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

Multidisciplinary cancer care: does it improve outcomes?

Multidisciplinary care has been advocated as a solution for increasingly complex treatment decisions in cancer patients. The impact of multidisciplinary care on patient survival has been studied, but evidence is limited by poor methodological quality. Lack of conclusive evidence for increased survival is balanced against improvements in quality of care, guideline adherence, reduction in wait times, and greater satisfaction for patients and care providers.

Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study

Objective

Multidisciplinary team (MDT) meetings are assumed to produce better decisions and are extensively used to manage chronic disease in the National Health Service (NHS). However, evidence for their effectiveness is mixed. Our objective was to investigate determinants of MDT effectiveness by examining factors influencing the implementation of MDT treatment plans. This is a proxy measure of effectiveness, because it lies on the pathway to improvements in health, and reflects team decision making which has taken account of clinical and non-clinical information. Additionally, this measure can be compared across MDTs for different conditions.

Methods

We undertook a prospective mixed-methods study of 12 MDTs in London and North Thames. Data were collected by observation of 370 MDT meetings, interviews with 53 MDT members, and from 2654 patient medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation, whether their preferences and other clinical/health behaviours were mentioned) and MDT features (as measured using the ‘Team Climate Inventory’ and skill mix) on the implementation of MDT treatment plans.

Results

The adjusted odds (or likelihood) of implementation was reduced by 25% for each additional professional group represented at the MDT meeting. Implementation was more likely in MDTs with clear goals and processes and a good ‘Team Climate’ (adjusted OR 1.96; 95% CI 1.15 to 3.31 for a unit increase in Team Climate Inventory (TCI) score). Implementation varied by disease category, with the lowest adjusted odds of implementation in mental health teams. Implementation was also lower for patients living in more deprived areas (adjusted odds of implementation for patients in the most compared with least deprived areas was 0.60, 95% CI 0.39 to 0.91).

Conclusions

Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care.

Multidisciplinary team meeting in digestive oncology: when opinions differ

In daily oncology, Multidisciplinary Team (MDT) meetings are used worldwide to take every main decision. In order to improve the MDT efficiency, an analysis of decision-making process relying on patients refusing to undergo MDT proposal during presentations, in accordance with their referent specialist, was retrospectively performed in an academic and tertiary center, from 1995 to 2010. Out of 1000 patients, 0.5% refused the MDT proposal because of (1) ignorance of current evidence-based literature, (2) heterogeneous interpretations of the technical feasibility, and (3) the MDT undervaluing patient's specificities and wishes. In order to offset the MDT decision, patient needs to come from a well-off and educated background and to get the uttered support of the referent specialist. MDT conclusion is not customized because of interindividual exceptions and technical evaluations. Clinical Nurse Specialists attending to "blind" MDT meetings may help to back oncologic patient's specificities and wishes.

Adapting lung cancer symptom investigation and referral guidelines for general practitioners in Australia: reflections on the utility of the ADAPTE framework

RATIONALE

The ADAPTE framework was established to enhance efficiency in guideline development and to facilitate adaptation of high-quality clinical practice guidelines for a local context. It offers guideline developers a systematic methodology for guideline adaptation; however, the feasibility and usability of the process has not been widely evaluated.

AIM

A pragmatic approach was undertaken throughout the evaluation of the ADATPE process throughout the development of a guide for general practitioners in Australia regarding the initial investigation of symptoms of lung cancer. At each step of the framework all members of the project team leading the development process reflected on the steps outlined in the ADAPTE. The reflections were collated into a lesson-learned log and analysed following completion of the project.

RESULTS

Several opportunities for improvement were identified to improve usability and practicability of the ADAPTE framework. These items were both specific, in response to using steps and tools, and general issues concerned with the overall ADAPTE framework. Key challenges to using ADAPTE, highlighted in this study, were the lack of clarity about efficiency of the guideline adaptation process, level of assumed knowledge and expertise, and requirement of resources. In response to these challenges, modifications to the ADAPTE have been recommended.

CONCLUSION

The ADAPTE framework offers an attractive alternative to de novo guideline synthesis in circumstances where high-quality, compatible guidelines already exist. Pending further evaluation, the modifications identified in this study may be applied to future versions of ADAPTE to improve usability and feasibility of the framework.

Reduction in gastric cancer surgical mortality over 10 years: An adverse events analysis

Background

The reduction in gastric cancer mortality is due to a reduction in incidence and of surgical mortality. This study was to examine adverse events in patients with gastric cancer dying under surgical care.

Methods

Adverse events in surgical care were prospectively audited in patients who died of gastric cancer in Scottish hospitals. A cohort retrospective study examining deaths and contributing adverse events was compared for the periods 1996–2000 and 2001–2005.

Results

Between 1996 and 2005, 1083 patients with gastric cancer died on surgical wards in Scottish hospitals. The annual number of deaths under surgical care fell significantly from an average of 128 deaths per annum in years 1996–2000 to 88 deaths per annum in 2001–2005 (p < 0.001). This occurred in parallel with the decline in gastric cancer incidence over the same period. There was an increase in the proportion of gastric cancer resections carried out in 7 major hospitals in Scotland in the second period of the study (p < 0.001). The mean number of deaths in the group of patients, who had gastric cancer resection and palliative surgery, were significantly lower in the second period of the study In addition, when all patients were considered as a group, the mean number of anaesthetic, critical care, medical management and technical surgery adverse events were significantly lower in the second study period.

Conclusion

There has been a reduction in deaths and adverse events for patients with gastric cancer under surgical care and this has been associated with surgical subspecialisation in oesophago-gastric cancer surgery.

Oncologic multidisciplinary team meetings: evaluation of quality criteria

RATIONALE, AIMS AND OBJECTIVES

To develop a guideline with quality criteria for an optimal structure and functioning of a multidisciplinary team meeting (MTM), and to assess to what extent the Dutch MTMs complied with these criteria.

METHOD

A literature search and expert opinions were used to develop a guideline for optimal MTMs. In order to assess adherence to the guideline, we conducted interviews with MTM chairs and observed general and tumour-specific MTMs in seven hospitals.

RESULTS

The new guideline included the following domains: (i) organization of the MTMs; (ii) membership of the MTM and roles and responsibilities of the members; (iii) the meeting itself; and (iv) documentation of meeting-recommendations. We observed good adherence to the quality criteria on the organization of the MTMs. Only the required coordinator/administrative support was often absent, particularly during general MTMs. Regarding membership of MTMs and roles, the recommended average attendance of 100% of the core disciplines was never reached and particularly the role of the chair needs improvement. Regarding the meeting itself, many interruptions took place and relevant information about the diagnoses of the cases was not available in 4-5% of the cases. Concerning the documentation of meeting-recommendations, only in a quarter of the meetings a specific form was used for the documentation.

CONCLUSIONS

We found a lot of diversity in the organization of MTMs. The variation in compliance with the quality criteria may decrease with better knowledge about the quality criteria around MTMs and by overcoming practical barriers for the effective organization of MTMs.

Benefits of multidisciplinary teamwork in the management of breast cancer

The widespread introduction of multidisciplinary team (MDT)-work for breast cancer management has in part evolved due to the increasing complexity of diagnostic and treatment decision-making. An MDT approach aims to bring together the range of specialists required to discuss and agree treatment recommendations and ongoing management for individual patients. MDTs are resource-intensive yet we lack strong (randomized controlled trial) evidence of their effectiveness. Clinical consensus is generally favorable on the benefits of effective specialist MDT-work. Many studies have shown the benefits of receiving treatment from a specialist center, and evidence continues to accrue from comparative studies of clinical benefits of an MDT approach, including improved survival. Patients’ views of the MDT model of decision-making (and in particular its impact on involvement in decisions about their care) have been under-researched. Barriers to effective teamwork and poor decision-making include excessive caseload, low attendance at meetings, lack of leadership, poor communication, role ambiguity, and failure to consider patients’ holistic needs. Breast cancer nurses have a key role in relation to assessing holistic needs, and their specialist contribution has also been associated with improved patient experience and quality of life. This paper examines the evidence for the benefits of MDT-work, in particular for breast cancer. Evidence is considered within a context of growing cancer incidence at a time of increased financial restraint, and it may now be important to reevaluate the structure and models of MDT-work to ensure that MDTs are an efficient use of resources.

Recent developments in esophageal adenocarcinoma

Answer questions and earn CME/CNE Esophageal adenocarcinoma (EAC) is characterized by 6 striking features: increasing incidence, male predominance, lack of preventive measures, opportunities for early detection, demanding surgical therapy and care, and poor prognosis. Reasons for its rapidly increasing incidence include the rising prevalence of gastroesophageal reflux and obesity, combined with the decreasing prevalence of Helicobacter pylori infection. The strong male predominance remains unexplained, but hormonal influence might play an important role. Future prevention might include the treatment of reflux or obesity or chemoprevention with nonsteroidal antiinflammatory drugs or statins, but no evidence-based preventive measures are currently available. Likely future developments include endoscopic screening of better defined high-risk groups for EAC. Individuals with Barrett esophagus might benefit from surveillance, at least those with dysplasia, but screening and surveillance strategies need careful evaluation to be feasible and cost-effective. The surgery for EAC is more extensive than virtually any other standard procedure, and postoperative survival, health-related quality of life, and nutrition need to be improved (eg, by improved treatment, better decision-making, and more individually tailored follow-up). Promising clinical developments include increased survival after preoperative chemoradiotherapy, the potentially reduced impact on health-related quality of life after minimally invasive surgery, and the new endoscopic therapies for dysplastic Barrett esophagus or early EAC. The overall survival rates are improving slightly, but poor prognosis remains a challenge.

Multidisciplinary decisions in breast cancer: does the patient receive what the team has recommended?

BACKGROUND

A multidisciplinary team (MDT) approach to breast cancer management is the gold standard. The aim is to evaluate MDT decision making in a modern breast unit.

METHODS

All referrals to the breast MDT where breast cancer was diagnosed from 1 July 2009 to 30 June 2011 were included. Multidisciplinary team decisions were compared with subsequent patient management and classified as concordant or discordant.

RESULTS

Over the study period, there were 3230 MDT decisions relating to 705 patients. Overall, 91.5% (2956 out of 3230) of decisions were concordant, 4.5% (146 out of 3230), were discordant and 4% (128 out of 3230) had no MDT decision. Of 146 discordant decisions, 26 (17.8%) were considered 'unjustifiable' as there was no additional information available after the MDT to account for the change in management. The remaining 120 discordant MDT decisions were considered 'justifiable', as management was altered due to patient choice (n=61), additional information available after MDT (n=54) or MDT error (n=5).

CONCLUSION

The vast majority of MDT decisions are implemented. Management alteration was most often due to patient choice or additional information available after the MDT. A minority of management alterations were 'unjustifiable' and the authors recommend that any patient whose treatment is subsequently changed should have MDT rediscussion prior to treatment.

Poor health-related quality of life in the Swedish general population: The association with disease and lifestyle factors

Aim: Poor health-related quality of life (HRQoL) is associated with increased use of healthcare services, but it remains unclear which individuals have a heightened risk in the general population. Methods: A Swedish population-based cross-sectional survey was conducted in 2008. Predefined risk characteristics including sex, age, educational level, marital status, body mass index, diseases, physical activity, and tobacco smoking were collected by a self-report questionnaire. Five aspects of the EORTC QLQ-C30 were used to assess HRQoL: physical, role, emotional, social, and cognitive function. Participants were defined as having “poor HRQoL” if they scored ≥10 points (scale 0–100) lower than the mean score of the total sample. To assess the characteristics of individuals with poor HRQoL, classification and regression tree (CART) analysis was performed. Results: A total of 4910 (70.5% participation rate) randomly selected individuals participated in the study. The CART analysis showed that for each of the five functional aspects of HRQoL, the most important covariate HRQoL was the number of reported diseases, while the second strongest covariate was physical inactivity. Conclusion: This large population-based study indicates that a higher number of diseases and physical inactivity are the most important covariates of poor HRQoL in the Swedish general population.

Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature

Objective

To investigate the cost effectiveness of management of patients within the context of a multidisciplinary team (MDT) meeting in cancer and non-cancer teams in secondary care.

Design

Systematic review.

Data sources

EMBASE, MEDLINE, NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC.

Eligibility criteria for selecting studies

Randomised controlled trials (RCTs), cohort, case–control, before and after and cross-sectional study designs including an economic evaluation of management decisions made in any disease in secondary care within the context of an MDT meeting.

Data extraction

Two independent reviewers extracted data and assessed methodological quality using the Consensus on Health Economic Criteria (CHEC-list). MDTs were defined by evidence of two characteristics: decision making requiring a minimum of two disciplines; and regular meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing. Studies that reported on the costs of administering, preparing for, and attending MDT meetings and/or the subsequent direct medical costs of care, non-medical costs, or indirect costs, and any health outcomes that were relevant to the disease being investigated were included and classified as cancer or non-cancer MDTs.

Results

Fifteen studies (11 RCTs in non-cancer care, 2 cohort studies in cancer and non-cancer care, and 2 before and after studies in cancer and non cancer care) were identified, all with a high risk of bias. Twelve papers reported the frequency of meetings which varied from daily to three monthly and all reported the number of disciplines included (mean 5, range 2 to 9). The results from all studies showed mixed effects; a high degree of heterogeneity prevented a meta-analysis of findings; and none of the studies reported how the potential savings of MDT working may offset the costs of administering, preparing for, and attending MDT meetings.

Conclusions

Current evidence is insufficient to determine whether MDT working is cost-effective or not in secondary care. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective cancer and non-cancer care are required.

Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective

BACKGROUND

It is becoming a standard practice worldwide for cancer patients to be discussed by a multidisciplinary team (MDT or 'tumour board') in order to formulate an expert-derived management plan. Evidence suggests that MDTs do not always work optimally in making clinical decisions and that not all MDT decisions get implemented into care. We investigated factors influencing decision-making and decision implementation in cancer MDTs.

METHODS

Semi-structured interviews were carried out with expert MDT members of Urological and Gastro-Intestinal tumours of 3 London (UK) hospitals. The standardised interview protocol assessed MDT experts' views on decision-making, barriers to reaching a decision and implementing it into care, and interventions to improve this process. All interviews were audio-taped, transcribed verbatim and analysed using a standardised approach. Emergent themes were identified by 2 clinical coders and tabulated.

RESULTS

Twenty-two participants participated in the study and data collection achieved 'saturation' (i.e., similar themes raised by different participants). Barriers to clinical decision-making included: inadequate clinical information; lack of investigation results; non-attendance of key members; teleconferencing failures. Barriers to implementation of MDT recommendations included: non-consideration of patients' choices or co-morbidities; disease progression at the time of implementation. Proposed interventions included improving the information available for the discussion through a standardised proforma; improving video-conferencing; reducing the MDT caseload (e.g., via selective MDT review of certain patients); and including patients more in the decision process.

CONCLUSIONS

There is an increasing drive to improve the clinical role of the MDT within cancer care. This study demonstrates the main barriers that MDTs face in deciding on and, importantly, implementing a management plan. Further research should prospectively evaluate interventions to enhance translation of MDT decision-making into cancer care and thus to expedite and improve care.

The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease

Stable complex coronary artery disease can be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy. Multidisciplinary decision-making has gained more emphasis over the recent years to select the most optimal treatment strategy for individual patients with stable complex coronary artery disease. However, the so-called 'Heart Team' concept has not been widely implemented. Yet, decision-making has shown to remain suboptimal; there is large variability in PCI-to-CABG ratios, which may predominantly be the consequence of physician-related factors that have raised concerns regarding overuse, underuse, and inappropriate selection of revascularization. In this review, we summarize these and additional data to support the statement that a multidisciplinary Heart Team consisting of at least a clinical/non-invasive cardiologist, interventional cardiologist, and cardiac surgeon, can together better analyse and interpret the available diagnostic evidence, put into context the clinical condition of the patient as well as consider individual preference and local expertise, and through shared decision-making with the patient can arrive at a most optimal joint treatment strategy recommendation for patients with stable complex coronary artery disease. In addition, other aspects of Heart Team decision-making are discussed: the organization and logistics, involvement of physicians, patients, and assisting personnel, the need for validation, and its limitations.

Multidisciplinary management of esophageal cancer

This article reviews the current management of esophageal cancer, including staging and treatment options, as well as providing support for using multidisciplinary teams to better manage esophageal cancer patients.

American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Rapid evaluation and establishment of treatment goals are imperative for optimum patient management and require a multidisciplinary team approach. Here we present guidelines for the management of ATC. The development of these guidelines was supported by the American Thyroid Association (ATA), which requested the authors, members the ATA Taskforce for ATC, to independently develop guidelines for ATC.

METHODS

Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The quality and strength of recommendations were adapted from the Clinical Guidelines Committee of the American College of Physicians, which in turn was developed by the Grading of Recommendations Assessment, Development and Evaluation workshop.

RESULTS

The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues including end of life. The guidelines include 65 recommendations.

CONCLUSIONS

These are the first comprehensive guidelines for ATC and provide recommendations for management of this extremely aggressive malignancy. Patients with stage IVA/IVB resectable disease have the best prognosis, particularly if a multimodal approach (surgery, radiation, systemic therapy) is used, and some stage IVB unresectable patients may respond to aggressive therapy. Patients with stage IVC disease should be considered for a clinical trial or hospice/palliative care, depending upon their preference.

The role of multi-disciplinary teams in decision-making for patients with recurrent malignant disease

BACKGROUND

It is mandatory in many countries for decisions for all new patients with cancer to be made within multi-disciplinary teams (MDTs). Whether patients with disease recurrence should also routinely be discussed by the MDT is unknown.

AIM

This study investigated the role of an upper gastro intestinal (UGI) MDT in decision-making for patients with disease recurrence.

DESIGN

A retrospective review of prospectively kept MDT records (2010 to 2011) was performed identifying patients discussed with recurrence of oesophagogastric cancer. Information was recorded about: i) why an MDT referral was made, ii) who made the referral and iii) the final MDT recommendation. Implementation of the MDT recommendation was also examined.

PARTICIPANTS

All patients discussed with recurrence of cancer at a central UGI cancer MDT were included.

RESULTS

During the study 54 MDT meetings included discussions regarding 304 new patients and 29 with disease recurrence. Referrals to the MDT for patients with recurrence came from outpatient clinics (n=19, 65.5%) or following emergency admission (n=10). Most referrals were made by the surgical team (n=25, 86.2%). MDT recommendations were best supportive care (n=11, 37.9%), palliative chemotherapy (n=9, 31.0%), stent (n=5, 17.2%), palliative radiotherapy (n=3, 10.3%) and further surgery (n=1, 3.4%), with 25 (86.2%) of these implemented.

CONCLUSION

UGI MDTs focus on new referrals and only a small proportion of patients with recurrent disease are re-discussed. Many patients go on to receive further treatments. Whether such patients are optimally managed within the standard MDT is uncertain, however, and warrants further consideration.

Multidisciplinary management of cancer patients: chasing a shadow or real value? An overview of the literature

PURPOSE

Multidisciplinary cancer conferences (mccs) are designed to optimize patient outcomes. It appears intuitive that mccs are essential to clinical decision-making and patient management; however, it is unclear whether that belief is supported by evidence. Our objectives were to assess the currently published literature addressing the impact of mccs on clinical decision-making and patient outcomes.

METHODS

Ovid medline was searched from 1950 to June 2010 using these keywords: "multidisciplinary/interdisciplinary/clinical meeting$/conference$/round$/team$," "decision making," "neoplasms$/cancer$/oncology/tumo(u)r conference$/board$/meeting$," "multidisciplinary/interdisciplinary cancer conference$/meeting$." All trials, guidelines, metaanalyses, reviews, and prospective and retrospective studies were included.

RESULTS

The keywords retrieved 595 abstracts, and 30 manuscripts were obtained. Most of the studies assessed the impact of mccs on clinical decision-making rather than on patient outcomes.

CONCLUSIONS

Available evidence supports the belief that mccs significantly influence clinical decision-making and treatment recommendations. In contrast, scant evidence suggests that mccs improve patient outcomes. Unfortunately, the current literature is substantially heterogeneous and therefore does not allow for firm conclusions.

Decision-making in oncology: a selected literature review and some recommendations for the future

PURPOSE OF REVIEW

Decision-making in oncology is associated with uncertainty and potential decisional conflict. The purpose of this paper is to review strategies suggested to improve treatment decision-making, discuss their limits and describe recommendations that have been made to improve the decision-making process.

RECENT FINDINGS

To improve the decision-making process, uncertainty reduction, shared decision-making and multidisciplinary teamwork have been initially proposed. Due to their limits, alternative approaches such as uncertainty management, collaborative decision-making and collaborative multidisciplinary teamwork have been recommended. Uncertainty management considers uncertainty as a multilevel concept. It may be achieved through collaborative decision-making and collaborative multidisciplinary teamwork. Collaborative decision-making is an in-depth personalized iterative assessment of patient medical, psychological and social status. It promotes the patient's proactive role as a key stakeholder of decision-making and the physician's proactive role as a key support to patient decision-making. Collaborative multidisciplinary teamwork promotes an optimal environment for collaborative decision-making in which patients are key stakeholders and all relevant healthcare professionals are actively involved. These approaches require developing interventions for patients, and trainings for physicians and multidisciplinary teams.

SUMMARY

On the basis of these recent approaches, we propose a 'three-step model of multidisciplinary collaborative treatment decision-making' in oncology. This model should be tested for its validity.

Developing and testing TEAM (Team Evaluation and Assessment Measure), a self-assessment tool to improve cancer multidisciplinary teamwork

BACKGROUND

Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the "characteristics of an effective MDT."

METHODS

Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity.

RESULTS

A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r < 0.20). Team members were positive about its value.

CONCLUSIONS

Self-assessment of team performance using this tool may support MDT development.

Measuring the quality of MDT working: an observational approach

Background

Cancer multidisciplinary teams (MDTs) are established in many countries but little is known about how well they function. A core activity is regular MDT meetings (MDMs) where treatment recommendations are agreed. A mixed methods descriptive study was conducted to develop and test quality criteria for observational assessment of MDM performance calibrated against consensus from over 2000 MDT members about the “characteristics of an effective MDT”.

Methods

Eighteen of the 86 ‘Characteristics of Effective MDTs’ were considered relevant and feasible to observe. They collated to 15 aspects of MDT working covering four domains: the team (e.g. attendance, chairing, teamworking); infrastructure for meetings (venue, equipment); meeting organisation and logistics; and patient-centred clinical decision-making (patient-centredness, clarity of recommendations). Criteria for rating each characteristic from ‘very poor’ to ‘very good’ were derived from literature review, observing MDMs and expert input. Criteria were applied to 10 bowel cancer MDTs to assess acceptability and measure variation between and within teams. Feasibility and inter-rater reliability was assessed by comparing three observers.

Results

Observational assessment was acceptable to teams and feasible to implement. Total scores from 29 to 50 (out of 58) highlighted wide diversity in quality between teams. Eight teams were rated either ‘very good/good’ or ‘very poor/poor’ for at least three domains demonstrating some internal consistency. ‘Very good’ ratings were most likely for attendance and administrative preparation, and least likely for patient-centredness of decision-making and prioritisation of complex cases. All except two characteristics had intra-class correlations of ≥0.50.

Conclusions

This observational tool (MDT-OARS) may contribute to the assessment of MDT performance. Further testing to confirm validity and reliability is required.

Coordination of breast cancer care between radiation oncologists and surgeons: a survey study

PURPOSE

To assess whether radiation oncologists and surgeons differ in their attitudes regarding the local management of breast cancer, and to examine coordination of care between these specialists.

METHODS AND MATERIALS

We surveyed attending surgeons and radiation oncologists who treated a population-based sample of patients diagnosed with breast cancer in metropolitan Detroit and Los Angeles. We identified 419 surgeons, of whom 318 (76%) responded, and 160 radiation oncologists, of whom 117 (73%) responded. We assessed demographic, professional, and practice characteristics; challenges to coordinated care; and attitudes toward management in three scenarios.

RESULTS

92.1% of surgeons and 94.8% of radiation oncologists indicated access to a multidisciplinary tumor board. Nevertheless, the most commonly identified challenge to radiation oncologists, cited by 27.9%, was failure of other providers to include them in the treatment decision process early enough. Nearly half the surgeons (49.7%) stated that few or almost none of the breast cancer patients they saw in the past 12 months had consulted with a radiation oncologist before undergoing definitive surgery. Surgeons and radiation oncologists differed in their recommendations in management scenarios. Radiation oncologists were more likely to favor radiation than were surgeons for a patient with 3/20 lymph nodes undergoing mastectomy (p = 0.03); surgeons were more likely to favor more widely clear margins after breast conservation than were radiation oncologists (p = 0.001).

CONCLUSIONS

Despite the widespread availability of tumor boards, a substantial minority of radiation oncologists indicated other providers failed to include them in the breast cancer treatment decision-making process early enough. Earlier inclusion of radiation oncologists may influence patient decisions, and interventions to facilitate this should be considered.

Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC

BACKGROUND

The quality of decision-making in cancer multidisciplinary team (MDT) meetings is variable, which can result in suboptimal clinical decision making. We developed MDT-QuIC, an evidence-based tool to support clinical decision making by MDTs, which was evaluated by key users.

METHODS

Following a literature review, factors important for high-quality clinical decision making were listed and then converted into a preliminary checklist by clinical and safety experts. Attitudes of MDT members toward the tool were evaluated via an online survey, before adjustments were made giving rise to a final version: MDT-QuIC.

RESULTS

The checklist was evaluated by 175 MDT members (surgeons = 38, oncologists = 40, specialist nurses = 62, and MDT coordinators = 35). Attitudes toward the checklist were generally positive (P < 0.001, 1-sample t test), although nurses were more positive than other groups regarding whether the checklist would improve their contribution in MDT meetings (P < 0.001, Mann-Whitney U test). Participants thought that the checklist could be used to prepare cases for MDT meetings, to structure and guide case discussions, or as a record of MDT discussion. Regarding who could use the checklist, 70% thought it should be used by the MDT chair, 54% by the MDT coordinator, and 38% thought all MDT members should use it.

CONCLUSION

We have developed and validated an evidence-based tool to support the quality of MDT decision making. MDT members were positive about the checklist and felt it may help to structure discussion, improve inclusivity, and patient centeredness. Further research is needed to assess its effect on patient care and outcomes.

[Multidisciplinary team meetings in cancerology: setting priorities for improvement]

Resulting medical decision from a multidisciplinary team (MDT) meeting has to be accurate regarding to various patient criteria and relevant specialists participation. The target is to optimize treatment or management options for patients taking into account patients' benefit. The aim of our study was to examine quality criteria of MDT meeting processes, implementation of the MDT decision, and the follow-up of national or regional clinical guidelines. The results lead us to discuss about care management in cancer. Ten various medical specialities of MDT meetings were studied. Relevant multidisciplinarity varied between MDT meetings specialities and was effective between 55 and 100%. Implementation of the decisions that arise from MDT meetings was 86.3%. The most frequent grounds of non-application were patient refusal and new or previous unknown clinical data. The percentage of MDT meetings decisions following national or regional recommendations was 74%. The main reason of not following was the complexity of clinical patient circumstances. Participation in MDT meetings is more and more time-consuming related to enforce the completeness referred to the Plan Cancer (National recommendations). Leading to completeness raises questions about medical time employment and meaning of the MDT meeting for standard clinical cases. The priority seems to enforce multidisciplinarity rather than reach completeness.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

The effect of multidisciplinary team care on cancer management

Over the past 15 years, the multidisciplinary team management of many medical conditions especially cancers has increasingly taken a prominent role in patient management in many hospitals and medical centres in the developed countries. In the United Kingdom, it began to gain prominence following the Calman-Heine report in 1995 which suggested that each Cancer Unit in a hospital should have in place arrangements for non-surgical oncological input into services, with a role for a non-surgical oncologist. The report further suggested that a lead clinician with a well established interest in cancer care should be appointed to organise and coordinate the whole range of cancer services provided within the Cancer Unit. Many people have argued that the multidisciplinary team management of patients has resulted in better care and improved survival. However, there are barriers to the optimal effectiveness of the multidisciplinary team. This paper aims to review various studies on the effectiveness of the multidisciplinary team in the management of cancer patients and also discuss some of the barriers to the multidisciplinary team.

Quality improvement in multidisciplinary cancer teams: an investigation of teamwork and clinical decision-making and cross-validation of assessments

PURPOSE

Teamworking and clinical decision-making are important in multidisciplinary cancer teams (MDTs). Our objective is to assess the quality of information presentation and MDT members' contribution to decision-making via expert observation and self-report, aiming to cross-validate the two methods and assess the insight of MDT members into their own team performance.

MATERIALS AND METHODS

Behaviors were scored using (i) a validated observational tool employing Likert scales with objective anchors, and (ii) a 29-question online self-report tool. Data were collected from observation of 164 cases in five MDTs, and 47 surveys from MDT members (response rate 70%). Presentation of information (case history, radiological, pathological, comorbidities, psychosocial, and patients' views) and quality of contribution to decision-making of MDT members (surgeons, oncologists, radiologists, pathologists, nurses, and MDT coordinators) were analyzed via descriptive statistics and the Jonckheere-Terpstra test. Correlation between observational and self-report assessments was assessed with Spearman's correlations.

RESULTS

Quality of information presentation: Case histories and radiology information rated highest; patients' views and comorbidities/psychosocial issues rated lowest (observed: Z = 14.80, P ≤ 0.001; self-report: Z = 3.70, P < 0.001). Contribution to decision-making: Surgeons and oncologists rated highest, nurses and MDT coordinators rated lowest, and others in between (observed: Z = 20.00, P ≤ 0.001; self-report: Z = 8.10, P < 0.001). Correlations between observational and self-report assessments: Median Spearman's rho = 0.74 (range = 0.66-0.91; P < 0.05).

CONCLUSIONS

The quality of teamworking and clinical decision-making in MDTs can reliably be assessed using observational and self-report metrics. MDT members have good insight into their own team performance. Such robust assessment methods could provide the basis of a toolkit for MDT team evaluation and improvement.

Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy

AIM: To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China.

METHODS: Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared.

RESULTS: The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049).

CONCLUSION: MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.

Quality of care management decisions by multidisciplinary cancer teams: a systematic review

BACKGROUND

Factors that affect the quality of clinical decisions of multidisciplinary cancer teams (MDTs) are not well understood. We reviewed and synthesised the evidence on clinical, social and technological factors that affect the quality of MDT clinical decision-making.

METHODS

Electronic databases were searched in May 2009. Eligible studies reported original data, quantitative or qualitative. Data were extracted and tabulated by two blinded reviewers, and study quality formally evaluated.

RESULTS

Thirty-seven studies were included. Study quality was low to medium. Studies assessed quality of care decisions via the effect of MDTs on care management. MDTs changed cancer management by individual physicians in 2-52% of cases. Failure to reach a decision at MDT discussion was found in 27-52% of cases. Decisions could not be implemented in 1-16% of cases. Team decisions are made by physicians, using clinical information. Nursing personnel do not have an active role, and patient preferences are not discussed. Time pressure, excessive caseload, low attendance, poor teamworking and lack of leadership lead to lack of information and deterioration of decision-making. Telemedicine is increasingly used in developed countries, with no detriment to quality of MDT decisions.

CONCLUSIONS

Team/social factors affect management decisions by cancer MDTs. Inclusion of time to prepare for MDTs into team-members' job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel would address some of the current shortcomings. These improvements ought to be considered at national policy level, with the ultimate aim of improving cancer care.

Controversies on the management of clinical situations with low therapeutic effectiveness in oncology

Clinical scenarios associated with low therapeutic effectiveness (LTE) are especially complex and highly relevant in oncology. The objective was to test a methodological framework for creating consensual clinical recommendations for routine practice. The study was in three phases from Mars 2006 to January 2008: 1) Definition of LTE situations; 2) Preparation by 10 experts of a panel of LTE situations in cancers of breast, lung, head and neck, colon and rectum and brain; and 3) Development of a consensus on each situation and its optimal treatment by gathering agreement and disagreements (two-round Delphi method) from 68 practicing oncologists in Andalusian Community. Three major and three minor criteria were established for an LTE situation, defined when at least one major or two minor criteria were met. The expert group proposed 48 possible LTE clinical scenarios for breast (n = 7), lung (10), brain (11), head and neck (11) and colorectal cancers (9). Sixty-eight oncologists agreed to participate in the study; the response rate was 79% (from 34 medical and 17 radiation oncologists) In the first round (definition), maximum agreement was obtained with the LTE definition of 10 of the 48 scenarios; in the second round (treatment options), maximum agreement was obtained on the treatment of 3 of these 10 scenarios. Oncologists reached low levels of agreement on the definition of an LTE situation and on its treatment recommendations. This study proposes an approach to the improvement of cancer management in situations of high uncertainty.

Decision making in surgical oncology

Decisions in surgical oncology are increasingly being made by multi-disciplinary teams (MDTs). Although MDTs have been widely accepted as the preferred model for cancer service delivery, the process of decision making has not been well described and there is little evidence pointing to the ideal structure of an MDT. Performance in surgery has been shown to depend on non-technical skills, such as decision making, as well as patient factors and the technical skills of the healthcare team. Application of this systems approach to MDT working allows the identification of factors that affect the quality of decision making for cancer patients. In this article we review the literature on decision making in surgical oncology and by drawing from the systems approach to surgical performance we provide a framework for understanding the process of decision making in MDTs. Technical factors that affect decision making include the information about patients, robust ICT and video-conferencing equipment, a minimum dataset with expert review of radiological and pathological information, implementation and recording of the MDTs decision. Non-technical factors with an impact on decision making include attendance of team members at meetings, leadership, teamwork, open discussion, consensus on decisions and communication with patients and primary care. Optimising these factors will strengthen the decision making process and raise the quality of care for cancer patients.

Clinical decision-making in a multidisciplinary gynaecological cancer team: a qualitative study

OBJECTIVE

To explore the factors that influence treatment decision-making in a gynaecological cancer team (MDT).

DESIGN

Qualitative study using interviews and observations.

SETTING

Gynaecological cancer MDT meetings and participants' offices.

SAMPLE

A gynaecological cancer MDT and members of that team.

METHODS

Observations of ten MDT meetings and semistructured interviews with 16 team members. Data analysis using the constant comparison technique of grounded theory and ethnography.

MAIN OUTCOME MEASURES

Factors affecting treatment decisions in the MDT meetings.

RESULTS

Disease-centred information was central to decision-making, whereas patient-centred factors such as patient choice and co-morbidity were more peripheral. This was partly due to variation in team members' type and level of participation: senior clinicians occupied the most dominant roles in discussions and decision-making, whereas nurses contributed less but were more likely to focus on patient-related factors. Three main decision-making pathways emerged: a short discussion followed by a clear decision, a prolonged discussion ending in a definite treatment plan, and a lengthy discussion with no clearly stated decision at the end. The type of pathway followed depended on a case's complexity and the extent of agreement among team members.

CONCLUSIONS

The process of treatment decision-making was not consistent for all women but was affected by factors such as the complexity of the case, which team members participated, and the extent of team members' agreement. Improvements are needed to ensure patient-centred information is included for all women and that clear decisions are reached and recorded in all cases.

An evaluation of treatment decisions at a colorectal cancer multi-disciplinary team

OBJECTIVE

It is mandatory for treatment decisions for patients with colorectal cancer to be made within the context of a multi-disciplinary team (MDT) meeting. It is currently uncertain, however, how to best evaluate the quality of MDT decision-making. This study examined MDT decision-making by studying whether MDT treatment decisions were implemented and investigated the reasons why some decisions changed after the meeting.

METHOD

Consecutive MDT treatment decisions were prospectively recorded. Implementation of decisions was studied by examining hospital records. Reasons for changes in MDT decisions were identified.

RESULTS

In all, 201 consecutive treatment decisions were analysed, concerning 157 patients. Twenty decisions (10.0%, 95% confidence interval 6.3-15.2%) were not implemented. Looking at the reasons for nonimplementation, nine (40%) related to co-morbidity, seven (35%) to patient choice, two changed in light of new clinical information, one doctor changed a decision and for one changed decision, no reason was apparent. When decisions changed, the final treatment was always more conservative than was originally planned and decisions were more likely to change for colon rather than rectal cancer (P = 0.024).

CONCLUSION

The vast majority of colorectal MDT decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account. Analysis of the implementation of team decisions is an informative process to monitor the quality of MDT decision-making.

Predictors of multivisceral resection in patients with locally advanced colorectal cancer

BACKGROUND

Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.

METHODS

Rates of MVR were examined by observational study. Eligible patients were aged 20-74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.

RESULTS

Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.

CONCLUSION

Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.