Decision making in surgical oncology

Insights from explainable AI in oesophageal cancer team decisions

BACKGROUND

Clinician-led quality control into oncological decision-making is crucial for optimising patient care. Explainable artificial intelligence (XAI) techniques provide data-driven approaches to unravel how clinical variables influence this decision-making. We applied global XAI techniques to examine the impact of key clinical decision-drivers when mapped by a machine learning (ML) model, on the likelihood of receiving different oesophageal cancer (OC) treatment modalities by the multidisciplinary team (MDT).

METHODS

Retrospective analysis of 893 OC patients managed between 2010 and 2022 at our tertiary unit, used a random forests (RF) classifier to predict four possible treatment pathways as determined by the MDT: neoadjuvant chemotherapy followed by surgery (NACT + S), neoadjuvant chemoradiotherapy followed by surgery (NACRT + S), surgery-alone, and palliative management. Variable importance and partial dependence (PD) analyses then examined the influence of targeted high-ranking clinical variables within the ML model on treatment decisions as a surrogate model of the MDT decision-making dynamic.

RESULTS

Amongst guideline-variables known to determine treatments, such as Tumour-Node-Metastasis (TNM) staging, age also proved highly important to the RF model (16.1 % of total importance) on variable importance analysis. PD subsequently revealed that predicted probabilities for all treatment modalities change significantly after 75 years (p < 0.001). Likelihood of surgery-alone and palliative therapies increased for patients aged 75-85yrs but lowered for NACT/NACRT. Performance status divided patients into two clusters which influenced all predicted outcomes in conjunction with age.

CONCLUSION

XAI techniques delineate the relationship between clinical factors and OC treatment decisions. These techniques identify advanced age as heavily influencing decisions based on our model with a greater role in patients with specific tumour characteristics. This study methodology provides the means for exploring conscious/subconscious bias and interrogating inconsistencies in team-based decision-making within the era of AI-driven decision support.

Improving the quality of patient care in lung cancer: key factors for successful multidisciplinary team working

International Guidelines as well as Cancer Associations recommend a multidisciplinary approach to lung cancer care. A multidisciplinary team (MDT) can significantly improve treatment decision-making and patient coordination by putting different physicians and other health professionals "in the same room", who collectively decide upon the best possible treatment. However, this is not a panacea for cancer treatment. The impact of multidisciplinary care (MDC) on patient outcomes is not univocal, while the effective functioning of the MDT depends on many factors. This review presents the available MDT literature with an emphasis on the key factors that characterize high-quality patient care in lung cancer. The study was conducted with a bibliographic search using different electronic databases (PubMed Central, Scopus, Google Scholar, and Google) referring to multidisciplinary cancer care settings. Many key elements appear consolidated, while others emerge as prevalent and actual, especially those related to visible barriers which work across geographic, organizational, and disciplinary boundaries. MDTs must be sustained by strategic management, structured within the entity, and cannot be managed as a separate care process. Furthermore, they need to coordinate with other teams (within and outside the organization) and join with the broad range of services delivered by multiple providers at various points of the cancer journey or within the system, with the vision of integrated care.

Interprofessional clinical decision-making process in health: A scoping review

AIMS

To describe the key elements of the interprofessional decision-making process in health, based on published scientific studies. To describe the authors, reviews and subject matter of those publications.

DESIGN

Scoping review of the literature.

DATA SOURCES

MEDLINE, APA Psycinfo OpenGrey, Lissa and Cochrane databases were searched in December 2019 and January 2023.

REVIEW METHODS

References were considered eligible if they (i) were written in French or English, (ii) concerned health, (iii) studied a clinical decision-making process, (iv) were performed in an interprofessional context. 'PRISMA-scoping review' guidelines were respected. The eligible studies were analysed and classified by an inductive approach RESULTS: We identified 1429 sources of information, 145 of which were retained for the analysis. Based on these studies, we identified five key elements of interprofessional decision-making in health. The process was found to be influenced by group dynamics, the available information and consideration of the unique characteristics of the patient. An organizational framework and specific training favoured improvements in the process.

CONCLUSION

Decision-making can be based on a willingness of the healthcare organization to promote models based on more shared leadership and to work on professional roles and values. It also requires healthcare professionals trained in the entire continuum of collaborative practices, to meet the unique needs of each patient. Finally, it appears essential to favour the sharing of multiple sources of accessible and structured information. Tools for knowledge formalization should help to optimize interprofessional decision-making in health.

IMPACT

The quality of a team decision-making is critical to the quality of care. Interprofessional decision-making can be structured and improved through different levels of action. These improvements could benefit to patients and healthcare professionals in every settings of care involving care collaboration.

IMPACT STATEMENT

Interprofessional decision-making in health is an essential lever of quality of care, especially for the most complex patients which are a contemporary challenge. This scoping review article offers a synthesis of a large corpus of data published to date about the interprofessional clinical decision-making process in healthcare. It has the potential to provide a global vision, practical data and a list of references to facilitate the work of healthcare teams, organizations and teachers ready to initiate a change.

Implementation of a Multi-Disciplinary Team and Quality of Goals of Care Discussions in Palliative Surgical Oncology Patients

BACKGROUND

Palliative surgical oncology patients represent a unique group with complex needs who often require multidisciplinary input for the provision of timely and holistic care. The authors assembled a multi-disciplinary palliative intervention team and evaluated its association with the quality of discussions on goals of care (GOC) among advanced cancer patients undergoing palliative interventions.

METHODS

This prospective cohort study analyzed advanced cancer patients undergoing palliative interventions at a single urban academic center from October 2019 to March 2022. In January 2021, a multi-disciplinary palliative surgical intervention (MD-PALS) team was assembled. All palliative surgical oncology patients were discussed at multi-disciplinary meetings and managed by members of the MD-PALS team. An interrupted time series (ITS) model was built to evaluate the association of MD-PALS implementation and the quality of GOC discussions as measured by a consensus-derived four-point GOC discussion quality score.

RESULTS

The study recruited 126 palliative surgical oncology patients: 44 in the pre-MD-PALS group and 82 in the post-MD-PALS group. The two groups did not differ significantly in baseline demographics, treatment, or postoperative and survival outcomes. Compared with the pre-MD-PALS group, the post-MD-PALS group had a significantly higher mean GOC discussion quality score (1.34 vs 2.61; p < 0.001). Based on the ITS model, the average quarterly GOC discussion quality score increased significantly among patients after implementation of the MD-PALS team (change = 1.93; 95 % confidence interval, 0.96-2.90; P = 0.003).

CONCLUSION

The implementation of an MD-PALS team was associated with improvements in the quality of GOC discussions among palliative surgical oncology patients.

Hospital practice variation in the proportion of patients with esophagogastric cancer discussed during an expert multidisciplinary team meeting

BACKGROUND

Multidisciplinary team meetings (MDTM) and especially MDTMs in which expert centres are involved (expert MDTMs) are a key element in adequate cancer care. However, variation among hospitals in the proportion of patients presented during an expert MDTM has been described. This study aims to investigate national practice variation in the proportion of patients with oesophageal or gastric cancer being discussed during an expert MDTM.

METHODS

Patients diagnosed with oesophageal or gastric cancer in 2018-2019 were selected from the Netherlands Cancer Registry (n = 6,921). Multilevel logistic regression analyses were used to analyse the association between patient, and tumour characteristics, and the probability to be discussed in an expert MDTM. Variation was analysed according to the hospital and region of diagnosis for: all patients, patients with a potentially curable (cT1-4A cTX, any cN, cM0) or incurable tumour stage (cT4b and/or cM1).

RESULTS

In total, 79% of patients were discussed during an expert MDTM, of whom 84% (n = 3,424) and 71% (n = 2,018) with potentially curable, or incurable oesophageal or gastric cancer, respectively. The proportion of patients discussed during an expert MDTM ranged from 54% to 98%, and 17% to 100% between hospitals for potentially curable and incurable patients, respectively (all p < 0.0001). Adjusted analyses showed significant hospital (all p < 0.0001), but no regional variation regarding the patients discussed during an expert MDTM.

CONCLUSION

For patients with oesophageal or gastric cancer the probability of being discussed during an expert MDTM varies considerably according to the hospital of diagnosis.

Determining Contemporary Barriers to Effective Multidisciplinary Team Meetings in Neurological Surgery: A Review of the Literature

OBJECTIVE

The integration of multidisciplinary team meetings (MDTMs) for neurosurgical care has been accepted worldwide. Our objective was to review the literature for the limiting factors to MDTMs that may introduce bias to patient care.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis was used to perform a literature review of MDTMs for neuro-oncology, pituitary oncology, cerebrovascular surgery, and spine surgery and spine oncology. Limiting factors to productive MDTMs and factors that introduce bias were identified, as well as determining whether MDTMs led to improved patient outcomes.

RESULTS

We identified 1264 manuscripts from a PubMed and Ovid Medline search, of which 27 of 500 neuro-oncology, 4 of 279 pituitary, and 11 of 260 spine surgery articles met our inclusion criteria. Of 224 cerebrovascular manuscripts, none met the criteria. Factors for productive MDTMs included quaternary/tertiary referral centers, nonhierarchical environment, regularly scheduled meetings, concise inclusion of nonmedical factors at the same level of importance as patient clinical information, inclusion of nonclinical participants, and use of clinical guidelines and institutional protocols to provide recommendations. Our review did not identify literature that described the use of artificial intelligence to reduce bias and guide clinical care.

CONCLUSIONS

The continued implementation of MDTMs in neurosurgery should be recommended but cautioned by limiting bias.

Risk Management Activities in a Lung Cancer Multidisciplinary Team at a Comprehensive Cancer Center: Results of a Prospective Analysis

PURPOSE

The objective of the study was to highlight sources of harm that could negatively affect the lung cancer multidisciplinary team (MDT) activities to reduce the level of risk of each factor.

METHODS

A modified Delphi approach was used by a board of multi-health care professionals of the lung cancer MDT to identify the main processes, subprocesses, and risk factors of the multidisciplinary pathway of patients with lung cancer. A semiquantitative matrix was built with a five-point scale for probability of harm (likelihood) and severity of harm (consequences) according to the international risk management standards (ISO 31000-2018). The risk level was calculated by multiplying likelihood × consequences. Mitigation strategies have been identified and applied by the MDT to reduce risks to acceptable levels.

RESULTS

Three main processes (outpatient specialist visit, MDT discussion, and MDT program implementation), eight related subprocesses, and 16 risk factors were identified. Four risk factors (25%) were related to outpatient specialist visit, seven (43.75%) to case discussion, and five (31.25%) to program implementation. Overall, two risk factors were assigned a low-risk level (12.5%), 11 a moderate-risk level (68.75%), one (6.25%) a high-risk level, and two (12.5%) a very high-risk level. After the implementation of mitigation measures, the new semiquantitative risk analysis showed a reduction in almost all hazardous situations: two risk factors (12.5%) were given a very low level, six (37.5%) a low level, seven (43.75%) a moderate level, and one (6.25%) a very high level.

CONCLUSION

An interdisciplinary risk assessment analysis is applicable to MDT activities by using an ad hoc risk matrix: if the hazard is identified and monitored, the risk could be reduced and managed in a short time.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Streamlining the Multi-Disciplinary Team Meeting: The Introduction of Robust Pre-Preparation Methods and Its Effect on the Length of Case Discussions

Introduction

The multidisciplinary team (MDT) approach has long been considered the optimal way in which to deliver a high standard of care to patients with breast cancer. With a growing number of patients and ever-increasing complexity of cases, the strain on time and resource of the MDT is becoming increasingly evident. It is therefore essential that local hospital departments adapt their MDT processes to better streamline discussions and optimise efficiency. The Royal United Hospital in Bath is a district general hospital in the UK. Approximately 500 patients with cancers are treated annually, and the MDT discusses approximately 60 patients per week.

Methods

To improve our MDT meeting processes and increase productivity, we created a concise MDT template using Microsoft Access™: giving all clinicians the ability to add patients and information in real time. We also allocated weekly preparation time whereby a senior clinician ensured all patients were prepared prior to the meeting with results and potential outcomes prepopulated where possible.

Results

We recorded the time spent discussing patients during 6 MDT meetings before and after implementation of changes. Cases were classified by pathology category to determine if there were differences following the preparation changes. Overall, we significantly reduced our average MDT discussion time (p=0.02). We significantly reduced average discussion time in postoperative malignant cases (p<0.0006) and expected benign core biopsy cases (p<0.0047), allowing appropriate redistribution of time towards discussion of more complex cases, reflected by the significant increase in time spent discussing complex radiology cases (p<0.025).

Conclusion

We offer an effective method for improving the MDT meeting preparation and presentation by ensuring each patient is appropriately prepared prior to the meeting, and outcomes for those simple cases are already prepopulated. This creates additional time within the meeting to discuss more complex clinical cases while allowing all members of the team an opportunity to discuss all patients if needed.

Preparing tomorrow's medical specialists for participating in oncological multidisciplinary team meetings: perceived barriers, facilitators and training needs

INTRODUCTION

The optimal treatment plan for patients with cancer is discussed in multidisciplinary team meetings (MDTMs). Effective meetings require all participants to have collaboration and communication competences. Participating residents (defined as qualified doctors in training to become a specialist) are expected to develop these competences by observing their supervisors. However, the current generation of medical specialists is not trained to work in multidisciplinary teams; currently, training mainly focuses on medical competences. This study aims to identify barriers and facilitators among residents with respect to learning how to participate competently in MDTMs, and to identify additional training needs regarding their future role in MDTMs, as perceived by residents and specialists.

METHODS

Semi-structured interviews were conducted with Dutch residents and medical specialists participating in oncological MDTMs. Purposive sampling was used to maximise variation in participants' demographic and professional characteristics (e.g. sex, specialty, training duration, type and location of affiliated hospital). Interview data were systematically analysed according to the principles of thematic content analysis.

RESULTS

Nineteen residents and 16 specialists were interviewed. Three themes emerged: 1) awareness of the educational function of MDTMs among specialists and residents; 2) characteristics of MDTMs (e.g. time constraints, MDTM regulations) and 3) team dynamics and behaviour. Learning to participate in MDTMs is facilitated by: specialists and residents acknowledging the educational function of MDTMs beyond their medical content, and supervisors fulfilling their teaching role and setting conditions that enable residents to take a participative role (e.g. being well prepared, sitting in the inner circle, having assigned responsibilities). Barriers to residents' MDTM participation were insufficient guidance by their supervisors, time constraints, regulations hindering their active participation, a hierarchical structure of relations, unfamiliarity with the team and personal characteristics of residents (e.g. lack of confidence and shyness). Interviewees indicated a need for additional training (e.g. simulations) for residents, especially to enhance behavioural and communication skills.

CONCLUSION

Current practice with regard to preparing residents for their future role in MDTMs is hampered by a variety of factors. Most importantly, more awareness of the educational purposes of MDTMs among both residents and medical specialists would allow residents to participate in and learn from oncological MDTMs. Future studies should focus on collaboration competences.

Crisis recovery in surgery: Error management and problem solving in safety-critical situations

BACKGROUND

Surgical crises, both clinical and executive, carry risk of harm to patients, staff, and organizations. Once stabilized and contained, crisis recovery requires complex decision-making and problem-solving to address primary failures (errors) and their consequences. In contrast to other safety-critical professions, surgeons may lack access to crisis recovery strategies and tools that go beyond the technical aspects of clinical practice. This study aims to develop a framework for surgical crisis recovery based on problem-solving interventions used by pilots in commercial aviation.

METHODS

This study undertook observational fieldwork, semistructured interviews, and focus groups with senior airline pilots and health care safety experts. Thematic analysis using the framework method identified key interventions applicable to surgical crisis recovery. Subsequently, expert group consensus adapted and content validated this model for clinical use.

RESULTS

Qualitative data from 22 aviation and health care safety experts informed surgical crisis resolution. This consisted of 3 strategies: (1) building cognitive capacity by improving situational awareness and workload management; (2) using checklists in abnormal situations to implement emergency operating procedures; (3) undertaking structured decision-making using analysis-based problem-solving cycles (eg, T-DODAR framework). Twelve tools were validated and adapted to aid implementation of these strategies.

CONCLUSION

Once stabilized, surgical crises may be resolved using 3 sequential strategies derived from commercial aviation.

Benefits and drawbacks of videoconferencing for collaborating multidisciplinary teams in regional oncology networks: a scoping review

INTRODUCTION

Various forms of videoconferenced collaborations exist in oncology care. In regional oncology networks, multidisciplinary teams (MDTs) are essential in coordinating care in their region. There is no recent overview of the benefits and drawbacks of videoconferenced collaborations in oncology care networks. This scoping review presents an overview of videoconferencing (VC) in oncology care and summarises its benefits and drawbacks regarding decision-making and care coordination.

DESIGN

We searched MEDLINE, Embase, CINAHL (nursing and allied health) and the Cochrane Library from inception to October 2020 for studies that included VC use in discussing treatment plans and coordinating care in oncology networks between teams at different sites. Two reviewers performed data extraction and thematic analyses.

RESULTS

Fifty studies were included. Six types of collaboration between teams using VC in oncology care were distinguished, ranging from MDTs collaborating with similar teams or with national or international experts to interactions between palliative care nurses and experts in that field. Patient benefits were less travel for diagnosis, better coordination of care, better access to scarce facilities and treatment in their own community. Benefits for healthcare professionals were optimised treatment plans through multidisciplinary discussion of complex cases, an ability to inform all healthcare professionals simultaneously, enhanced care coordination, less travel and continued medical education. VC added to the regular workload in preparing for discussions and increased administrative preparation.

DISCUSSION

Benefits and drawbacks for collaborating teams were tied to general VC use. VC enabled better use of staff time and reduced the time spent travelling. VC equipment costs and lack of reimbursement were implementation barriers.

CONCLUSION

VC is highly useful for various types of collaboration in oncology networks and improves decision-making over treatment plans and care coordination, with substantial benefits for patients and specialists. Drawbacks are additional time related to administrative preparation.

Team functioning across different tumour types: Insights from a Swiss cancer center using qualitative and quantitative methods

Background

Multidisciplinary care is pivotal in cancer centres and the interaction of all cancer disease specialists in decision making processes is state‐of‐the‐art.

Aim

To describe differences of MDTMs by tumour type.

Methods

Twelve multidisciplinary team meetings (MDTMs) with participation of different cancer disease specialists at a tertiary hospital were assessed by an exploratory sequential mixed method approach with interviews, observations and a survey to address the following five topics: organisational structure and supporting technology; leadership; teamwork; decision‐making, perceived value and motivation. Thirteen persons with different tumour specialities and levels of seniority were interviewed. The 12 MDTMs were observed twice by uninvolved persons and evaluated by the participating physicians with a survey.

Results

There were no systematic differences between MDTMs for different tumour types with the exception of the non‐disease specific type MDTM, which was the only one for which the organisational structure was not driven by an electronic tool. However, several factors could be identified that generally influenced the functioning of the MDTMs. In particular, the quality of decision‐making was highly dependent on the availability of case‐based information and the presence of relevant cancer disease specialists. Leadership and teamwork were rated as important and were comparable across the MDTM. Team participants' motivation and perceived value of MDTMs was high across all meetings.

Conclusion

MDTM at a single institution did not demonstrate disease specific characteristics. An effective MDTM, irrespective of the tumour type, can be successfully structured by technical means and a chairperson coordinating the interaction of cancer disease specialists to improve the decision‐making process.

Physician practice variation in head and neck cancer therapy: Results of a national survey

OBJECTIVES

Choice between surgical or medical treatments in head and neck cancer depends of many patient-related and disease-related factors. We investigated how patients' socioeconomic status and practitioners' specialty could affect medical decision-making.

MATERIALS AND METHODS

We conducted a cross-sectional online, nationwide survey, send to surgeons, oncologists and radiotherapists specialized in head and neck oncology. We collected data on medical decision-making for seven clinical scientific scenarios involving head and neck carcinoma and physicians' demographic data. Patients' gender and socioeconomic position were distributed across scientific scenarios using a Latin square design. The scientific scenarios were grouped into several categories according to the prognostic and functional impact of the therapeutic choice.

RESULTS

We obtained 206 assessable answers. Surgeons seemed to propose surgery in 49% of cases, whereas oncologists and radiotherapists opted for it in 34% of cases only. This was particularly relevant when the oncological result of surgery and the medical approach were equivalent, and when the surgery appeared to be superior in terms of curative potential but was burdened by a large functional impact. Patient's socioeconomic position also influence therapeutic decision. Among surgeons, the "single male manager" had significantly more chance of being offered surgery than the "married male blue-collar worker". Among oncologists and radiotherapists, the "single male blue-collar worker" had the lowest probability of being proposed surgery. Regarding gender, surgeons tended to offer surgical management more to women regardless of their clinical profile.

CONCLUSIONS

Patients' sex, marital status, socioeconomic status, practitioners' specialty affect therapeutic management decisions in head and neck oncology.

Survival Trends for Resectable Pancreatic Cancer Using a Multidisciplinary Conference: the Impact of Post-operative Chemotherapy

PURPOSE

Despite advances in various treatment modalities, surgical resection for pancreatic ductal adenocarcinoma (PDA) remains the only curative treatment. Data remains limited regarding survival rates for resectable PDA when managed by a multidisciplinary pancreas conference (MDPC). The aim of this study is to assess survival rates, identify significant predictors of mortality, and assess the benefits of adjuvant chemotherapy for resectable PDA following presentation at a MDPC.

METHODS

All patients presented from April 2013 to August 2016 with resectable PDA were discussed at a MDPC at a tertiary care center and were followed prospectively until November 2017. Survival analysis was performed using Kaplan-Meier for age, tumor size, tumor differentiation, T-stage, lymph node status, and completion of adjuvant chemotherapy cycles. Independent predictors of survival were determined using multivariate Cox regression modeling.

RESULTS

After MDPC consensus and exclusions, total of 64 patients underwent successful surgery. Amongst this cohort, 1-, 2-, and 3-year survival was 78.13%, 46.30%, and 27.27%, respectively. A total of 37 patients (58%) initiated and 16 patients (25%) finished chemotherapy following surgery. Log-rank analysis revealed that tumor size, age, surgical margins, lymph node status, and number of adjuvant chemotherapy cycles received significantly influenced post-operative survival. Tumor size (p < 0.001), lymph node status (p = 0.035), and number of adjuvant chemotherapy cycles (p = 0.041) remained significant after multivariate Cox regression model.

CONCLUSIONS

Our results suggest that patients with PDA with tumor size > 50 mm and/or lymph node involvement have poor outcomes despite being surgically resectable. Successful completion of adjuvant chemotherapy has better survival outcomes as compared with incomplete or no adjuvant chemotherapy. The role of alternative management such as down-staging with neoadjuvant therapy should be considered.

Reorganizing the Multidisciplinary Team Meetings in a Tertiary Centre for Gastro-Intestinal Oncology Adds Value to the Internal and Regional Care Pathways. A Mixed Method Evaluation

INTRODUCTION

The reorganisation of the structure of a Gastro-Intestinal Oncology Multidisciplinary Team Meeting (GIO-MDTM) in a tertiary centre with three care pathways is evaluated on added value.

METHODS

In a mixed method investigation, process indicators such as throughput times were analysed and stakeholders were interviewed regarding benefits and drawbacks of the reorganisation and current MDTM functioning.

RESULTS

For the hepatobiliary care pathway, the time to treatment plan increased, but the time to start treatment reduced significantly. The percentage of patients treated within the Dutch standard of 63 days increased for the three care pathways. From the interviews, three themes emerged: added value of MDTMs, focus on planning integrated care and awareness of possible improvements.

DISCUSSION

The importance of evaluating interventions in oncology care pathways is shown, including detecting unexpected drawbacks. The evaluation provides insight into complex dynamics of the care pathways and contributes with recommendations on functioning of an MDTM.

CONCLUSIONS

Throughput times are only partly determined by oncology care pathway management, but have influence on the functioning of MDTMs. Process indicator information can help to reflect on integration of care in the region, resulting in an increase of patients treated within the Dutch standard.

Development and validation of an individualized prediction calculator of postoperative mortality within 6 months after surgical resection for hepatocellular carcinoma: an international multicenter study

BACKGROUND

Evidence-based decision-making is critical to optimize the benefits and mitigate futility associated with surgery for patients with malignancies. Untreated hepatocellular carcinoma (HCC) has a median survival of only 6 months. The objective was to develop and validate an individualized patient-specific tool to predict preoperatively the benefit of surgery to provide a survival benefit of at least 6 months following resection.

METHODS

Using an international multicenter database, patients who underwent curative-intent liver resection for HCC from 2008 to 2017 were identified. Using random assignment, two-thirds of patients were assigned to a training cohort with the remaining one-third assigned to the validation cohort. Independent predictors of postoperative death within 6 months after surgery for HCC were identified and used to construct a nomogram model with a corresponding online calculator. The predictive accuracy of the calculator was assessed using C-index and calibration curves.

RESULTS

Independent factors associated with death within 6 months of surgery included age, Child-Pugh grading, portal hypertension, alpha-fetoprotein level, tumor rupture, tumor size, tumor number and gross vascular invasion. A nomogram that incorporated these factors demonstrated excellent calibration and good performance in both the training and validation cohorts (C-indexes: 0.802 and 0.798). The nomogram also performed better than four other commonly-used HCC staging systems (C-indexes: 0.800 vs. 0.542-0.748).

CONCLUSIONS

An easy-to-use online prediction calculator was able to identify patients at highest risk of death within 6 months of surgery for HCC. The proposed online calculator may help guide surgical decision-making to avoid futile surgery for patients with HCC.

Evaluation of the Decision-Making Mode during Digestive Oncology Multidisciplinary Meetings: a Prospective Study in a Moroccan Center

Introduction: The multidisciplinary team oncology meeting (MDT) has become a standard in oncology. The objective of this study was to evaluate the value of a validated tool, the Metric for the Observation of Decision-Making, in the evaluation of the decision-making mode during the digestive cancer MDT in order to reach recommendations for improvement. Results: Eight consecutive MDTs were observed (N = 228 patients). On average, 32 patients were discussed by MDT with an average of 2 min 55 s (interval: 30 s-10 min 16 s) per patient. A decision was reached in 84.6% of the cases. Although the medical information was judged to be of good quality, the psychosocial information (average 1.29) and the patients' point of view (average 1.03) were judged to be of low quality. For teamwork, the contribution of surgeons (average 4.56) and oncologists (average 3.99) was greater than radiologists (3.12), radiotherapists (1.74) and pathologists (1.02). Conclusions: The tool made it possible to identify a disparity in the quality of the different aspects of the information and in the participation of specialists, making it possible to identify specific improvement measures. Its regular use would improve the quality of patient care. Keywords: Decision making, Quality improvement, Multidisciplinary Concertation meeting, MDT-MODe, Morocco

Evaluation of the Decision-Making Mode during Digestive Oncology Multidisciplinary Meetings: a Prospective Study in a Moroccan Center

Introduction: The multidisciplinary team oncology meeting (MDT) has become a standard in oncology. The objective of this study was to evaluate the value of a validated tool, the Metric for the Observation of Decision-Making, in the evaluation of the decision-making mode during the digestive cancer MDT in order to reach recommendations for improvement. Results: Eight consecutive MDTs were observed (N = 228 patients). On average, 32 patients were discussed by MDT with an average of 2 min 55 s (interval: 30 s-10 min 16 s) per patient. A decision was reached in 84.6% of the cases. Although the medical information was judged to be of good quality, the psychosocial information (average 1.29) and the patients' point of view (average 1.03) were judged to be of low quality. For teamwork, the contribution of surgeons (average 4.56) and oncologists (average 3.99) was greater than radiologists (3.12), radiotherapists (1.74) and pathologists (1.02). Conclusions: The tool made it possible to identify a disparity in the quality of the different aspects of the information and in the participation of specialists, making it possible to identify specific improvement measures. Its regular use would improve the quality of patient care. Keywords: Decision making, Quality improvement, Multidisciplinary Concertation meeting, MDT-MODe, Morocco

Use of the theoretical domains framework and behaviour change wheel to develop a novel intervention to improve the quality of multidisciplinary cancer conference decision-making

BACKGROUND

Multidisciplinary Cancer Conferences (MCCs) are prospective meetings involving cancer specialists to discuss treatment plans for patients with cancer. Despite reported gaps in MCC quality, there have been few efforts to improve its functioning. The purpose of this study was to use theoretically-rooted knowledge translation (KT) theories and frameworks to inform the development of a strategy to improve MCC decision-making quality.

METHODS

A multi-phased approach was used to design an intervention titled the KT-MCC Strategy. First, key informant interviews framed using the Theoretical Domains Framework (TDF) were conducted with MCC participants to identify barriers and facilitators to optimal MCC decision-making. Second, identified TDF domains were mapped to corresponding strategies using the COM-B Behavior Change Wheel to develop the KT-MCC Strategy. Finally, focus groups with MCC participants were held to confirm acceptability of the proposed KT-MCC Strategy.

RESULTS

Data saturation was reached at n = 21 interviews. Twenty-seven barrier themes and 13 facilitator themes were ascribed to 11 and 10 TDF domains, respectively. Differences in reported barriers by physician specialty were observed. The resulting KT-MCC Strategy included workshops, chair training, team training, standardized intake forms and a synoptic discussion checklist, and, audit and feedback. Focus groups (n = 3, participants 18) confirmed the acceptability of the identified interventions.

CONCLUSION

Myriad factors were found to influence MCC decision making. We present a novel application of the TDF and COM-B to the context of MCCs. We comprehensively describe the barriers and facilitators that impact MCC decision making and propose strategies that may positively impact the quality of MCC decision making.

The impact of an educational video about radiotherapy and its toxicities in head and neck cancer patients. Evaluation of patients' understanding, anxiety, depression, and quality of life

OBJECTIVES

Head and neck radiotherapy can cause several toxicities, and its management has important treatment implications. Proper information about treatment is crucial to assist patients by preparing them and enhancing their ability to manage their illness. Thus, this study aimed to verify the impact of an educational video on the improvement of the patient's understanding, satisfaction, quality of life, and influence on their emotional state in different moments of treatment.

METHODS

A 10 min video about head and neck radiotherapy and its toxicities was produced. A prospective randomized clinical trial was performed in two groups: a control group (n = 65), which received standard verbal and written information, and an experimental group (n = 65), which received standard information and the video. Appropriated questionnaires (HADS, UW-QOLv4, IRTU, and Post-RTU) were applied in four different moments in order to evaluate patients' understanding, anxiety, depression, and quality of life.

RESULTS

The video improved the understanding of treatment and its side effects. Also, the video group reported better awareness about oral health care during the treatment. Osteoradionecrosis and radiation-related caries were the most unknown side effects. On the other hand, the educational video did not modify the patients' anxiety, depression, and quality of life. All patients reported high satisfaction with the video.

CONCLUSIONS

Audiovisual tools may improve patients' understanding of radiotherapy and were shown to be a useful tool when used in association with verbal and written information in cancer centers. In addition, information about osteoradionecrosis and radiation-related caries must be reinforced to patients.

Multidisciplinary meetings at the emergency department: A conversation-analytic study of decision-making

Multidisciplinary meetings (MDMs) have become an established part of many medical disciplines. Much research has been done to investigate the conditions under which they work best. This research, however, has been mostly retrospective and has had little consideration for the actual workings of MDMs. The aim of this study was to determine how Multidisciplinary Teams (MDTs) come to a shared decision and thus how they organize MDMs moment by moment. For this purpose we recorded twenty MDMs at the Department of Emergency Medicine (ED) of the Radboud University Medical Center in The Netherlands between November 2017 and June 2018. These meetings, contrary to those discussed in the literature, were scheduled ad-hoc as patients were seen at the ED and were conducted by small MDTs of between three and six participants, always involving a surgeon, a geriatrician, and an emergency physician. Using Conversation Analysis we found that despite the ad hoc nature of these meetings, teams collaboratively developed a structure that was grounded in everyday medical practice and reached a decision in on average slightly over 10 min. First they do a case presentation in which they share the patient's medical history and results of the physical examination and any medical tests. They subsequently agree on a differential diagnosis, and then develop a work plan. Finally, the decision is often formulated to invite confirmation and make it an interactionally shared decision. The benefit of having an MDM was evidenced by discussion of patients' frailty in particular: it was sometimes omitted during the case presentation, but then consistently requested by the geriatrician. And as we show, it was occasionally invoked as a definitive argument for deciding between surgical or conservative treatment. Our analysis suggests that MDMs can have added value in other disciplines where it is feasible to schedule meetings ad hoc.

Understanding and improving multidisciplinary team working in geriatric medicine

Geriatric medicine is a speciality that has historically relied on team working to best serve patients. The nature of frailty in older people means that people present with numerous comorbidities, which in turn require a team-based approach to be managed, including allied health professionals, social work and nursing alongside medicine. The 'engine room' of the speciality has thus for many years been the multidisciplinary team (MDT) meeting-something other specialities have discovered only recently. Yet, rather paradoxically, the speciality has been slow compared to others (e.g. trauma, surgery, cancer) to reflect more formally on how team working can be enhanced, trained and supported in geriatric teams. This paper is a reflective review, grounded on our respective expertise in geriatric medicine and improvement science, on practice and its changing patterns within geriatric medicine, and the role of MDTs within it (Part 1). It offers a perspective from behavioural safety science, which has been studying team-working in healthcare for the last 20 years (Part 2) and concludes with practical suggestions, based on evidence, on how to integrate evidence and best practice into modern geriatric medicine-to address current and future challenges (Part 3).

Analysing Breast Cancer Multidisciplinary Patient Management: A Prospective Observational Evaluation of Team Clinical Decision-Making

Background

Multidisciplinary team (MDT)-driven cancer care is a mandatory UK national policy, widely used globally. However, few studies have examined how MDT members make decisions as a team. We report a single-centre prospective study on team working within breast cancer MDT.

Methods

This was a prospective observational study of 10 breast MDT meetings (MDM). Trained clinical observer scored quality of presented information and disciplinary contribution to case reviews in real time, using a validated tool, namely Metric for the Observation of Decision-Making. Data were analysed to evaluate quality of team working.

Results

Ten MDMs were observed (N = 346 patients). An average of 42 patients were discussed per MDM (range: 29–51) with an average 3 min 20 s (range: 31 s–9 min) dedicated to each patient. Management decision was made in 99% of cases. In terms of contribution to case reviews, breast care nurses scored significantly (p < 0.05) lower (M = 1.79, SD = 0.12) compared to other team members (e.g. surgeons, M = 4.65; oncologists, M = 3.07; pathologists, M = 4.51; radiologists, M = 3.21). Information on patient psychosocial aspects (M = 1.69, SD = 0.68), comorbidities (M = 1.36, SD = 0.39) and views on treatment options (M = 1.47, SD = 0.34) was also significantly (p < 0.05) less well represented compared to radiology (M = 3.62, SD = 0.77), pathology (M = 4.42, SD = 0.49) and patient history (M = 3.91, SD = 0.48).

Conclusion

MDT evaluation via direct observation in a meeting is feasible and reliable. We found consistent levels of quality of information coverage and contribution within the team, but certain aspects could be improved. Contribution to patient review resides predominantly with surgeons, while presented patient information is largely of biomedical nature. These findings can be fed to cancer MDTs to identify potential interventions for improvement.

Quality of teamwork in multidisciplinary cancer team meetings: A feasibility study

BACKGROUND

Tumor boards (TB) play an important role to formulate a management plan for the treatment of patients with a malignancy. Recent evidence suggests that optimally functioning teams (teamwork, communication and decision making) are major prerequisites to conduct efficient TB meetings. The aims of this study were i) to use a readily published tool as a template for the development of a teamwork perspective extended assessment tool and ii) to evaluate the tool in a feasibility study by clinical and non-clinical observers.

METHODS

A systematic literature search in four databases revealed the "Metric for the Observation of Decision-making (MODe)" to be consistently used. MODe served as a template for the clinical evaluation, additional, notably teamwork items were integrated, and the resulting tool was tested in a feasibility study in TBs by clinical and non-clinical observers. The percentage of agreement between observers was assessed in a two-step approach: first, agreement of raters on discussion of items by TB members, and second, agreement of raters based on ordinal scale.

RESULTS

In total, 244 patients were discussed in 27 TB sessions, thereof 136 (56%) fast track cases and 108 (44%) complex cases. In 228 (93%) of all cases an agreement for recommendation of a treatment plan was reached. Observers showed in general high agreement on discussion of the items. For the majority of items, the percentage of agreement between the different pairs of rater was similar and mostly high.

CONCLUSION

A newly developed TB team performance tool using MODe as a template was piloted in a German-speaking country and enabled the assessment of specialized multidisciplinary teams with a special focus on teamwork patterns. The developed assessment tool requires evaluation in a larger collective for validation, and additional assessment whether it can be applied equally by non-clinicians and clinicians.

Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer

OBJECTIVES

Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC.

METHODS

Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC).

RESULTS

A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage.

CONCLUSIONS

The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.

The efficiency of electronic list-based multidisciplinary team meetings in management of gastrointestinal malignancy: a single-center experience in Southern China

Background

The multidisciplinary team (MDT) discussion has earned increasing popularity for the delivery of cancer care. However, MDT meeting (MDTM) is time and resource intensive, and some efforts to optimize discussion processes are required. This study aims to investigate the efficiency of electronic list-based MDTM in treatment of gastrointestinal (GI) malignancy.

Methods

Between January 2015 and December 2016, patients with GI cancers were retrospectively reviewed. Patients permitting an MDTM with our novel technique (eMDT group) were compared with those undergoing a traditional discussion (cMDT group). The efficiency of MDT working, including time cost per meeting or case and overall number of reviewed cases, was checked, with accuracy of clinical staging and other outcomes explored meanwhile.

Results

Three thousand six hundred seventy-four patients were included, with 2156 (58.7%) and 1518 (41.3%) cases for eMDT and cMDT groups, respectively. Comparisons in age (P = 0.529), gender (P = 0.844), cancer type (P = 0.218), treatment plan (P = 0.737), and pathological stage (P = 0.098) were not significant between groups. However, the average time cost in both each meeting (149.4 vs. 205.1 min; P < 0.001) and each case (3.1 vs. 6.2 min; P < 0.001) was markedly reduced. Besides, this novel technique was associated with improved accuracy of clinical staging (P = 0.070) and reduced hospital stay (P < 0.001) compared with the traditional approach, with similar incidence of complications observed (P = 0.243).

Conclusions

The MDT working based on an intelligent checklist could save considerable time while not affecting treatment of GI malignancies. The improved efficiency also earns an increased capacity of hospital admission and in-patient care.

Determinants of variable resource use for multidisciplinary team meetings in cancer care

BACKGROUND

Multidisciplinary team meetings (MDTMs) have developed into standard of care to provide expert opinion and to grant evidence-based recommendations on diagnostics and treatment of cancer. Though MDTMs are associated with a range of benefits, a growing number of cases, complex case discussion and an increasing number of participants raise questions on cost versus benefit. We aimed to determine cost of MDTMs and to define determinants hereof based on observations in Swedish cancer care.

METHODS

Data were collected through observations of 50 MDTMs and from questionnaire data from 206 health professionals that participated in these meetings.

RESULTS

The MDTMs lasted mean 0.88 h and managed mean 12.6 cases with mean 4.2 min per case. Participants were mean 8.2 physicians and 2.9 nurses/other health professionals. Besides the number of cases discussed, meeting duration was also influenced by cancer diagnosis, hospital type and use of video facilities. When preparatory work, participation and post-MDTM work were considered, physicians spent mean 4.1 h per meeting. The cost per case discussion was mean 212 (range 91-595) EUR and the cost per MDTM was mean 2675 (range 1439-4070) EUR.

CONCLUSIONS

We identify considerable variability in resource use for MDTMs in cancer care and demonstrate that 84% of the total cost is derived from physician time. The variability demonstrated underscores the need for regular and structured evaluations to ensure cost effective MDTM services.

Benefits, barriers and opinions on multidisciplinary team meetings: a survey in Swedish cancer care

BACKGROUND

Case review and discussion at multidisciplinary team meetings (MDTMs) have evolved into standard practice in cancer care with the aim to provide evidence-based treatment recommendations. As a basis for work to optimize the MDTMs, we investigated participants' views on the meeting function, including perceived benefits and barriers.

METHODS

In a cross-sectional study design, 244 health professionals from south Sweden rated MDTM meeting structure and function, benefits from these meetings and barriers to reach a treatment recommendation.

RESULTS

The top-ranked advantages from MDTMs were support for patient management and competence development. Low ratings applied to monitoring patients for clinical trial inclusion and structured work to improve the MDTM. Nurses and cancer care coordinators did less often than physicians report involvement in the case discussions. Major benefits from MDTM were reported to be more accurate treatment recommendations, multidisciplinary evaluation and adherence to clinical guidelines. Major barriers to a joint treatment recommendation were reported to be need for supplementary investigations and insufficient pathology reports.

CONCLUSIONS

Health professionals' report multiple benefits from MDTMs, but also define areas for improvement, e.g. access to complete information and clarified roles for the different health professions. The emerging picture suggests that structures for regular MDTM evaluations and increased focus on patient-related perspectives should be developed and implemented.

Benefits, barriers and opinions on multidisciplinary team meetings: a survey in Swedish cancer care

BACKGROUND

Case review and discussion at multidisciplinary team meetings (MDTMs) have evolved into standard practice in cancer care with the aim to provide evidence-based treatment recommendations. As a basis for work to optimize the MDTMs, we investigated participants' views on the meeting function, including perceived benefits and barriers.

METHODS

In a cross-sectional study design, 244 health professionals from south Sweden rated MDTM meeting structure and function, benefits from these meetings and barriers to reach a treatment recommendation.

RESULTS

The top-ranked advantages from MDTMs were support for patient management and competence development. Low ratings applied to monitoring patients for clinical trial inclusion and structured work to improve the MDTM. Nurses and cancer care coordinators did less often than physicians report involvement in the case discussions. Major benefits from MDTM were reported to be more accurate treatment recommendations, multidisciplinary evaluation and adherence to clinical guidelines. Major barriers to a joint treatment recommendation were reported to be need for supplementary investigations and insufficient pathology reports.

CONCLUSIONS

Health professionals' report multiple benefits from MDTMs, but also define areas for improvement, e.g. access to complete information and clarified roles for the different health professions. The emerging picture suggests that structures for regular MDTM evaluations and increased focus on patient-related perspectives should be developed and implemented.

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

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

Establishing the aims, format and function for multidisciplinary team-driven care within an inflammatory bowel disease service: a multicentre qualitative specialist-based consensus study

OBJECTIVE

To obtain a specialist-based consensus on the aims, format and function for MDT-driven care within an inflammatory bowel disease (IBD) service.

DESIGN

This was a prospective, multicentre study using a Delphi formal consensus-building methodology.

SETTING

Participants were recruited nationally across 13 centres from July to August 2014.

PARTICIPANTS

24 participants were included into the Delphi Specialist Consensus Panel. They included six consultant colorectal surgeons, six gastroenterologists, five consultant radiologists, three consultant histopathologists and 4 IBD nurse specialists.

INTERVENTIONS

Panellists ranked items on a Likert scale (1=not important to 5=very important). Items with a median score >3 were considered eligible for inclusion.

MAIN OUTCOME MEASURES

Consensus was defined with an IQR ≤1. Consensus on categorical responses was defined by an agreement of >60%.

RESULTS

A consensus on items (median; IQR) that described the aims of the MDT-driven care that were considered very important included: advance patient care (5;5-5), provide multidisciplinary input for the patient's care plan (5;5-5), provide shared experience and expertise (5;5-5), improve patient outcome (5;5-5), deliver the best possible care for the patient (5;5-5) and to obtain consensus on management for a patient with IBD (5;4-5). A consensus for being a core MDT member was demonstrated for colorectal surgeons (24/24), radiologists (24/24), gastroenterologists (24/24), nurse specialists (24/24), dieticians (14/23), histopathologists (21/23) and coordinators (21/24).

CONCLUSIONS

This study has provided a consensus for proposed aims, overall design, format and function MDT-driven care within an IBD service. This can provide a focus for core members, and aid a contractual recognition to ensure attendance and proactive contribution.

Classification of Ovarian Cancer Surgery Facilitates Treatment Decisions in a Gynecological Multidisciplinary Team

Objective

Proper planning of intervention and care of ovarian cancer surgery is of outmost importance and involves a wide range of personnel at the departments involved. The aim of this study is to evaluate the introduction of an ovarian surgery classification (COVA) system for facilitating multidisciplinary team (MDT) decisions.

Materials and Methods

Four hundred eighteen women diagnosed with ovarian cancers (n = 351) or borderline tumors (n = 66) were selected for primary debulking surgery from January 2008 to July 2013. At an MDT meeting, women were allocated into 3 groups named “pre-COVA” 1 to 3 classifying the expected extent of the primary surgery and need for postoperative care. On the basis of the operative procedures performed, women were allocated into 1 of the 3 corresponding COVA 1 to 3 groups. The outcome measure was the predictive value of the pre-COVA score compared with the actual COVA performed.

Results

The MDT meeting allocated 213 women (51%) to pre-COVA 1, 136 (33%) to pre-COVA 2, and 52 (12%) to pre-COVA 3. At the end of surgery, 168 (40%) were classified as COVA 1, 158 (38%) were classified as COVA 2, and 28 (7%) were classified as COVA 3. Traced individually, 212 (51%) patients were correctly preclassified at the MDT meeting and distributed into 110 (52%) COVA 1, 71 (52%) COVA 2, and 17 (32%) COVA 3. Analyzing the subgroup of patients with cancer, 164 (47%) were correctly preclassified. Regarding the International Federation of Gynecology and Obstetrics (FIGO) stages, the pre-COVA classification predicted the actual COVA group in 79 (49%) FIGO stages I to IIIB and in 85 (45%) FIGO stages IIIC to IV.

Conclusions

The COVA classification system is a simple and useful tool in the MDT setting where specialists make treatment decisions based on advanced technology. The use of pre-COVA classification facilitates well-organized patient care–relevant procedures to be undertaken. Pre-COVA accurately predicts the final COVA in 51% classified women.

Regional Multiteam Systems in Cancer Care Delivery

Teamwork is essential for addressing many of the challenges that arise in the coordination and delivery of cancer care, especially for the problems that are presented by patients who cross geographic boundaries and enter and exit multiple health care systems at various times during their cancer care journeys. The problem of coordinating the care of patients with cancer is further complicated by the growing number of treatment options and modalities, incompatibilities among the vast variety of technology platforms that have recently been adopted by the health care industry, and competing and misaligned incentives for providers and systems. Here we examine the issue of regional care coordination in cancer through the prism of a real patient journey. This article will synthesize and elaborate on existing knowledge about coordination approaches for complex systems, in particular, in general and cancer care multidisciplinary teams; define elements of coordination derived from organizational psychology and human factors research that are applicable to team-based cancer care delivery; and suggest approaches for improving multidisciplinary team coordination in regional cancer care delivery and avenues for future research. The phenomenon of the mobile, multisystem patient represents a growing challenge in cancer care. Paradoxically, development of high-quality, high-volume centers of excellence and the ease of virtual communication and data sharing by using electronic medical records have introduced significant barriers to effective team-based cancer care. These challenges urgently require solutions.

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

Background

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

Methods

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

Results

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

Conclusions

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

"We talk it over"--mixed-method study of interdisciplinary collaborations in private practice among urologists and oncologists in Germany

BACKGROUND

Utilisation of multidisciplinary teams is considered the best approach to care and treatment for cancer patients. However, the multidisciplinary approach has mainly focused on inpatient care rather than routine outpatient care. The situation in private practice care and outpatient care is gradually changing. We aimed to 1), investigate interdisciplinary cooperations in the care of tumor patients among urologists and oncologists in the community setting, 2), establish an estimate of the prevalence of cooperation among oncologists and organ-specific providers in community settings in Germany and 3), characterise existing cooperations among oncologists and urologists.

METHODS

We conducted simultaneously a cross-sectional survey with private practice urologists (n=1,925) and a qualitative study consisting of semi-structured interviews with urologists and oncologists (n=42), primarily with private practices, who had indicated cooperation the care of urological tumor patients.

RESULTS

Most of the participants (66%) treated their own tumor patients. When physicians referred patients, they did so for co- and subsequent treatments (43%). Most cooperating urologists were satisfied with the partnership and appreciated the competency of their partners. Qualitative interviews revealed two types of collaboration in the community setting: formal and informal. Collaborations were usually ongoing with many physicians and depended equally on both patient preference and diagnosis.

CONCLUSION

Joint patient treatment requires clear delineation of roles and responsibilities and simple means of communication. Formal frameworks should allow for incorporation of patients' critical role in collaboration decisions in treatment and care.

Improving decision making in multidisciplinary tumor boards: prospective longitudinal evaluation of a multicomponent intervention for 1,421 patients

BACKGROUND

Due to its complexity, cancer care is increasingly being delivered by multidisciplinary tumor boards (MTBs). Few studies have investigated how best to organize and run MTBs to optimize clinical decision making. We developed and evaluated a multicomponent intervention designed to improve the MTB's ability to reach treatment decisions.

STUDY DESIGN

We conducted a prospective longitudinal study during 16 months that evaluated MTB decision making for urological cancer patients at a university hospital in London, UK. After a baseline period, MTB improvement interventions (eg, MTBs checklist, MTB team training, and written guidance) were delivered sequentially. Outcomes measures were the MTB's ability to reach a decision, the quality of information presentation, and the quality of teamwork (as assessed by trained assessors using a previously validated observational assessment tool). The efficacy of the intervention was evaluated using multivariate analyses.

RESULTS

There were 1,421 patients studied between December 2009 and April 2, 2011. All outcomes improved considerably between baseline and intervention implementation: the MTB's ability to reach a decision rose from 82.2% to 92.7%, quality of information presentation rose from 29.6% to 38.3%, and quality of teamwork rose from 37.8% to 43.0%. The MTB's ability to reach a treatment decision was related to the quality of available information (r = 0.298; p < 0.05) and quality of teamwork within the MTB (r = 0.348; p < 0.05). The most common barriers to reaching clinical decisions were inadequate radiologic information (n = 77), inadequate pathologic information (n = 51), and inappropriate patient referrals (n = 21).

CONCLUSIONS

Multidisciplinary tumor board-delivered treatment is becoming the standard for cancer care worldwide. Our intervention is efficacious and applicable to MTBs and can improve decision making and expedite cancer care.

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 cancer multi-disciplinary team from the coordinators' perspective: results from a national survey in the UK

Background

The MDT-Coordinators’ role is relatively new, and as such it is evolving. What is apparent is that the coordinator’s work is pivotal to the effectiveness and efficiency of an MDT. This study aimed to assess the views and needs of MDT-coordinators.

Methods

Views of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators’ educational/training needs.

Results

265 coordinators responded to the survey. More than one third of the respondents felt that the job plan does not reflect their actual duties. It was reported that medical members of the MDT always contribute to case discussions. 66.9% of the respondents reported that the MDTs are chaired by Surgeons. The majority reported having training on data management and IT skills but more than 50% reported that they felt further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills.

Conclusions

MDT-Coordinators’ role is central to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the resources and training available to MDT-coordinators can give them an opportunity to develop the required additional skills and contribute to improved MDT performance and ultimately cancer care. Finally, this study looks forward to the impact of the recent launch of a new e-learning training programme for MDT coordinators and discusses implications for future research.

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.

The development of a supraregional network for the management of penile cancer

INTRODUCTION

Although its incidence is increasing, penile cancer remains a rare disease in the UK. In view of this low volume, the National Institute for Clinical Excellence recommended that treatment is centralised in a limited number of centres arranged as supraregional networks. The aim of this centralisation is to allow the best standardised treatment for the primary tumours and nodal disease, thereby avoiding under or overtreatment. In this paper we review the formation and functioning of our network in the East Midlands.

METHODS

Data were collected up to August 2010 from our prospective penile network database since its inception in 2005. These data were analysed to see our workload, patterns of referral and surgeries performed over this time period.

RESULTS

The structure and function of the East Midlands network are described. There has been an increase in the number of cases discussed since its formation. There has also been a trend towards more conservative surgery, both of the primary tumour and of nodal management. Between September 2009 and August 2010, 16 glansectomies were performed versus 5 total and 9 partial penectomies. The same period saw 18 dynamic sentinel lymph node biopsies against 7 bilateral and 3 unilateral superficial groin dissections. There was a very high patient satisfaction rate, with patients feeling they had good support and information.

CONCLUSIONS

On reviewing the literature it can be clearly seen that supraregional networks have led to a decrease in overtreatment and better recognition of the need to manage lymph node status optimally. Our network has demonstrated the trend toward conservative surgery and sentinel node biopsy. The formation of supraregional networks with a multidisciplinary approach will facilitate high volume centres that will offer optimal surgical therapy and also allow recruitment into studies and new chemotherapeutic regimens. It will also allow better data collection to aid clinical studies that hopefully will also demonstrate better outcomes.

Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance

OBJECTIVES

The cancer multidisciplinary team (MDT) meeting (MDM) is regarded as the best platform to reduce unwarranted variation in cancer care through evidence-compliant management. However, MDMs are often overburdened with many different agendas and hence struggle to achieve their full potential. The authors developed an interactive clinical decision support system called MATE (Multidisciplinary meeting Assistant and Treatment sElector) to facilitate explicit evidence-based decision making in the breast MDMs.

DESIGN

Audit study and a questionnaire survey.

SETTING

Breast multidisciplinary unit in a large secondary care teaching hospital.

PARTICIPANTS

All members of the breast MDT at the Royal Free Hospital, London, were consulted during the process of MATE development and implementation. The emphasis was on acknowledging the clinical needs and practical constraints of the MDT and fitting the system around the team's workflow rather than the other way around. Delegates, who attended MATE workshop at the England Cancer Networks' Development Programme conference in March 2010, participated in the questionnaire survey.

OUTCOME MEASURES

The measures included evidence-compliant care, measured by adherence to clinical practice guidelines, and promoting research, measured by the patient identification rate for ongoing clinical trials.

RESULTS

MATE identified 61% more patients who were potentially eligible for recruitment into clinical trials than the MDT, and MATE recommendations demonstrated better concordance with clinical practice guideline than MDT recommendations (97% of MATE vs 93.2% of MDT; N=984). MATE is in routine use in breast MDMs at the Royal Free Hospital, London, and wider evaluations are being considered.

CONCLUSIONS

Sophisticated decision support systems can enhance the conduct of MDMs in a way that is acceptable to and valued by the clinical team. Further rigorous evaluations are required to examine cost-effectiveness and measure the impact on patient outcomes. The decision support technology used in MATE is generic and if found useful can be applied across medicine.

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.