It Takes a Village: The Importance of Multidisciplinary Care

Trust Development Between Speech-Language Pathologists and Laryngologists: A Thematic Analysis

OBJECTIVES

Speech-language pathologists (SLPs) and laryngologists often work closely in interdisciplinary settings evaluating and treating patients with voice, swallowing, and airway disorders. This collaboration is integral to providing optimum patient care. We theorize that trust is an essential component of this relationship and contributes to effective patient care and professional satisfaction. There is currently no literature that explores the development and role of trust in this unique interprofessional relationship. We aim to explore the SLP and laryngologist interprofessional relationship and the development and role of trust in that relationship.

STUDY DESIGN

Qualitative Realist Thematic Analysis.

METHODS

Thematic analysis of semistructured qualitative interviews was performed to explore the relationship between SLPs and laryngologists. Through purposive sampling from November 2022-January 2023, we recruited SLPs (n = 10) and laryngologists (n = 10) from 12 centers with varying years of practice, practice setting (academic or private), geographic location, and team structures.

RESULTS

Trust between SLPs and laryngologists is comprised of confidence in (1) ability (clinical judgment, technical skill), (2) benevolence, and (3) integrity. Trust formation is enhanced by frequency and quality of communication, physical proximity, and reduction of practical barriers (scheduling, billing, departmental structure). Role negotiation was not identified as a factor. The presence of all three components of trust contributes to job satisfaction, perceptions of patient experience and care outcomes, and the willingness to collaborate in academic areas beyond clinical care.

CONCLUSIONS

All three elements (ability, benevolence, integrity) must be present for trust in an interprofessional relationship between SLPs and laryngologists, and formation of trust is facilitated by robust communication, physical proximity, and reduction of practical barriers to collaboration. The lack of these elements and lack of trust between the two professions can negatively impact collaboration, job satisfaction, and patient care outcomes, contributing to inefficiencies in patient care.

Virtual Tumor Boards for Remote Learning in Head and Neck Surgical Oncology

Importance

In addition to their patient management value, multidisciplinary tumor boards have been recognized as effective learning tools. However, the value of using a virtual tumor board as a learning tool for head and neck surgical oncology fellows has not been studied.

Objective

To describe the structure and content of the American Head and Neck Society (AHNS) Virtual Tumor Board and assess its educational value as perceived by attendees.

Design, Setting, and Participants

All sessions of the AHNS Virtual Tumor Board from April 8, 2020, to June 1, 2022, were reviewed. Topics, presenters, participants, and viewership data were collected as of October 15, 2022, from session recordings posted to an online video sharing and social media platform. Additionally, an anonymous, 14-question online survey was designed to elicit feedback from head and neck surgery trainees on virtual tumor board engagement, strengths, and weaknesses. The survey was electronically distributed in June and July 2022 to the 101 fellows enrolled in AHNS-accredited programs between July 1, 2020, and June 30, 2022.

Main Outcomes and Measures

The primary aim was to tabulate online viewership of the sessions. The secondary aim was to qualitatively assess the experience of head and neck trainees with the AHNS Virtual Tumor Board using a survey.

Results

Forty-two sessions of the virtual tumor board were held between April 8, 2020, and June 1, 2022. Almost all sessions (41 [98%]) were case based. One hundred and sixteen cases were presented, representing 2 to 3 cases per session, by 75 unique faculty members. Each session was viewed a mean of 217 times (range, 64-2216 views). In the 2021 to 2022 academic year, a mean of 60 viewers (range, 30-92 viewers) attended each live session. In all, 29 survey responses were collected from 101 fellows in AHNS-accredited programs (29% response rate). Most respondents felt the format allowed for excellent teaching (18 of 26 respondents [69%]) and discussion (19 of 26 respondents [73%]). Most respondents (22 of 29 respondents [76%]) believed that practicing head and neck surgeons would benefit from the sessions.

Conclusions and Relevance

This survey study found that the AHNS Virtual Tumor Board was well-attended and well-reviewed by head and neck surgical oncology trainees. The virtual tumor board format could be used as model of remote learning for other organizations.

Management of Patients with Spine Tumors Strengthened by a Dedicated Multidisciplinary Spine Tumor Board: A 15-Year Single-Institutional Experience

BACKGROUND

Patients with spine tumors frequently require timely, multistep, and multidisciplinary care. A Spine Tumor Board (STB) provides a consistent forum wherein diverse specialists can interact, facilitating complex coordinated care for these patients. This study aims to present a single, large academic center's STB experience specifically reviewing case diversity, recommendations, and quantifying growth over time.

METHODS

All patient cases discussed at STB from May 2006 (STB inception) to May 2021 were evaluated. Collected data submitted by presenting physicians and formal documentation completed during the STB are summarized.

RESULTS

A total of 4549 cases were reviewed by STB over the study period, representing 2618 unique patients. Over the course of the study, a 266% increase in number of cases presented per week was observed (4.1 to 15.0). Cases were presented by surgeons (74%), radiation oncologists (18%), neurologists (2%), and other specialists (6%). The most common pathologic diagnoses discussed were spinal metastases (n = 1832; 40%), intradural extramedullary tumors (n = 798; 18%), and primary glial tumors (n = 567; 12%). Treatment recommendations included surgery, radiation therapy, or systemic therapy for 1743 cases (38%), continued routine follow-up/expectant management for 1592 cases (35%), supplementary imaging to better clarify the diagnosis for 549 cases (12%), and variable tailored recommendations for the remainder of cases (18%).

CONCLUSIONS

Care of patients with spine tumors is complex. We believe that the formation of a stand-alone STB is instrumental to accessing multidisciplinary input, enhancing confidence in management decisions for both patients and providers, assisting with care orchestration, and improving quality of care for patients with spine tumors.

How the Hospital Works: An Interdisciplinary, Systems-Based Practice Medical Student Elective

OBJECTIVES

Although proficient systems-based practice is a foundational skill for physicians, how best to teach it has not been well established. An elective course for fourth-year medical students wherein participants had an immersive experience with multiple interprofessional staff was created and analyzed. The authors hypothesized that participating students and interprofessional staff would show gains in systems-based knowledge and interprofessional communication.

METHODS

The course was a 2-week elective experience for fourth-year medical students at the Larner College of Medicine at the University of Vermont, Burlington, VT, USA. Participants integrated into a variety of interprofessional, non-physician, and administrative roles within the hospital system. Pre- and post-elective systems-based knowledge and interprofessional communication were assessed. Participating interprofessional staff were also surveyed on their experiences.

RESULTS

From 2019 through 2022, 14 students participated in the elective, all of whom provided data. All participating students showed a quantitative improvement in systems-based knowledge and qualitatively commented on the high value of the elective in furthering their understanding of interdisciplinary care and communication. Of the 22 participating interprofessional staff surveyed, 17 responded (response rate 77%), and data showed high satisfaction with the experience and that having students learn more about their jobs improved their own job satisfaction.

CONCLUSIONS

An immersive, hands-on experience with interprofessional colleagues showed dual benefits for both students and staff alike. Such an elective experience is scalable to other institutions nationally and should become a standard part of medical student curricula.

Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance

OBJECTIVE

Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM.

METHODS

It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017.

RESULTS

In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita's prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35-0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64-0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54-0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen's kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen's kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a "slight" rate of agreement (weighted Cohen's kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival.

CONCLUSIONS

The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.

Telemedicine as an Alternative Way to Provide Multidisciplinary Cleft Care During the COVID-19 Pandemic

The current coronavirus pandemic is changing the way healthcare professionals provide services to patients. Healthcare professionals are required to provide quality care while reducing the risk of viral transmission. This pandemic has disrupted the timely multidisciplinary team care for patients with clefts across the globe. Thus, telemedicine has been recognized and accepted by various medical and dental specialists as a viable alternative to face-to-face consultation. In addition, telemedicine incorporating a digital workflow in cleft management will further reduce the risk of viral transmission and enhance the quality of treatment being provided to these patients.

A field guide to U.S. healthcare reform: The evolution to value-based healthcare

OBJECTIVE

A consolidated state-of-the-art review of U.S. healthcare reform efforts that documents the evolution towards value-based healthcare (VBH) is lacking in peer-review literature. This field guide attempts to clarify working definitions and conceptual boundaries within the lexicon of U.S. healthcare reform efforts that predated and have common thematic perspectives within the evolving VBH reform paradigm.

DATA SOURCES

Pubmed/MEDLINE/Google search.

REVIEW METHODS

Pubmed/MEDLINE/Google search was performed during August 1, 2020-January14, 2021 for U.S. healthcare reform terms, legislative and government agency publications. Those citing relevant legislative, regulatory, philosophical and technological advancements integral to the development and function of VBH were catalogued according to the targeted stakeholders and evolving reform strategy or technology.

CONCLUSIONS

Eight healthcare reform paradigms were identified as influential precursors to VBH: Patient-Centered Care Model, Patient-Centered Medical Home, Population Health, Personalized Medicine, P4 Medicine, Precision Medicine, Managed Care, and Accountable Care. Several of these models have similar nomenclature and, confusingly, many have multiple interpretations of the terms used to describe these models. However, consistent stakeholders identified within these paradigms are key to VBH; notably the patient, the physician and the payer (the "Big 3"). Demonstrable healthcare spending reductions have been best achieved when the Big 3 stakeholder interests are aligned within healthcare reform legislation. The definition of "Value" within each reform model was found to be based upon the perspective of the targeted stakeholder. Within VBH, the perspectives of the Big 3 stakeholders form a multidimensional meaning of "Value" that can be represented by the equation Value = Patient Experience Management 3 .

A roadmap of six different pathways to improve survival in laryngeal cancer patients

PURPOSE OF REVIEW

Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view.

RECENT FINDINGS

This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies.

SUMMARY

Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results.

An online tumor board with international neurosurgical collaboration guides surgical decision-making in Western Kenya

Telecollaboration via web-based platforms has emerged as a tool to relieve constraints on the establishment of tumor boards for neurosurgical oncology. Challenging tumor cases arising in low- and middle-income countries may benefit from the use of such models. The case of a 5-year-old boy presenting in Western Kenya with a challenging tumor and symptomatic hydrocephalus was presented on a novel web platform to a multi-national audience of neurosurgeons. The treating neurosurgeon invited a physician network to review the case vignette and radiographic images. Respondents independently offered input during a prescribed response period. Three respondents provided surgical opinions during a 24-h response period. The treating neurosurgeon utilized the pooled input to determine a course of action for the patient. When a web-based platform is available, lone neurosurgeons in low-resource settings may nevertheless apply multi-national, multi-institutional perspectives to challenging oncology cases.

Clinical and surgical management of patients with head and neck cancer in a COVID-19 dedicated center in Italy

Introduction

For the EARs NOSE AND THROAT (ENT) surgeon, there are many challenges that show‐up in the clinical management of a patient affected by a head and neck cancer during COVID‐19 pandemic, especially in the postoperative period.

Methods

During the acute COVID‐19 emergency phase in Italy, we analyzed the management of a patient affected by a head and neck cancer. We reported several clinical data about the hospitalization period, pointing out the difficulties encountered both from clinical and management point of view.

Results

During pandemic, we admitted 27 oncological patients at our ENT Department. Delays in surgical procedures, complications of hospitalizations, need for radiological studies, and possible transfer to other hospital ward, due to suspect SARS‐CoV‐2 infection, were registered.

Conclusions

The changes in the whole health care system during the COVID‐19 pandemic have impacted the management of patients with head and neck cancer, generating several clinical challenges for the ENT surgeon.

Transition to a virtual multidisciplinary tumor board during the COVID-19 pandemic: University of Pittsburgh experience

Multidisciplinary conferences (MDC) are an important component of head and neck oncologic care including diagnosis, treatment, and survivorship. Virtual MDC allows for improved collaboration between providers at distant sites and proper allocation of health care resources in a time of crisis. When approached systematically, a virtual MDC is feasible to design and implement in a large academic medical center with multiple satellite hospitals.

“Exposed and Vulnerable”: Parent Reports of Their Child’s Experience of Multidisciplinary Craniofacial Consultations

Objective:

Childhood is a period of extensive socioemotional development, which can be impacted by the presence of a congenital craniofacial anomaly (CFA). Complex multidisciplinary treatment and long-term follow-up are normally required, yet understanding of children’s treatment experiences is limited. The objective of this study was to investigate children’s experiences of multidisciplinary team (MDT) consultations from the perspective of their parents.

Design:

Thirty-eight parents of children with a rare CFA were interviewed in person or over the telephone. Interviews were transcribed verbatim, translated into English, and explored using thematic analysis.

Results:

Background factors influencing the child’s experience of the consultation included age, developmental stage, personality, and prior treatment experiences. Participants tried to prepare their child for meeting the MDT, but did not fully understand what to expect themselves. During consultations, participants were acutely focused on their child’s emotional state, making it difficult to balance their desire to protect the child from potentially negative experiences, and the need to engage in a constructive dialogue with health professionals. Participants believed that health professionals’ conduct could considerably influence the child’s well-being and subsequent treatment decisions. Finally, participants highlighted the need to debrief their child to help them adjust positively.

Conclusions:

The ultimate goal of craniofacial care is to help children develop into confident adults who are able to cope with the challenges associated with their condition. Multidisciplinary teams play a vital role in creating a safe and supportive environment in which children feel genuinely informed and involved in key aspects of their care.

The impact of the multidisciplinary tumor board on head and neck cancer outcomes

OBJECTIVES/HYPOTHESIS

Although the multidisciplinary tumor board (MTB) is accepted as best practice for the management of head and neck squamous cell carcinoma (HNSCC), there is limited evidence showing its impact on survival. Our goal was to investigate the impact of an MTB following the hiring of a fellowship-trained head and neck surgeon and implementation of an MTB at our institution. We hypothesized that these changes would demonstrate an improvement in survival.

STUDY DESIGN

Retrospective chart review.

METHODS

A review of HNSCC treated at our institution between October 2006 and May 2015 was performed. The cohort was divided into pre-MTB (October 2006-February 2011) and post-MTB (February 2011-May 2015) cohorts. Patient demographics, cancer stage, and treatment outcomes were reviewed. Univariate, multivariate, and survival analysis were performed.

RESULTS

The study included 224 patients, 98 in the pre-MTB cohort and 126 in the post-MTB cohort. Of total patients, 139 (62%) were black and 91 (40%) were on Medicaid or uninsured. Average follow-up time was 2.8 years, and most cases were advanced stage (68%). On Kaplan-Meier evaluation, overall survival and disease-specific survival were significantly improved in the post-MTB cohort compared with the pre-MTB cohort, with a 5-year disease-specific survival of 52% vs. 75% (P = .003). A matched cohort analysis showed that the post-MTB cohort had significantly lower risk of death (hazard ratio: 0.48).

CONCLUSIONS

Our study demonstrates that treatment of HNSCC by a dedicated multidisciplinary team results in improved survival. Multidisciplinary care should be considered best practice in the care of HNSCC.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:946-950, 2020.

“All Eyes on Me”: A Qualitative Study of Parent and Patient Experiences of Multidisciplinary Care in Craniofacial Conditions

Objective:

The present study investigated how adults with congenital craniofacial anomalies (CFAs) and parents experience the long-term and complex treatment offered by a multidisciplinary team (MDT).

Design:

Exploratory-descriptive qualitative study based on individual semistructured interviews.

Setting:

Centralized national follow-up and treatment of CFAs by a multidisciplinary craniofacial team from which participants were systematically recruited.

Participants:

The sample included 48 parents of children with CFAs and 16 adults with CFAs (N = 64).

Results:

In general, participants reported to be satisfied with the follow-up and treatment they received from the MDT. Still, some aspects of treatment were experienced as demanding such as the large number of health professionals present during the consultation and being the object of their scrutinizing attention. Health professionals’ communication skills were described as central for participants’ involvement in, and satisfaction with, treatment. Participants also expressed a need for more treatment-related information regarding future treatment.

Conclusions:

Findings could have implications for the organization of care for parents and patients with rare CFAs. The many advantages of MDTs also create unique challenges for patients and parents that need to be addressed. Patients and families should be prepared for the first consultation with the MDT. Health professionals should be aware of their communication style when interacting with patients and be aware of individual differences and needs regarding treatment-related experiences and expectations.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

The Role of Maxillofacial Prosthetics for the Surgically Treated Patient at National Cancer Institute-Designated Comprehensive Cancer Centers

OBJECTIVES/HYPOTHESIS

The current role of maxillofacial prosthetic care for head and neck cancer patients is not well understood. Additionally, perceived barriers for service provision are unknown. The purpose of this study was to evaluate the current role of maxillofacial prosthetic care at National Cancer Institute (NCI)-designated comprehensive cancer centers and to identify perceived barriers to care.

STUDY DESIGN

Multicenter, cross-sectional survey of head and neck division leaders at NCI-designated comprehensive cancer centers.

METHODS

Each head and neck division leader from the 47 NCI-designated comprehensive cancer centers was invited to participate. The main outcomes of this study were: 1) to evaluate the current role of maxillofacial prosthetics for the surgically treated head and neck cancer patient within NCI-designated comprehensive cancer centers and 2) to identify perceived barriers to care. Measured outcomes were obtained from an anonymous online survey and reported.

RESULTS

Twenty-eight of the 47 head and neck service chiefs responded (60% response rate). Respondents expressed preference for prosthetic rehabilitation for hard palate/upper gum, auricular, and nasal defects. Local flap or free tissue transfer was preferred for lower gum and soft palate defects. Cost-related factors were among the most reported perceived barriers to maxillofacial prosthetic care.

CONCLUSIONS

Maxillofacial prosthetics have an important role in the rehabilitation of the head and neck cancer patient. Perceived barriers for services exist, particularly as it relates to cost. Providers should be aware that these issues are likely to be more severe in regional or community centers.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:409-414, 2019.

Multidisciplinary Team Planning for Patients with Head and Neck Cancer

The multidisciplinary team planning conference is critical in the evaluation and management of patients with head and neck cancer. The management is complex and dictates the care of a multidisciplinary team for optimal results. First, the head and neck multidisciplinary team ensures the complete evaluation of patients before beginning treatment. Second, the team improves the accuracy of diagnosis and staging on which to base the most appropriate treatment. Third, the team improves the outcomes of treatment by appealing to the best available evidence, by following clinical practice guidelines and treatment algorithms, and by engaging in clinical research trials.