11) for 21 recommendations. These included the explicit agreement and auditing of MDT meeting objectives, and the documentation and monitoring of treatment plan implementation.

CONCLUSIONS

Formal consensus development methods that involved learning across specialities led to feasible recommendations for improved MDT meeting effectiveness in a wide range of settings. Our findings may be used by adult mental health teams to reflect on their practice and facilitate improvement. In some other contexts, the recommendations will require modification. For example, in Child and Adolescent Mental Health Services, context-specific issues such as the role of carers should be taken into account. A limitation of the comparative approach adopted was that only five members of the panel of 16 experts were mental health specialists.

Managing synchronous liver metastases from colorectal cancer: a multidisciplinary international consensus

An international panel of multidisciplinary experts convened to develop recommendations for managing patients with colorectal cancer (CRC) and synchronous liver metastases (CRCLM). A modified Delphi method was used. CRCLM is defined as liver metastases detected at or before diagnosis of the primary CRC. Early and late metachronous metastases are defined as those detected ⩽12months and >12months after surgery, respectively. To provide information on potential curability, use of high-quality contrast-enhanced computed tomography (CT) before chemotherapy is recommended. Magnetic resonance imaging is increasingly being used preoperatively to aid detection of subcentimetric metastases, and alongside CT in difficult situations. To evaluate operability, radiology should provide information on: nodule size and number, segmental localization and relationship with major vessels, response after neoadjuvant chemotherapy, non-tumoral liver condition and anticipated remnant liver volume. Pathological evaluation should assess response to preoperative chemotherapy for both the primary tumour and metastases, and provide information on the tumour, margin size and micrometastases. Although the treatment strategy depends on the clinical scenario, the consensus was for chemotherapy before surgery in most cases. When the primary CRC is asymptomatic, liver surgery may be performed first (reverse approach). When CRCLM are unresectable, the goal of preoperative chemotherapy is to downsize tumours to allow resection. Hepatic resection should not be denied to patients with stable disease after optimal chemotherapy, provided an adequate liver remnant with inflow and outflow preservation remains. All patients with synchronous CRCLM should be evaluated by a hepatobiliary multidisciplinary team.

Multidisciplinary team conferences promote treatment according to guidelines in rectal cancer

BACKGROUND

Multidisciplinary team (MDT) conferences have been introduced into standard cancer care, though evidence that it benefits the patient is weak. We used the national Swedish Rectal Cancer Register to evaluate predictors for case discussion at a MDT conference and its impact on treatment.

MATERIAL AND METHODS

Of the 6760 patients diagnosed with rectal cancer in Sweden between 2007 and 2010, 78% were evaluated at a MDT. Factors that influenced whether a patient was discussed at a preoperative MDT conference were evaluated in 4883 patients, and the impact of MDT evaluation on the implementation of preoperative radiotherapy was evaluated in 1043 patients with pT3c-pT4 M0 tumours, and in 1991 patients with pN+ M0 tumours.

RESULTS

Hospital volume, i.e. the number of rectal cancer surgical procedures performed per year, was the major predictor for MDT evaluation. Patients treated at hospitals with < 29 procedures per year had an odds ratio (OR) for MDT evaluation of 0.15. Age and tumour stage also influenced the chance of MDT evaluation. MDT evaluation significantly predicted the likelihood of being treated with preoperative radiotherapy in patients with pT3c-pT4 M0 tumours (OR 5.06, 95% CI 3.08-8.34), and pN+ M0 (OR 3.55, 95% CI 2.60-4.85), even when corrected for co-morbidity and age.

CONCLUSION

Patients with rectal cancer treated at high-volume hospitals are more likely to be discussed at a MDT conference, and that is an independent predictor of the use of adjuvant radiotherapy. These results indirectly support the introduction into clinical practice of discussing all rectal cancer patients at MDT conferences, not least those being treated at low-volume hospitals.

A new approach to managing patients with problematic metal hip implants: the use of an Internet-enhanced multidisciplinary team meeting: AAOS exhibit selection

BACKGROUND

Over one million patients worldwide are estimated to have a metal-on-metal hip arthroplasty. To improve the management of these patients and reduce surgeon uncertainty regarding decision-making, we designed an Internet-enhanced multidisciplinary team (iMDT) working approach.

METHODS

From August 2012 to April 2014, the iMDT discussed 215 patients with 266 metal-on-metal hip arthroplasties. Of these, 236 primary arthroplasties (132 hip resurfacing and 104 total hip) were analyzed. The remaining thirty cases involved problematic revised hips and were therefore excluded. The possible recommendations of the iMDT were monitoring, further investigation, or surgery. The concordance between the recommendation and the actual management was used to assess the usefulness of this approach in reducing uncertainty in surgeon-level decision-making.

RESULTS

The median Oxford Hip Score was 35 (range, 4 to 48), and median cobalt and chromium levels in whole blood were 3.54 ppb (range, 0.18 to 161.46 ppb) and 3.17 ppb (range, 0.20 to 100.67 ppb), respectively. Magnetic resonance imaging revealed abductor muscle atrophy in ninety-two (39%) of the hips and a pseudotumor in eighty (34%). The iMDT recommended monitoring of 146 (61.9%) of the hips, further investigation of thirty (12.7%), and surgery in sixty (25.4%). The actual outcome was concordant with the recommendation in 211 (91.7%) of the hips.

CONCLUSIONS

Our iMDT approach to the metal-on-metal hip burden combines the tacit knowledge of an expert panel, regulatory guidance, and up-to-date evidence to improve decision-making among surgeons. The high level of concordance between the recommendation and the actual outcome, combined with the feasibility of the methods used, suggest that this method effectively reduces uncertainty among surgeons and may lead to improved patient outcomes.

Consideration of comorbidity in treatment decision making in multidisciplinary cancer team meetings: a systematic review

BACKGROUND

Comorbidity is very common among patients with cancer. Multidisciplinary team meetings (MDTs) are increasingly the context within which cancer treatment decisions are made internationally. Little is known about how comorbidity is considered, or impacts decisions, in MDTs.

METHODS

A systematic literature review was conducted to evaluate previous evidence on consideration, and impact, of comorbidity in cancer MDT treatment decision making. Twenty-one original studies were included.

RESULTS

Lack of information on comorbidity in MDTs impedes the ability of MDT members to make treatment recommendations, and for those recommendations to be implemented among patients with comorbidity. Where treatment is different from that recommended due to comorbidity, it is more conservative, despite evidence that such treatment may be tolerated and effective. MDT members are likely to be unaware of the extent to which issues such as comorbidity are ignored.

CONCLUSIONS

MDTs should systematically consider treatment of patients with comorbidity. Further research is needed to assist clinicians to undertake MDT decision making that appropriately addresses comorbidity. If this were to occur, it would likely contribute to improved outcomes for cancer patients with comorbidities.

Normative data and clinically significant effect sizes for single-item numerical linear analogue self-assessment (LASA) scales

BACKGROUND

Single-item assessments have been the most often-used measures in National Cancer Institute (NCI) cancer control clinical trials, but normative data are not available. Our objective was to examine the normative data and clinically significant effect sizes for single-item numerical linear analogue self-assessment (LASA) scale for overall quality of life (QOL).

METHODS

We analyzed baseline data from 36 clinical trials and 6 observational studies with various populations, including healthy volunteers, cancer trial patients (patients with advanced incurable cancer or patients receiving treatment with curative intent) and hospice patients as well as their caregivers. The overall QOL LASA was rated 0 (as bad as it can be) to 10 (as good as it can be). We calculated the summary statistics and the proportion of patients reporting a clinically meaningful deficit (CMD) of a score equal to 5 or less on the 0-10 scale.

RESULTS

In total, for the collective sample of 9,295 individuals, the average overall QOL reported was 7.39 (SD = 2.11) with a markedly skewed distribution with roughly 17% reporting a score of 5 or below indicating a clinically significant deficit in overall QOL. Hospice patients report a much worse average score of 5.7 upon entry to hospice; hospice caregivers average 7.4. Cancer patients vary within these two extremes with most patients averaging in the 7's on the 0-10 scale (range, 0 to 10 p-value < 0.0001). Men and women's QOL distributions were virtually identical (with average of 7.6 vs. 7.5, p-value = 0.046). Overall QOL was weakly related to performance status with a Spearman correlation coefficient of -0.29 (p-value < 0.0001). Overall QOL was related to tumor response (p-value = 0.0094), i.e. patients with a full or partial response reported a CMD in 11.4% of cases compared to 14.4% among those with stable disease and 18.5% among those with disease progression. Data missingness was high for performance status and tumor response associations.

CONCLUSIONS

This study provides the normative data for cancer patients and healthy volunteers for overall QOL using the LASA. These can serve as benchmarks for future studies and inform clinical practice decision-making.

"No decision about me without me" in the context of cancer multidisciplinary team meetings: a qualitative interview study

Background

Cancer care is commonly managed by multidisciplinary teams (MDTs) who meet to discuss and agree treatment for individual patients. Patients do not attend MDT meetings but recommendations for treatments made in the meetings directly influence the decision-making process between patients and their responsible clinician. No research to-date has considered patient perspectives (or understanding) regarding MDTs or MDT meetings, though research has shown that failure to consider patient-based information can lead to recommendations that are inappropriate or unacceptable, and can consequently delay treatment.

Methods

Semi-structured interviews were conducted with current cancer patients from one cancer centre who had either upper gastrointestinal or gynaecological cancer (n = 9) and with MDT members (n = 12) from the teams managing their care. Interview transcripts were analysed thematically using Framework approach. Key themes were identified and commonalities and discrepancies within and between individual transcripts and within and between patient and team member samples were identified and examined using the constant comparative method.

Results

Patients had limited opportunities to input to or influence the decision-making process in MDT meetings. Key explanatory factors included that patients were given limited and inconsistent information about MDTs and MDT meetings, and that MDT members had variable definitions of patient-centredness in the context of MDTs and MDT meetings. Patients that had knowledge of medicine (through current/previous employment themselves or that of a close family member) appeared to have greater understanding and access to the MDT. Reassurance emerged as a ‘benefit’ of informing patients about MDTs and MDT meetings.

Conclusions

There is a need to ensure MDT processes are both efficient and patient-centred. The operationalization of “No decision about me without me” in the context of MDT models of care – where patients are not present when recommendations for treatment are discussed - requires further consideration. Methods for ensuring that patients are actively integrated into the MDT processes are required to ensure patients have an informed choice regarding engagement, and to ensure recommendations are based on the best available patient-based and clinical evidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0488-2) contains supplementary material, which is available to authorized users.

Multidisciplinary cancer conferences for gastrointestinal malignancies result in measureable treatment changes: a prospective study of 149 consecutive patients

BACKGROUND

In most jurisdictions, a minority of patients are discussed at multidisciplinary cancer conference (MCC) despite recommendations for such reviews. We assessed the impact of MCC review of gastrointestinal (GI) cancers at a stand-alone cancer center.

METHODS

Patient data were prospectively collected on consecutive cases presented at a GI MCC during a 6-month period. Original treatment plans were collected confidentially before presentation and compared to post-MCC treatment plans. We defined changes in management plans as major (change in treatment modality) or minor (testing prior to original plan).

RESULTS

A total of 149 cases were evaluated: 115 upper GI (gastric/small bowel-10 %, liver-32 %, pancreaticobiliary-36 %), and 34 lower GI (23 %). Reasons for presentation were: questions regarding progression/metastases (44 %), management (26 %), diagnosis (21 %), pathology (15 %), and resectability (7 %). Physicians were certain of their original plans being the final recommendations in 84 % (n = 125). Change in management was recommended in 36 %; 72 % were major and 28 % were minor. Patients underwent all recommended treatments at our institution in 77 % of cases, a portion in 5 %, and no recommended treatments in 18 %. On multivariate analysis, physician degree of certainty for original management plan was not predictive of a change in management plan (p = 0.61).

CONCLUSIONS

Although certainty of prediscussion treatment plan is high, changes in treatment recommendations occurred in more than one-third of patients after GI MCC. This prospective study demonstrates the value of MCC in GI cancer sites, even at a stand-alone cancer center.

Improving the effectiveness of multidisciplinary team meetings for patients with chronic diseases: a prospective observational study

Background

Multidisciplinary team (MDT) meetings have been endorsed by the Department of Health as the core model for managing chronic diseases. However, the evidence for their effectiveness is mixed and the degree to which they have been absorbed into clinical practice varies widely across conditions and settings. We aimed to identify the key characteristics of chronic disease MDT meetings that are associated with decision implementation, a measure of effectiveness, and to derive a set of feasible modifications to MDT meetings to improve decision-making.

Methods

We undertook a mixed-methods prospective observational study of 12 MDTs in the London and North Thames area, covering cancer, heart failure, mental health and memory clinic teams. Data were collected by observation of 370 MDT meetings, completion of the Team Climate Inventory (TCI) by 161 MDT members, interviews with 53 MDT members and 20 patients, and review of 2654 patients’ medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation indicator, whether or not their preferences and other clinical/health behaviours were mentioned) and MDT features (team climate and skill mix) on the implementation of MDT treatment plans. Interview and observation data were thematically analysed and integrated to explore possible explanations for the quantitative findings, and to identify areas of diverse beliefs and practice across MDT meetings. Based on these data, we used a modified formal consensus technique involving expert stakeholders to derive a set of indications of good practice for effective MDT meetings.

Results

The adjusted odds of implementation were reduced by 25% for each additional professional group represented [95% confidence interval (CI) 0.66 to 0.87], though there was some evidence of a differential effect by type of disease. Implementation was more likely in MDTs with clear goals and processes and a good team climate (adjusted odds of implementation increased by 7%; 95% CI 1% to 13% for a 0.1-unit increase in TCI score). Implementation varied by disease category (with the lowest adjusted odds of implementation in mental health teams) and by patient deprivation (adjusted odds of implementation for patients in the most compared with least deprived areas were 0.60, 95% CI 0.39 to 0.91). We ascertained 16 key themes within five domains where there was substantial diversity in beliefs and practices across MDT meetings. These related to the purpose, structure, processes and content of MDT meetings, as well as to the role of the patient. We identified 68 potential recommendations for improving the effectiveness of MDT meetings. Of these, 21 engendered both strong agreement (median ≥ 7) and low variation in the extent of agreement (mean absolute deviation from the median of < 1.11) among the expert consensus panel. These related to the purpose of the meetings (e.g. that agreeing treatment plans should take precedence over other objectives); meeting processes (e.g. that MDT decision implementation should be audited annually); content of the discussion (e.g. that information on comorbidities and past medical history should be routinely available); and the role of the patient (e.g. concerning the most appropriate time to discuss treatment options). Panellists from all specialties agreed that these recommendations were both desirable and feasible. We were unable to achieve consensus for 17 statements. In part, this was a result of disease-specific differences including the need to be prescriptive about MDT membership, with local flexibility deemed appropriate for heart failure and uniformity supported for cancer. In other cases, our data suggest that some processes (e.g. discussion of unrelated research topics) should be locally agreed, depending on the preferences of individual teams.

Conclusions

Substantial diversity exists in the purpose, structure, processes and content of MDT meetings. Greater multidisciplinarity is not necessarily associated with more effective decision-making and MDT decisions (as measured by decision implementation). Decisions were less likely to be implemented for patients living in more deprived areas. We identified 21 indications of good practice for improving the effectiveness of MDT meetings, which expert stakeholders from a range of chronic disease specialties agree are both desirable and feasible. These are important because MDT meetings are resource-intensive and they should deliver value to the NHS and patients. Priorities for future work include research to examine whether or not the 21 indications of good practice identified in this study will lead to better decision-making; for example, incorporating the indications into a modified MDT and experimentally evaluating its effectiveness in a pragmatic randomised controlled trial. Other areas for further research include exploring the value of multidisciplinarity in MDT meetings and the reasons for low implementation in community mental health teams. There is also scope to examine the underlying determinants of the inequalities demonstrated in this study, for example by exploring patient preferences in more depth. Finally, future work could examine the association between MDT decision implementation and improvements in patient outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Strategies to improve the efficiency and utility of multidisciplinary team meetings in urology cancer care: a survey study

Background

The prevalence of multidisciplinary teams (MDT) for the delivery of cancer care is increasing globally. Evidence exists of benefits to patients and healthcare professionals. However, MDT working is time and resource intensive. This study aims to explore members’ views on existing practices of urology MDT working, and to identify potential interventions for improving the efficiency and productivity of the MDT meeting.

Methods

Members of urology MDTs across the UK were purposively recruited to participate in an online survey. Survey items included questions about the utility and efficiency of MDT meetings, and strategies for improving the efficiency of MDT meetings: treating cases by protocol, prioritising cases, and splitting the MDT into subspeciality meetings.

Results

173 MDT members participated (Oncologists n = 77, Cancer Nurses n = 54, Urologists n = 30, other specialities n = 12). 68% of respondents reported that attending the MDT meeting improves efficiency in care through improved clinical decisions, planning investigations, helping when discussing plans with patients, speciality referrals, documentation/patient records. Participants agreed that some cases including low risk, non-muscle invasive bladder cancer and localised, low-grade prostate cancer could be managed by pre-agreed pathways, without full MDT review. There was a consensus that cases at the MDT meeting could be prioritised by complexity, tumour type, or the availability of MDT members. Splitting the MDT meeting was unpopular: potential disadvantages included loss of efficiency, loss of team approach, unavailability of members and increased administrative work.

Conclusion

Key urology MDT members find the MDT meeting useful. Improvements in efficiency and effectiveness may be possible by prioritising cases or managing some low-risk cases according to previously agreed protocols. Further research is needed to test the effectiveness of such strategies on MDT meetings, cancer care pathways and patient outcomes in clinical practice.

Using peer observers to assess the quality of cancer multidisciplinary team meetings: a qualitative proof of concept study

Background

Multidisciplinary team (MDT) working is well established as the foundation for providing cancer services in the UK and elsewhere. A core activity is the weekly meeting (or case conference/tumor boards) where the treatment recommendations for individual patients are agreed. Evidence suggests that the quality of team working varies across cancer teams, and this may impact negatively on the decision-making process, and ultimately patient care. Feedback on performance by expert observers may improve performance, but can be resource-intensive to implement. This proof of concept study sought to: develop a structured observational assessment tool for use by peers (managers or clinicians from the local workforce) and explore its usability; assess the feasibility of the principle of observational assessment by peers; and explore the views of MDT members and observers about the utility of feedback from observational assessment.

Methods

For tool development, the content was informed by national clinical consensus recommendations for best practice in cancer MDTs and developed in collaboration with an expert steering group. It consisted of ten subdomains of team working observable in MDT meetings that were rated on a 10-point scale (very poor to very good). For observational assessment, a total of 19 peer observers used the tool (assessing performance in 20 cancer teams from four hospitals). For evaluation, telephone interviews with 64 team members and all peer observers were analyzed thematically.

Results

The tool was easy to use and areas for refinement were identified. Peer observers were identified and most indicated that undertaking observation was feasible. MDT members generally reported that observational assessment and feedback was useful, with the potential to facilitate improvements in team working.

Conclusion

This study suggests that observation and feedback by peers may provide a feasible and acceptable approach to enhance MDT performance. Further tool refinement and validation is required.