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Hoier D, Groß-Ophoff-Müller C, Franklin C, Hallek M, von Stebut E, Elter T, Mauch C, Kreuzberg N, Koll P. Digital decision support for structural improvement of melanoma tumor boards: using standard cases to optimize workflow. J Cancer Res Clin Oncol 2024; 150:115. [PMID: 38457085 PMCID: PMC10923955 DOI: 10.1007/s00432-024-05627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE Choosing optimal cancer treatment is challenging, and certified cancer centers must present all patients in multidisciplinary tumor boards (MDT). Our aim was to develop a decision support system (DSS) to provide treatment recommendations for apparently simple cases already at conference registration and to classify these as "standard cases". According to certification requirements, discussion of standard cases is optional and would thus allow more time for complex cases. METHODS We created a smartphone query that simulated a tumor conference registration and requested all information needed to provide a recommendation. In total, 111 out of 705 malignant melanoma cases discussed at a skin cancer center from 2017 to 2020 were identified as potential standard cases, for which a digital twin recommendation was then generated by DSS. RESULTS The system provided reliable advice in all 111 cases and showed 97% concordance of MDT and DSS for therapeutic recommendations, regardless of tumor stage. Discrepancies included two cases (2%) where DSS advised discussions at MDT and one case (1%) with deviating recommendation due to advanced patient age. CONCLUSIONS Our work aimed not to replace clinical expertise but to alleviate MDT workload and enhance focus on complex cases. Overall, our DSS proved to be a suitable tool for identifying standard cases as such, providing correct treatment recommendations, and thus reducing the time burden of tumor conferences in favor for the comprehensive discussion of complex cases. The aim is to implement the DSS in routine tumor board software for further qualitative assessment of its impact on oncological care.
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Affiliation(s)
- David Hoier
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | | | - Cindy Franklin
- Department of Dermatology and Venereology, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Esther von Stebut
- Department of Dermatology and Venereology, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Thomas Elter
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Cornelia Mauch
- Department of Dermatology and Venereology, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Department of Dermatology, Venereology and Allergology, Ruhr-University Bochum, Bochum, Germany
| | - Nicole Kreuzberg
- Department of Dermatology and Venereology, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Philipp Koll
- Department of Dermatology and Venereology, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Ouattassi N, Azdad A, Debaghi H, Zarghili A, El Amine El Alami MN. "OCTOPUS": An Intelligent Tool for Assisted Multidisciplinary ORL Oncology Meetings-Preliminary Study. OTO Open 2023; 7:e64. [PMID: 37448624 PMCID: PMC10336480 DOI: 10.1002/oto2.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/20/2023] [Indexed: 07/15/2023] Open
Abstract
Current sessions of multidisciplinary team meetings (MDMs) have several limitations, including increased costs and duration, as well as limited discussion time for each case. To address these issues, we have developed a computer application called OCTOPUS, which helps manage the patients' list for MDMs. The application allows for the generation of automatic MDM decisions based on predetermined criteria filled in by the patient's doctor and algorithms that comply with the latest oncology guidelines from the National Comprehensive Cancer Network. These decisions must be validated by the MDM faculty members. In cases of nonagreement or complex cases, the application proposes a "face-to-face MDM." The internal mailing system connects all members and allows for the request of a second opinion regarding pathology or imaging results. Initial results suggest that this ergonomic tool provides more flexibility in time management and improved uniformity in selecting cases that would most benefit from face-to-face MDMs.
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Affiliation(s)
- Naouar Ouattassi
- ENT, Head and Neck Surgery Department, Anatomy Surgery and Anesthesiology LaboratoryHassan II University HospitalFezMorocco
| | - Anas Azdad
- Computer Science Department, Intelligent Systems and Applications Laboratory, Science and Technic FacultyUniversity Sidi Mohammed Ben Abdellah of FezFezMorocco
| | - Hamza Debaghi
- Computer Science Department, Intelligent Systems and Applications Laboratory, Science and Technic FacultyUniversity Sidi Mohammed Ben Abdellah of FezFezMorocco
| | - Arsalane Zarghili
- Computer Science Department, Intelligent Systems and Applications Laboratory, Science and Technic FacultyUniversity Sidi Mohammed Ben Abdellah of FezFezMorocco
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Ural Y, Elter T, Yilmaz Y, Hallek M, Datta RR, Kleinert R, Heidenreich A, Pfister D. Validation and implementation of a mobile app decision support system for prostate cancer to improve quality of tumor boards. PLOS DIGITAL HEALTH 2023; 2:e0000054. [PMID: 37285355 DOI: 10.1371/journal.pdig.0000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/27/2023] [Indexed: 06/09/2023]
Abstract
Certified Cancer Centers must present all patients in multidisciplinary tumor boards (MTB), including standard cases with well-established treatment strategies. Too many standard cases can absorb much of the available time, which can be unfavorable for the discussion of complex cases. In any case, this leads to a high quantity, but not necessarily a high quality of tumor boards. Our aim was to develop a partially algorithm-driven decision support system (DSS) for smart phones to provide evidence-based recommendations for first-line therapy of common urological cancers. To assure quality, we compared each single digital decision with recommendations of an experienced MTB and obtained the concordance.1873 prostate cancer patients presented in the MTB of the urological department of the University Hospital of Cologne from 2014 to 2018 have been evaluated. Patient characteristics included age, disease stage, Gleason Score, PSA and previous therapies. The questions addressed to MTB were again answered using DSS. All blinded pairs of answers were assessed for discrepancies by independent reviewers. Overall concordance rate was 99.1% (1856/1873). Stage specific concordance rates were 97.4% (stage I), 99.2% (stage II), 100% (stage III), and 99.2% (stage IV). Quality of concordance were independent of age and risk profile. The reliability of any DSS is the key feature before implementation in clinical routine. Although our system appears to provide this safety, we are now performing cross-validation with several clinics to further increase decision quality and avoid potential clinic bias.
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Affiliation(s)
- Yasemin Ural
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Urology, Uro-Oncology and robot assisted surgery, Germany
| | - Thomas Elter
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany
| | - Yasemin Yilmaz
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Urology, Uro-Oncology and robot assisted surgery, Germany
| | - Michael Hallek
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany
| | - Rabi Raj Datta
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of General, Visceral, Cancer and Transplantation Surgery, Germany
| | - Robert Kleinert
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of General, Visceral, Cancer and Transplantation Surgery, Germany
| | - Axel Heidenreich
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Urology, Uro-Oncology and robot assisted surgery, Germany
| | - David Pfister
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Urology, Uro-Oncology and robot assisted surgery, Germany
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Walraven JEW, Verhoeven RHA, van der Hoeven JJM, van der Meulen R, Lemmens VEPP, Hesselink G, Desar IME. Pros and cons of streamlining and use of computerised clinical decision support systems to future-proof oncological multidisciplinary team meetings. Front Oncol 2023; 13:1178165. [PMID: 37274246 PMCID: PMC10233094 DOI: 10.3389/fonc.2023.1178165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Nowadays nearly every patient with cancer is discussed in a multidisciplinary team meeting (MDTM) to determine an optimal treatment plan. The growth in the number of patients to be discussed is unsustainable. Streamlining and use of computerised clinical decision support systems (CCDSSs) are two major ways to restructure MDTMs. Streamlining is the process of selecting the patients who need to be discussed and in which type of MDTM. Using CCDSSs, patient data is automatically loaded into the minutes and a guideline-based treatment proposal is generated. We aimed to identify the pros and cons of streamlining and CCDSSs. Methods Semi-structured interviews were conducted with Dutch MDTM participants. With purposive sampling we maximised variation in participants' characteristics. Interview data were thematically analysed. Results Thirty-five interviews were analysed. All interviewees agreed on the need to change the current MDTM workflow. Streamlining suggestions were thematised based on standard and complex cases and the location of the MDTM (i.e. local, regional or nationwide). Interviewees suggested easing the pressure on MDTMs by discussing standard cases briefly, not at all, or outside the MDTM with only two to three specialists. Complex cases should be discussed in tumour-type-specific regional MDTMs and highly complex cases by regional/nationwide expert teams. Categorizing patients as standard or complex was found to be the greatest challenge of streamlining. CCDSSs were recognised as promising, although none of the interviewees had made use of them. The assumed advantage was their capacity to generate protocolised treatment proposals based on automatically uploaded patient data, to unify treatment proposals and to facilitate research. However, they were thought to limit the freedom to deviate from the treatment advice. Conclusion To make oncological MDTMs sustainable, methods of streamlining should be developed and introduced. Physicians still have doubts about the value of CCDSSs.
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Affiliation(s)
- Janneke E. W. Walraven
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Rob H. A. Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center location University of Amsterdam, Amsterdam, Netherlands
| | | | - Renske van der Meulen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Valery E. P. P. Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Gijs Hesselink
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ingrid M. E. Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
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Soukup T, Winters D, Chua K, Rowland P, Moneke J, Skolarus TA, Bharathan R, Harling L, Bali A, Asher V, Gandamihardja T, Sevdalis N, Green JSA, Lamb BW. Evaluation of changes to work patterns in multidisciplinary cancer team meetings due to the COVID-19 pandemic: A national mixed-method survey study. Cancer Med 2023; 12:8729-8741. [PMID: 36647755 PMCID: PMC10134365 DOI: 10.1002/cam4.5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND It is not well understood the overall changes that multidisciplinary teams (MDTs) have had to make in response to the COVID-19 pandemic, nor the impact that such changes, in addition to the other challenges faced by MDTs, have had on decision-making, communication, or participation in the context of MDT meetings specifically. METHODS This was a mixed method, prospective cross-sectional survey study taking place in the United Kingdom between September 2020 and August 2021. RESULTS The participants were 423 MDT members. Qualitative findings revealed hybrid working and possibility of virtual attendance as the change introduced because of COVID-19 that MDTs would like to maintain. However, IT-related issues, slower meetings, longer lists and delays were identified as common with improving of the IT infrastructure necessary going forward. In contrast, virtual meetings and increased attendance/availability of clinicians were highlighted as the positive outcomes resulting from the change. Quantitative findings showed significant improvement from before COVID-19 for MDT meeting organisation and logistics (M = 45, SD = 20) compared to the access (M = 50, SD = 12, t(390) = 5.028, p = 0.001), case discussions (M = 50, SD = 14, t(373) = -5.104, p = 0.001), and patient representation (M = 50, SD = 12, t(382) = -4.537, p = 0.001) at MDT meetings. DISCUSSION Our study explored the perception of change since COVID-19 among cancer MDTs using mixed methods. While hybrid working was preferred, challenges exist. Significant improvements in the meeting organisation and logistics were reported. Although we found no significant perceived worsening across the four domains investigated, there was an indication in this direction for the case discussions warranting further 'live' assessments of MDT meetings.
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Affiliation(s)
- Tayana Soukup
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | | | - Kia‐Chong Chua
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | - Philip Rowland
- Department of UrologyCambridge University Hospital NHS TrustLondonUK
| | - Jacqueline Moneke
- Department of UrologyCambridge University Hospital NHS TrustLondonUK
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of UrologyUniversity of Michigan, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | | | - Leanne Harling
- Department of Surgery and CancerImperial College LondonLondonUK
- School of Cancer and Pharmaceutical ScienceKings College LondonLondonUK
| | - Anish Bali
- Gynaecology Cancer CentreUniversity Hospitals of Derby & BurtonDerbyUK
| | - Viren Asher
- Gynaecology Cancer CentreUniversity Hospitals of Derby & BurtonDerbyUK
| | | | - Nick Sevdalis
- Institute of Psychiatry, Psychology, and Neuroscience, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | | | - Benjamin W. Lamb
- Department of UrologyBarts Health NHS TrustLondonUK
- Bart’s Cancer InstituteQueen Mary University of LondonLondonUK
- Department of UrologyUniversity London College HospitalsLondonUK
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Walraven JEW, Verhoeven RHA, van der Meulen R, van der Hoeven JJM, Lemmens VEPP, Hesselink G, Desar IME. Facilitators and barriers to conducting an efficient, competent and high-quality oncological multidisciplinary team meeting. BMJ Open Qual 2023; 12:bmjoq-2022-002130. [PMID: 36759037 PMCID: PMC9923284 DOI: 10.1136/bmjoq-2022-002130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Optimal oncological care nowadays requires discussing every patient in a multidisciplinary team meeting (MDTM). The number of patients to be discussed is rising rapidly due to the increasing incidence and prevalence of cancer and the emergence of new multidisciplinary treatment options. This puts MDTMs under considerable time pressure. The aim of this study is therefore to identify the facilitators and barriers with regard to performing an efficient, competent and high-quality MDTM. METHODS Semistructured interviews were conducted with Dutch medical specialists and residents participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' professional and demographic characteristics (eg, sex, medical specialist vs resident, specialty, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis. RESULTS Sixteen medical specialists and 19 residents were interviewed. All interviewees agreed that attending and preparing MDTMs is time-consuming and indicated the need for optimal execution in order to ensure that MDTMs remain feasible in the near future. Four themes emerged that are relevant to achieving an optimal MDTM: (1) organisational aspects; (2) participants' responsibilities and requirements; (3) competences, behaviour and team dynamics and (4) meeting content. Good organisation, a sound structure and functioning information and communication technology facilitate high-quality MDTMs. Multidisciplinary collaboration and adequate communication are essential competences for participants; a lack thereof and the existence of a hierarchy are hindering factors. CONCLUSION Conducting an efficient, competent and high-quality oncological MDTM is facilitated and hindered by many factors. Being aware of these factors provides opportunities for optimising MDTMs, which are under pressure due to the increase in the number of patients to discuss.
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Affiliation(s)
- Janneke E W Walraven
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands .,Department of Research & Development, IKNL, Utrecht, The Netherlands
| | - Rob H A Verhoeven
- Department of Research & Development, IKNL, Utrecht, The Netherlands,Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - Gijs Hesselink
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands,Department of IQ healthcare, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboudumc, Nijmegen, The Netherlands
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Soukup T, Lamb BW, Green JSA, Sevdalis N, Murtagh G. Analysis of communication styles underpinning clinical decision-making in cancer multidisciplinary team meetings. Front Psychol 2023; 14:1105235. [PMID: 37205076 PMCID: PMC10185756 DOI: 10.3389/fpsyg.2023.1105235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/13/2023] [Indexed: 05/21/2023] Open
Abstract
Introduction In cancer care, multidisciplinary team (MDT) meetings are the gold standard. While they are trying to maximize productivity on the back of the steadily increasing workload, growing cancer incidence, financial constraints, and staff shortages, concerns have been raised with regards to the quality of team output, as reported by Cancer Research UK in 2017: "Sometimes we discuss up to 70 patients. This is after a whole day of clinics, and we do not finish until after 19.00. Would you want to be number 70?". This study aimed to explore systematically some of the dynamics of group interaction and teamwork in MDT meetings. Materials and methods This was a prospective observational study conducted across three MDTs/university hospitals in the United Kingdom. We video-recorded 30 weekly meetings where 822 patient cases were reviewed. A cross-section of the recordings was transcribed using the Jefferson notation system and analyzed using frequency counts (quantitative) and some principles of conversation analysis (qualitative). Results We found that, across teams, surgeons were the most frequent initiators and responders of interactional sequences, speaking on average 47% of the time during case discussions. Cancer nurse specialists and coordinators were the least frequent initiators, with the former speaking 4% of the time and the latter speaking 1% of the time. We also found that the meetings had high levels of interactivity, with an initiator-responder ratio of 1:1.63, meaning that for every sequence of interactions initiated, the initiator received more than a single response. Lastly, we found that verbal dysfluencies (laughter, interruptions, and incomplete sentences) were more common in the second half of meetings, where a 45% increase in their frequency was observed. Discussion Our findings highlight the importance of teamwork in planning MDT meetings, particularly with regard to Cancer Research UK in 2017 cognitive load/fatigue and decision-making, the hierarchy of clinical expertise, and the increased integration of patients' psychosocial information into MDT discussion and their perspectives. Utilizing a micro-level methodology, we highlight identifiable patterns of interaction among participants in MDT meetings and how these can be used to inform the optimization of teamwork.
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Affiliation(s)
- Tayana Soukup
- Health Service and Population Research Department, Centre for Implementation Science, King's College London, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Epidemiology and Environmental Health, University of Buffalo, Buffalo, NY, United States
- School of Health and Sport Sciences, University of Suffolk, Suffolk, United Kingdom
- *Correspondence: Tayana Soukup
| | - Benjamin W. Lamb
- Whipps Cross University Hospital, Barts Health NHS Trust, London, United Kingdom
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - James S. A. Green
- Whipps Cross University Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Nick Sevdalis
- Health Service and Population Research Department, Centre for Implementation Science, King's College London, London, United Kingdom
| | - Ged Murtagh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Soukup T, Lamb BW, Morbi A, Shah NJ, Bali A, Asher V, Gandamihardja T, Giordano P, Darzi A, Sevdalis N, Green JSA. Cancer multidisciplinary team meetings: impact of logistical challenges on communication and decision-making. BJS Open 2022; 6:6677491. [PMID: 36029030 PMCID: PMC9418925 DOI: 10.1093/bjsopen/zrac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Multidisciplinary teams (MDTs) are widely used in cancer care. Recent research points to logistical challenges impeding MDT decision-making and dissatisfaction among members. This study sought to identify different types of logistical issues and how they impacted team processes. Methods This was a secondary analysis of a cross-sectional observational study. Three cancer MDTs (breast, colorectal, and gynaecological) were recruited from UK hospitals. Validated observational instruments were used to measure decision-making (Metrics of Observational Decision-making, MDT-MODe), communication (Bales' Interaction Process Analysis, Bales' IPA), and case complexity (Measure of Case Discussion Complexity, MeDiC), including logistical challenges (Measure of Case Discussion Complexity, MeDiC), across 822 case discussions from 30 videoed meetings. Descriptive analysis and paired samples t tests were used to identify and compare frequency of different types of logistical challenges, along with partial correlations, controlling for clinical complexity of cases, to understand how such issues related to the MDT decision-making and communication. Results A significantly higher frequency of administrative and process issues (affecting 30 per cent of cases) was seen compared with the frequency of equipment issues (affecting 5 per cent of cases; P < 0.001) and the frequency of the attendance issues (affecting 16 per cent of cases; P < 0.001). The frequency of the attendance issues was significantly higher than the frequency of equipment issues (P < 0.001). Partial correlation analysis revealed that administrative and process issues, including attendance, were negatively correlated with quality of information (r = −0.15, P < 0.001; r = −0.11, P < 0.001), and equipment issues with the quality of contribution to meeting discussion (r = −0.14, P < 0.001). More questioning and answering by MDT members was evident with the administrative and process issues (r = 0.21, P < 0.001; r = 0.19, P < 0.001). Some differences were observed in teams' socioemotional reactions to the administrative and process issues with the gynaecological MDT showing positive correlation with positive socioemotional reactions (r = 0.20, P < 0.001), and the breast cancer MDT with negative socioemotional reactions (r = 0.17, P < 0.001). Conclusion Administrative and process issues were the most frequent logistical challenges for the studied teams. Where diagnostic results were unavailable, and inadequate patient details provided, the quality of decision-making was reduced.
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Affiliation(s)
- Tayana Soukup
- Centre for Implementation Science, Health Service & Population Research Department, King's College London , London , UK
| | - Benjamin W Lamb
- Department of Urology, Cambridge University Hospital NHS Trust , London , UK
| | - Abigail Morbi
- Department of Surgery and Cancer, Imperial College London , London , UK
| | - Nisha J Shah
- HeLEX Centre, University of Oxford , Oxford , UK
| | | | | | | | - Pasquale Giordano
- Whipps Cross University Hospital, Barts Health NHS Trust , London , UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London , London , UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service & Population Research Department, King's College London , London , UK
| | - James S A Green
- Whipps Cross University Hospital, Barts Health NHS Trust , London , UK
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Nobori A, Jumniensuk C, Chen X, Enzmann D, Dry S, Nelson S, Arnold CW. Electronic Health Record-Integrated Tumor Board Application to Save Preparation Time and Reduce Errors. JCO Clin Cancer Inform 2022; 6:e2100142. [PMID: 35025671 DOI: 10.1200/cci.21.00142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Multidisciplinary oncology meetings, or tumor boards (TBs), ensure and facilitate communication between specialties regarding the management of cancer cases to improve patient care. The organization of TB and the preparation and presentation of patient cases are typically inefficient processes that require the exchange of patient information via e-mail, the hunting for data and images in the electronic health record, and the copying and pasting of patient data into desktop presentation software. METHODS We implemented a standards-based electronic health record-integrated application that automated several aspects of TB organization and preparation. We hypothesized that this application would increase the efficiency of TB preparation, reduce errors in patient entry, and enhance communication with the clinical team. Our experimental design used a prospective evaluation by pathologists who were timed in preparing for weekly TBs using both the new application and the conventional method. In addition, patient data entry errors associated with each method were tracked, and TB attendees completed a survey evaluating satisfaction with the new application. RESULTS The total time savings for TB preparation using the digital TB application over the conventional method was 5 hours and 19 minutes, representing a 45% reduction in preparation time (P < .01). Survey results showed that 91% of respondents preferred the digital method and believed that it improved the flow of the TB meeting. In addition, most believed that the digital method had an impact on subsequent patient care. CONCLUSION This study provides further evidence that new electronic systems have the potential to significantly improve the overall TB paradigm by optimizing and enhancing case organization, preparation, and presentation.
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Affiliation(s)
- Alex Nobori
- Department of Pathology & Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Chayanit Jumniensuk
- Department of Pathology, Phramongkutklao Hospital and College of Medicine, Army Institute of Pathology, Bangkok, Thailand
| | - Xiang Chen
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, CA
| | - Dieter Enzmann
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Dry
- Department of Pathology & Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Scott Nelson
- Department of Pathology & Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Corey W Arnold
- Departments of Radiological Sciences, Pathology & Laboratory Medicine, Bioengineering, and Electrical & Computer Engineering, University of California, Los Angeles, Los Angeles, CA
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Fradgley EA, Booth K, Paul C, Zdenkowski N, Rankin NM. Facilitating High Quality Cancer Care: A Qualitative Study of Australian Chairpersons' Perspectives on Multidisciplinary Team Meetings. J Multidiscip Healthc 2021; 14:3429-3439. [PMID: 34938082 PMCID: PMC8687680 DOI: 10.2147/jmdh.s332972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
Aim Multidisciplinary team meetings (MDMs) are a critical element of quality care for people diagnosed with cancer. The MDM Chairperson plays a significant role in facilitating these meetings, which are often time-poor environments for clinical decision making. This study examines the perceptions of MDM Chairpersons including their role and the factors that determine the quality of a Chair, as well as the Chairperson's perception of the value of personally attending meetings. Methods This qualitative study used telephone interviews to explore the experiences of MDM Chairpersons from metropolitan and regional New South Wales, Australia. Using a state-wide register, 43 clinicians who chaired lung, genitourinary, gastrointestinal, and breast cancer meetings were approached to participate. Thematic data analysis was used to develop and organise themes. Results Themes from the 16 interviews identified the perceived need for an expert and efficient MDM Chairperson with emphasis on personal rather than technical skills. The remaining themes related to the benefits of meetings to ensure quality and consistency of care; improve inter-professional relationships; and provide communication with and reassurance for patients. Conclusion The role of the MDM Chairperson requires expert management and leadership skills to ensure meetings support quality patient-centred care. MDMs are perceived to provide multiple benefits to both clinicians and patients. Efforts to train Chairs and to maximise clinician and patient benefits may be warranted given the costly and time-consuming nature of MDMs.
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Affiliation(s)
- Elizabeth A Fradgley
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, New South Wales, Australia
| | - Kate Booth
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nicholas Zdenkowski
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Nicole M Rankin
- Faculty of Medicine and Health Sciences, University of Sydney, Camperdown, New South Wales, Australia
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11
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Combination Therapies with PRRT. Pharmaceuticals (Basel) 2021; 14:ph14101005. [PMID: 34681229 PMCID: PMC8538931 DOI: 10.3390/ph14101005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
Peptide receptor radionuclide therapy (PRRT) is a successful targeted radionuclide therapy in neuroendocrine tumors (NETs). However, complete responses remain elusive. Combined treatments anticipate synergistic effects and thus better responses by combining ionizing radiation with other anti-tumor treatments. Furthermore, multimodal therapies often have a balanced toxicity profile. To date, few studies have evaluated the effect of combination therapies with PRRT, some of them phase I/II trials. This review will focus on several clinically tested, tailored approaches to improving the effects of PRRT. The aim is to help clinicians in the treatment planning of NETs to choose the most effective and safe treatment for each patient in the sense of personalized medicine. Current promising combination partners of PRRT are somatostatin analogues (SSAs), chemotherapy, molecular targeted treatment, liver radioembolization, and dual radionuclide PRRT (Lutetium-177-PRRT combined with Yttrium-90-PRRT).
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12
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Winters DA, Soukup T, Sevdalis N, Green JSA, Lamb BW. The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives. BJU Int 2021; 128:271-279. [PMID: 34028162 DOI: 10.1111/bju.15495] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Two decades since their inception, multidisciplinary teams (MDTs) are widely regarded as the 'gold standard' of cancer care delivery. Benefits of MDT working include improved patient outcomes, adherence to guidelines, and even economic benefits. Benefits to MDT members have also been demonstrated. An increasing body of evidence supports the use of MDTs and provides guidance on best practise. The system of MDTs in cancer care has come under increasing pressure of late, due to the increasing incidence of cancer, the popularity of MDT working, and financial pressures. This pressure has resulted in recommendations by national bodies to implement streamlining to reduce workload and improve efficiency. In the present review we examine the historical evidence for MDT working, and the scientific developments that dictate best practise. We also explore how streamlining can be safely and effectively undertaken. Finally, we discuss the future of MDT working including the integration of artificial intelligence and decision support systems and propose a new model for improving patient centredness.
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Affiliation(s)
- David A Winters
- Department of Urology, Barts Health NHS Trust, Whipps Cross University Hospital, London, UK
| | - Tayana Soukup
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - Nick Sevdalis
- Department of Urology, Barts Health NHS Trust, Whipps Cross University Hospital, London, UK.,Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - James S A Green
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | - Benjamin W Lamb
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Faculty of Health, Education, Medicine and Social Care, School of Allied Health, Anglia Ruskin University, Cambridge, UK
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13
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Thery L, Vaflard P, Vuagnat P, Soulie O, Dolbeault S, Burnod A, Laouisset C, Marchal T, Massiani MA, Bozec L, Bidard FC, Cottu P, Angellier E, Bouleuc C. Advanced cancer and COVID-19 comorbidity: medical oncology-palliative medicine ethics meetings in a comprehensive cancer centre. BMJ Support Palliat Care 2021:bmjspcare-2021-002946. [PMID: 33927013 PMCID: PMC8098300 DOI: 10.1136/bmjspcare-2021-002946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES In managing patients with cancer in the COVID-19 era, clinical oncologists and palliative care practitioners had to face new, disrupting and complex medical situations, challenging the quality of the shared decision-making process. During the first lockdown in France, we developed an onco-palliative ethics meeting to enhance the quality of the decision-making process for patients with advanced cancer treated for COVID-19. METHODS A least one of the institutional ethics committee members was present along with oncologists, palliative care teams, psycho-oncologists, radiologists and intensive care specialists. Specific medical parameters were systematically collected to form a standardised framework for the discussions. RESULTS The main raised issues were the definition of new criteria for the implementation of invasive resuscitation techniques, optimal ways to adapt or delay anticancer treatment and best procedures to address terminal respiratory failure and end-of-life care. The main clinical and ethical guidelines that emerged during these debates are presented. The palliative care team played a major role in assessing and reporting patients' awareness of cancer-related prognosis and their wishes concerning invasive therapies or transfer to intensive care units, enabling an individualised benefit-risk balance assessment. The ethics committee members ensured continuous monitoring during the discussions. Their function was to recall the main ethical principles including dignity, which is conferred on people when there are treated as having equal status. CONCLUSIONS The onco-palliative ethics meeting provided a powerful avenue for improvement of collegiality and reinforcement of teamwork, which could be a major protection against burnout for healthcare professionals facing an epidemic onslaught.
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Affiliation(s)
- Laura Thery
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- PSL University, Paris, France
| | - Pauline Vaflard
- PSL University, Paris, France
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
| | - Perrine Vuagnat
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
- Paris-Saclay University, Saint-Aubin, France
| | - Ophélie Soulie
- PSL University, Paris, France
- Psycho-Oncology Unit, Institut Curie, Paris, France
| | - Sylvie Dolbeault
- PSL University, Paris, France
- Psycho-Oncology Unit, Institut Curie, Paris, France
| | - Alexis Burnod
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- PSL University, Paris, France
| | - Céline Laouisset
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- PSL University, Paris, France
| | - Timothée Marchal
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- PSL University, Paris, France
| | - Marie-Ange Massiani
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
- Paris-Saclay University, Saint-Aubin, France
| | - Laurence Bozec
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
- Paris-Saclay University, Saint-Aubin, France
| | - François-Clément Bidard
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
- Paris-Saclay University, Saint-Aubin, France
| | - Paul Cottu
- PSL University, Paris, France
- Department of Medical Oncology, Institut Curie, Paris et Saint-Cloud, France
| | - Elisabeth Angellier
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- Paris-Saclay University, Saint-Aubin, France
| | - Carole Bouleuc
- Department of Supportive and Palliative Care, Institut Curie, Paris et Saint-Cloud, France
- PSL University, Paris, France
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14
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Soukup T, Lamb BW, Morbi A, Shah NJ, Bali A, Asher V, Gandamihardja T, Giordano P, Darzi A, SA Green J, Sevdalis N. A multicentre cross-sectional observational study of cancer multidisciplinary teams: Analysis of team decision making. Cancer Med 2020; 9:7083-7099. [PMID: 32794351 PMCID: PMC7541152 DOI: 10.1002/cam4.3366] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Multidisciplinary teams (MDT) formulate expert informed treatment recommendations for people with cancer. We set out to examine how the factors proposed by the functional perspective of group decision making (DM), that is, interaction process, internal factors (factors emanating from within the group such as group size), external circumstances (factors coming from the outside of the team), and case-complexity affect the quality of MDT decision making. METHODS This was a cross-sectional observational study. Three cancer MDTs were recruited with 44 members overall and 30 of their weekly meetings filmed. Validated observational instruments were used to measure quality of DM, interactions, and complexity of 822 case discussions. RESULTS The full regression model with the variables proposed by the functional perspective was significant, R2 = 0.52, F(20, 801) = 43.47, P < .001, adjusted R2 = 0.51. Positive predictors of DM quality were asking questions (P = .001), providing answers (P = .001), team size (P = .007), gender balance (P = .003), and clinical complexity (P = .001), while negative socioemotional reactions (P = .007), gender imbalance (P = .003), logistical issues (P = .001), time-workload pressures (P = .002), and time spent in the meeting (P = .001) were negative predictors. Second half of the meetings also saw significant decrease in the DM quality (P = .001), interactions (P = .001), group size (P = .003), and clinical complexity (P = .001), and an increase in negative socioemotional reactions (P = .001) and time-workload pressures (P = .001). DISCUSSION To the best of our knowledge, this is the first study to attempt to assess the factors proposed by the functional perspective in cancer MDTs. One novel finding is the effect of sociocognitive factors on team DM quality, while another is the cognitive-catch 22 effect: while the case discussions are significantly simpler in the second half of the meeting, there is significantly less time left to discuss the remaining cases, further adding to the cognitive taxation in teams who are now rapidly attempting to close their time-workload gap. Implications are discussed in relation to quality and safety.
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Affiliation(s)
- Tayana Soukup
- Centre for Implementation ScienceKing’s College LondonUK
| | | | - Abigail Morbi
- Department of Surgery and CancerImperial College LondonLondonUK
| | | | | | | | | | | | - Ara Darzi
- Department of Surgery and CancerImperial College LondonLondonUK
| | - James SA Green
- Whipps Cross University HospitalBarts Health NHS TrustLondonUK
| | - Nick Sevdalis
- Centre for Implementation ScienceKing’s College LondonUK
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15
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Pluyter JR, Jacobs I, Langereis S, Cobben D, Williams S, Curfs J, van den Borne B. Looking through the eyes of the multidisciplinary team: the design and clinical evaluation of a decision support system for lung cancer care. Transl Lung Cancer Res 2020; 9:1422-1432. [PMID: 32953514 PMCID: PMC7481580 DOI: 10.21037/tlcr-19-441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Decision-making in lung cancer is complex due to a rapidly increasing amount of diagnostic data and treatment options. The need for timely and accurate diagnosis and delivery of care demands high-quality multidisciplinary team (MDT) collaboration and coordination. Clinical decision support systems (CDSSs) can potentially support MDTs in constructing a shared mental model of a patient case. This enables the team to assess the strength and completeness of collected diagnostic data, stratification for the right personalized therapy driven by clinical stage and other treatment-influencing factors, and adapt care management strategies when needed. Current CDSSs often have a suboptimal fit into the decision-making workflow, which hampers their impact in clinical practice. Methods A CDSS for multidisciplinary decision-making in lung cancer was designed to support the abovementioned goals through presentation of relevant clinical data in line with existing mental model structures of the MDT members. The CDSS was tested in a simulated multidisciplinary tumor board meeting for primary diagnosis and treatment selection, based on de-identified primary lung cancer cases (n=8). Decision course analysis, eye-tracking data and questionnaires were used to assess the impact of the CDSS on constructing shared mental models to improve the decision-making process and outcome. Results The CDSS supported the team in their self-correcting capacity for accurate diagnosis and TNM classification. It enabled cross-validation of diagnostic findings, surfaced discordance between diagnostic tests and facilitated cancer staging according the diagnostic evidence, as well as spotting contra-indications for personalized treatment selection. Conclusions This study shows the potential of CDSS on clinical decision making, when these systems are properly designed in line with clinical thinking. The presented setup enables assessment of the impact of CDSS design on clinical decision making and optimization of CDSSs to maximize their effect on decision quality and confidence.
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Affiliation(s)
- Jon R Pluyter
- Philips Experience Design, High Tech Campus 33, Eindhoven, The Netherlands
| | - Igor Jacobs
- Department of Oncology Solutions, Philips Research Europe, High Tech Campus 34, Eindhoven, The Netherlands
| | - Sander Langereis
- Department of Oncology Solutions, Philips Research Europe, High Tech Campus 34, Eindhoven, The Netherlands
| | - David Cobben
- Department of Radiotherapy Related Research, University of Manchester-The Christie National Health Trust, Manchester, UK
| | - Sharon Williams
- Philips Experience Design, High Tech Campus 33, Eindhoven, The Netherlands
| | - Jeannine Curfs
- Department of Pulmonary Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ben van den Borne
- Department of Pulmonary Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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16
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Soukup T, Morbi A, Lamb BW, Gandamihardja TA, Hogben K, Noyes K, Skolarus TA, Darzi A, Sevdalis N, Green JS. A measure of case complexity for streamlining workflow in multidisciplinary tumor boards: Mixed methods development and early validation of the MeDiC tool. Cancer Med 2020; 9:5143-5154. [PMID: 32476281 PMCID: PMC7367630 DOI: 10.1002/cam4.3026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is increasing emphasis in cancer care globally for care to be reviewed and managed by multidisciplinary teams (ie, in tumor boards). Evidence and recommendations suggest that the complexity of each patient case needs to be considered as care is planned; however, no tool currently exists for cancer teams to do so. We report the development and early validation of such a tool. METHODS We used a mixed-methods approach involving psychometric evaluation and expert review to develop the Measure of case-Discussion Complexity (MeDiC) between May 2014 and November 2016. The study ran in six phases and included ethnographic interviews, observations, surveys, feasibility and reliability testing, expert consensus, and multiple expert-team reviews. RESULTS Phase-1: case complexity factors identified through literature review and expert interviews; Phase-2: 51 factors subjected to iterative review and content validation by nine cancer teams across four England Trusts with nine further items identified; Phase 3: 60 items subjected to expert review distilled to the most relevant; Phase 4: item weighing and further content validation through a national UK survey; Phases 5 and 6: excellent interassessor reliability between clinical and nonclinical observers, and adequate validity on 903 video case discussions achieved. A final set of 27 factors, measuring clinical and logistical complexities were integrated into MeDiC. CONCLUSIONS MeDiC is an evidence-based and expert-driven tool that gauges the complexity of cancer cases. MeDiC may be used as a clinical quality assurance and screening tool for tumor board consideration through case selection and prioritization.
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Affiliation(s)
- Tayana Soukup
- Centre for Implementation Science, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | - Abigail Morbi
- Department of SurgeryUniversity College London Hospitals NHS Foundation TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Benjamin W. Lamb
- Department of UrologyCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | | | - Katy Hogben
- Department of Surgery and CancerImperial College London NHS TrustLondonUK
| | - Katia Noyes
- Department of Epidemiology and Environmental HealthUniversity of BuffaloBuffaloNYUSA
| | - Ted A. Skolarus
- Dow Division of Health Services ResearchDepartment of UrologyUniversity of MichiganCenter for Clinical Management ResearchVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMIUSA
| | - Ara Darzi
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research DepartmentKing's College LondonLondonUK
| | - James S.A. Green
- Centre for Implementation Science, Health Service and Population Research DepartmentKing's College LondonLondonUK
- Whipps Cross University HospitalBarts Health NHS TrustLondonUK
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