The Use of Hospital Services by Patients With Muscle Invasive Bladder Cancer in the Last Year of Life: Identifying the Areas to Improve Care

INTRODUCTION

Muscle-invasive bladder cancer (MIBC) is associated with significant morbidity. However, patients' specific health needs have not been well defined. This study analyses the utilisation of hospital resources by MIBC patients in the 12 months before death, informing healthcare modelling and enabling service redesign to improve their quality of life.

MATERIALS AND METHODS

All patients who died after being diagnosed with MIBC at a single hospital in the United Kingdom within four years were included. Patients' electronic health records were reviewed to collect data on all interactions with hospital services in their last year of life.

RESULTS

A total of 41 patients were included, with survival times ranging from one to 88 months (with a median of nine months). In the last year of life, a patient from this cohort had an average of 5.2 outpatient appointments and 2.3 emergency admissions leading to 17.1 days of inpatient stay and 1.3 operations/procedures. The most common reasons for emergency admission were for the management of haematuria (23%), urinary tract infection (23%), or chest infection (12%).

CONCLUSION

Patients with MIBC demonstrate significant utilisation of healthcare resources in their last year of life. An awareness of this should inform honest discussions with patients, earlier provision of palliative care, and proactive management of haematuria and urinary tract infections to improve care in this important stage of life.

Developing and centralising a nurse-led local anaesthetic transperineal biopsy service during COVID

Introduction

Transperineal (TP) biopsy has recently replaced the transrectal ultrasound (TRUS) approach as the ideal method of biopsy in the United Kingdom with growing trends to adopt. To minimise transmission of COVID-19 during the first wave of the pandemic, the British Association of Urological Surgeons Section of Oncology issued guidelines reducing general anaesthesia (GA) procedures and initiate COVID-secure 'green' site diagnostics. As a result of these guidelines and reduction in clinical diagnostics trust-wide, we ceased all TRUS diagnostics and implemented a centralised, nurse-led LA TP biopsy service.

Materials and methods

A waiting list was developed for those awaiting prostate cancer diagnostics across the network. A COVID-secure 'green' site was quickly identified with TP biopsies starting soon after. Quality improvement methodology was utilised and a run chart was used to show if changes were sustainable.

Results

Successful implementation and centralisation of a TP biopsy service occurred with TRUS guided biopsies ceasing across all sites on 12 May 2020. The procedures were carried out by urology advanced nurse practitioners under local anaesthesia with a select few occurring under GA. Centralising the service in a COVID-secure manner freed up dedicated theatre sessions and personal leading to increased efficiency elsewhere. The service was robust and was maintained upon lifting of COVID restrictions.

Conclusions

A centralised, nurse led LA TP biopsy service in a procedural unit was implemented successfully. The service has remained resilient upon lifting of restrictions and return to business as usual. This led to improved performance across trust by freeing up valuable resources and staff to undertake more duties. The service remains highly valued trust-wide.

Evaluation of changes to work patterns in multidisciplinary cancer team meetings due to the COVID-19 pandemic: A national mixed-method survey study

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.

Analysis of communication styles underpinning clinical decision-making in cancer multidisciplinary team meetings

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.

Interventions for obstructive uropathy in advanced prostate cancer: a population-based study

OBJECTIVES

To develop and validate a coding framework to identify interventions for upper tract obstructive uropathy (UTOU) in men with locally advanced and metastatic prostate cancer (PCa) using administrative hospital data to assess clinical outcomes. There are no population-based studies on the incidence, treatment, and outcomes of this complication.

PATIENTS AND METHODS

Patients newly diagnosed with PCa between April 2014 and March 2019 were identified in the English cancer registry. A coding framework based on procedure (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures fourth edition) and diagnostic (International Classification of Diseases, 10th edition) codes was developed and validated. Subsequent clinical outcomes were determined using Hospital Episodes Statistics to determine the utility of the intervention.

RESULTS

A total of 77 010 patients newly diagnosed with locally advanced, and 30 083 patients with metastatic PCa were identified. Of these, 1951 (1.8%) patients underwent an intervention for UTOU according to our coding framework: 830 (42.5%) had locally advanced disease and 1121 (57.5%) had metastatic disease. In all, 844 (43.3%) had a percutaneous nephrostomy (PCN), 473 (24.2%) had a PCN with antegrade stent, and 634 (32.5%) had a retrograde stent. The mean follow-up was 43.2 months. The cumulative incidence of the use of these interventions at 1, 3, and 5 years was 2.5%, 3.6% and 4.2% in men with metastases compared to 0.5%, 0.9% and 1.4% in men with locally advanced disease.

CONCLUSION

A new coding framework, developed to identify procedures for UTOU was applied in the largest study to date of UTOU in men with primary locally advanced and metastatic PCa. Results demonstrated that 2% of men with locally advanced PCa and 4% of men with metastatic PCa require an intervention to resolve UTOU within 5 years of their PCa diagnosis.

Developing a Diagnostic Multivariable Prediction Model for Urinary Tract Cancer in Patients Referred with Haematuria: Results from the IDENTIFY Collaborative Study

BACKGROUND

Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation.

OBJECTIVE

To develop a prediction model for urinary tract cancer in patients referred with haematuria.

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism.

RESULTS AND LIMITATIONS

The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy.

CONCLUSIONS

This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation.

PATIENT SUMMARY

We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

Cancer multidisciplinary team meetings: impact of logistical challenges on communication and decision-making

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.

Supporting a Learning System in Pediatric Emergency Pathways: Using Organizational Comparisons, Serious Incidents, and Near-Miss Events to Improve the Diagnosis and Treatment of Testicular Torsion

BACKGROUND

Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion and increase the opportunity for testicular salvage. Using national data obtained from the NHS Improvement, we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to learning from these and improving outcomes.

METHODS

A freedom of information request was made to all 134 hospital groups in England and Wales that manage testicular torsion. Serious incidents experienced by these hospitals were analyzed to see whether those with pediatric emergency departments fared better than those without. In addition, a qualitative thematic analysis of the NHS Improvement National Reporting and Learning System database over a 12-year period (2007-2019) was undertaken, to identify common themes associated with orchidectomies and "near-miss" events in the pediatric population.

RESULTS

Three hundred four patient safety incidents were returned and divided into 62 orchidectomies and 242 near-miss events. The most common factor in the orchidectomy group was individual factors (83.9%). Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialist surgeons (odds ratio = 1.46, P = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED with specialists (odds ratio = 6, P = 0.0355). Near-miss events, not leading to orchidectomy, are often due to a wider variety of factors. A Mann-Whitney U test showed that there was no statistical significance in incidents when comparing general ED units caring for all ages with pediatric EDs in terms of incidents ( U = 807.5, z = -1.124, P = 0.261).

CONCLUSIONS

There is a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It is also vital that specialist teams are cognizant of the standard operating procedures relevant to scrotal pain and testicular within the organization and the wider clinical network. Finally, there should be a drive for annual collation of data in urology and ED units with regards to testicular torsion as patient safety incidents may be underreported.

ADXBladder molecular urine testing to risk stratify and prioritise management of suspected and known bladder cancers during the COVID-19 pandemic

Objective:

COVID-19 has challenged diagnostic and surveillance pathways for suspected and known bladder transitional cell cancer (TCC). Exclusion of high-grade/invasive TCC by molecular urine testing could risk stratify patients for priority flexible cystoscopy and transurethral resection (TUR). We evaluated ADXBladder (ArquerDx), which has a high negative predictive value (NPV) for high-grade and ⩾ pT1 TCC.

Patients and methods:

Prospective cohort study of patients referred with haematuria for diagnostics or on TCC surveillance (Dec 2020–Feb 2021). Patients underwent ADXBladder testing, flexible cystoscopy and imaging (for haematuria), followed by TUR/biopsy as necessary. Clinico-radiological/pathology findings were compared with ADXBladder results.

Results:

Of 117 eligible patients, 39 and 78 had positive and negative ADXBladder tests, respectively. Of 15 suspected TCC on cystoscopy, eight were confirmed on TUR/biopsy. Overall ADXBladder NPV was 96.2% (CI: 91.0–98.4). NPV for high-grade and ⩾pT1 TCC was 97.4% (CI: 94.4–98.8) and 98.7% (CI: 95.0–99.7), respectively.

Conclusions:

Our ‘real world’ evaluation confirmed a high NPV for high grade and ⩾pT1 TCC using ADXBladder. Further larger studies are required to determine whether a negative ADXBladder test combined with negative imaging and patient risk factors may justify patient downgrading on timed diagnostic pathways.

Level of evidence:

IV

Testicular Pain Pathway in Children: Investigating Where Missed Torsion Occurs Most Often

OBJECTIVES

Acute scrotal pain in children is a common presenting complaint in hospital, and it is imperative that cases of testicular torsion are identified and managed promptly. We aim to identify the most influential points in the pathway in determining whether patients are managed in the appropriate time frame, so these areas can be targeted to improve salvage rates.

METHODS

Using quality improvement principles, the pediatric scrotal pain pathway was mapped out, commencing with initial symptom onset and ending with definitive surgical management. We retrospectively reviewed data on all patients between 0 and 18 years of age attending the emergency department at Whipps Cross University Hospital with acute scrotal pain between October 2010 and October 2013.

RESULTS

Over the 3-year period, 238 patients 18 years or younger presented to casualty with scrotal pain. Of the patients assessed initially by an emergency department physician, 52.8% (n = 67) were discharged without referral. To our knowledge, none of these patients presented later with a missed torsion. Torsion was diagnosed in 23.2% of the patients operated on (n = 22), of which 5 required orchidectomy, comprising 2.1% of all patients presenting with scrotal pain. In this group, 4 were due to late presentation by the patient.

CONCLUSIONS

We demonstrate the value of different stages of the pathway, as more than half of patients seen in A&E were correctly discharged without referral. In the context of our study, late presentation to hospital appears to be the most significant factor leading to orchidectomy. To target this issue, awareness among both children and parents must be improved.

How international is the International Prostate Symptom Score? A literature review of validated translations of the IPSS, the most widely used self-administered patient questionnaire for male lower urinary tract symptoms

OBJECTIVES

The International Prostate Symptom Score (IPSS) approaches its 30th anniversary. This ubiquitous clinical assessment tool is a standard in the assessment and research of lower urinary tract symptoms in men. The authors explore its history, development, and subsequent dissemination through validated translations across the world. An estimated global coverage is calculated and mapped according to language population.

METHODS

Embase and Medline literature searches were performed, with further hand searches of grey literature and online resources. Twenty-two abstracts and journal articles validating language translations of the IPSS were reviewed in full and tabulated. Language population data were gathered from an official database and mapped.

RESULTS

The IPSS is available in 53 languages. Twenty-seven languages have statistically or clinically validated translations for use in male patients. This corresponds to a conservative estimate of global population coverage of approximately 2.3 billion men, or 60% of the worldwide male population. Translation methodology involves forward and back translation. Statistical validation is performed with control patients. Cronbach's alpha is used for internal consistency, and Spearman's coefficient (p) or Pearson's coefficient (r) for test-retest reliability. Issues such as the emergence of altered versions deviating from original validated translations and translation difficulties due to cultural differences are observed. Further translational work is needed to validate versions of the IPSS in languages of the developing world.

CONCLUSIONS

The IPSS is the most prevalent patient-administered questionnaire used in urology across the world. There is no other clinical tool seen to have similar coverage. This paper aims to provide a roadmap for future clinical tools to acquire a similar level of translation and dissemination.

The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives

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.

Development and Validation of a Short Version of the Metric for the Observation of Decision-Making in Multidisciplinary Tumor Boards: MODe-Lite

Background

Evidence-based tools are necessary for scientifically improving the way MTBs work. Such tools are available but can be difficult to use. This study aimed to develop a robust observational assessment tool for use on cancer multidisciplinary tumor boards (MTBs) by health care professionals in everyday practice.

Methods

A retrospective cross-sectional observational study was conducted in the United Kingdom from September 2015 to July 2016. Three tumor boards from three teaching hospitals were recruited, with 44 members overall. Six weekly meetings involving 146 consecutive cases were video-recorded and scored using the validated MODe tool. Data were subjected to reliability and validity analysis in the current study to develop a shorter version of the MODe.

Results

Phase 1, a reduction of the original items in the MODe, was achieved through two focus group meetings with expert assessors based on previous research. The 12 original items were reduced to 6 domains, receiving full agreement by the assessors. In phase 2, the six domains were subjected to item reliability, convergent validation, and internal consistency testing against the MODe-Lite global score, the MODe global score, and the items of the MODe. Significant positive correlations were evident across all domains (p < 0.01), indicating good reliability and validity. In phase 3, feasibility and high inter-assessor reliability were achieved by two clinical assessors. Six domains measuring clinical input, holistic input, clinical collaboration, pathology, radiology, and management plan were integrated into MODe-Lite.

Conclusions

As an evidence-based tool for health care professionals in everyday practice, MODe-Lite gives cancer MTBs insight into the way they work and facilitates improvements in practice.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09989-7.

Serious incidents in testicular torsion management in England, 2007-2019: optimizing individual and training factors are the key to improved outcomes

OBJECTIVES

To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and 'near misses'. The secondary objective was to identify areas suitable for impactful quality improvement initiatives to be undertaken by National Health Service (NHS) healthcare providers nationally.

MATERIALS AND METHODS

This was a retrospective record review and analysis, carried out in four phases. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12-year period to the Strategic Executive Information System database. Clinical reviewers established the incident population (Phase 1), were trained and piloted the feasibility of using the London Protocol (Phase 2), applied the protocol and themed the identified contributing factors linked to adverse events (orchidectomies) and near-misses (Phase 3), and reviewed the evidence for improvement interventions (Phase 4).

RESULTS

Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were near misses. Factors contributing to all incidents were: individual staff/training (38%); team (18%); work environment (16%); task and technology (14%); and institutional context (13%). Subgroup analysis of incidents resulting in orchidectomies vs near misses demonstrated a different pattern of factors, with individual staff/training factors significantly more prominent: individual/training (88%); work environment (8%); and task and technology (1%). No evidenced improvement interventions were found in the literature.

CONCLUSION

This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near-miss incidents in patients presenting with testicular torsion. In England, a significant number of orchidectomies occur annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and (in the longer term) more exposure of trainees and medical students to urology to improve the testicular salvage rate.

Degrees of Multidisciplinarity Underpinning Care Planning for Patients with Cancer in Weekly Multidisciplinary Team Meetings: Conversation Analysis

Purpose

Despite an increase in research on multidisciplinary team (MDT) meetings, the implementation of MDT-driven decision-making, ie, its fidelity, remains unstudied. We report fidelity using an observational protocol measuring degree to which MDTs in their weekly meetings in the UK adhere to 1) the stages of group decision-making as per the ‘Orientation-Discussion-Decision-Implementation’ framework, and 2) cancer guidelines on the composition and characteristics of their weekly meetings produced by the UK’s Department of Health, UK’s National Cancer Action Team, Cancer Research UK, World Health Organization, and The Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales.

Patients and Methods

This is a prospective cross-sectional observational study of MDT meetings in the UK. Breast, colorectal, and gynecological cancer MDTs across three hospitals in the UK were video recorded over 12 weekly meetings, respectively, encompassing 822 case-reviews. A cross-section of 24 case-reviews was analysed with the main outcomes being adherence to the ‘Orientation-Discussion-Decision-Implementation’ framework, and the cancer guidelines.

Results

Eight percent of case-reviews in the MDT meetings involved all five core disciplines including surgeons, oncologists, radiologists, histopathologists, and specialist cancer nurses, and 38% included four. The majority of case-reviews (54%) were between two (25%) or three (29%) disciplines only. Surgeons (83%) and oncologists (8%) most consistently engaged in all stages of decision-making. While all patients put forward for MDT meeting were actually reviewed, 4% of them either bypassed the orientation (case presentation), and 8% did not articulate the final decision to the entire team.

Conclusion

We found that, despite being a set policy, cancer case-reviews in MDT meetings are not entirely MDT-driven, with more than half of the case-reviews not adhering to the cancer guidelines, and just over 10% not adhering to the group decision-making framework. The findings are in line with the UK recommendation on streamlining MDT meetings and could help decide how to re-organise the meetings to be most efficient. Implications are discussed in relation to quality and safety of care.

National implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of 'theory-of-change' methodology

BACKGROUND

There is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the 'Education in Quality Improvement' program (EQUIP) in UK urology residencies.

MATERIALS & METHODS

Theory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation 'Logic Model' in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis.

RESULTS

Core elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents' QI projects).

CONCLUSIONS

ToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.

The management of testicular torsion in the UK: How can we do better? A national quantitative and qualitative analysis of the factors affecting successful testicular salvage

BACKGROUND

Testicular torsion is a surgical emergency, requiring time-critical surgery to avoid potential organ loss. This study collates national data on paediatric testicular torsion, offering a comprehensive insight into the current standard of care in England for paediatric patients with suspected testicular torsion.

METHODS

National data collection using Freedom of Information requests. Of 134 acute secondary care NHS trusts in England that treat paediatric patients, responses were received from 121 trusts - representing 140 hospitals - providing a picture of the current standard of care in England.

FINDINGS

Less than two thirds of hospitals have a paediatric A&E department. One third of hospitals use inter-hospital transfer for paediatric patients with suspected torsion, with variable age restrictions. Mean transfer distance was 19·4 miles (range 2·2 to 61·6 miles). No statistically significant relationship between transfer arrangements and the number of non-viable testicle incidents was found (P = 0·15, ns). There was no correlation demonstrated nationally between size of population served and number of scrotal explorations completed (Pearson's r = 0·20 (CI -0·0·8-0·46), p = 0·16, ns). Qualitative thematic content analysis of serious incident reports identified common themes leading to missed diagnosis and delayed time to theatre: Education and Training, Communication, Transfer Complications, On-site Resources and Cross-site Working.

INTERPRETATION

We found variability in resource provision across England, as well as the number of explorations, and the number of unviable testicles found at exploration nationally. We received variable and incomplete data on emergency scrotal explorations and subsequent orchidectomies, very low levels of local audit and limited disclosure of incident reports. A mandatory national audit would allow more comprehensive data collection to accurately identify trends and make informed recommendations. To improve outcomes, we recommend continued education of ED and surgical teams, with mandatory testicular examination for young males presenting with abdominal pain. Whilst streamlining inpatient services is important, the time lost between symptom onset and seeking medical attention is crucial, and raising awareness in the community for young boys and parents may be imperative to improve rates of testicular salvage.

The Use of Healthcare Services by Prostate Cancer Patients in the Last 12 Months of Life: How Do We Improve the Quality of Care During This Period?

INTRODUCTION

Current research on prostate cancer is heavily focused on early detection and new treatments. There is a lack of research on the overall morbidity prostate cancer survivors face and the amount of healthcare treatment they receive toward the end of their lives. Identifying these care needs will allow appropriate healthcare modeling, resource allocation and service re-design to ensure higher quality care toward the end of life. The aim of this study is to quantify and analyze the use of healthcare services by patients dying with but not necessarily of prostate cancer.

METHODS

All patients who died with a diagnosis of prostate cancer during a 2-year period at a single hospital were included. Data on outpatient attendances, elective and emergency admissions and palliative care involvement in the 12 months prior to death were collected.

RESULTS

A total of 77 patients were included and of these, 60 (78.0%) had 545 scheduled appointments with 473 (86.8%) attendances. More non-attendances occurred in the last 6 months of life; 56 vs 16, p < 0.001. Nurse led clinics doubled in the last 6 months of life, 117 vs 66. There were 173 admissions from 63 (81.8%) patients resulting in 1816 days inpatient stay. This averaged to 2.7 admissions per patient for 10.5 days per episode. 32 (41.6%) patients were seen by palliative care resulting in 192 visits in total. 78 (40.6%) were inpatient and 114 (59.4%) were community reviews.

CONCLUSIONS

In the last year of life, prostate cancer patients use a considerable amount of healthcare resources. Understanding this clinical and economical burden is important for healthcare remodeling to provide better quality care that is cost effective.

Quality improvement for cancer multidisciplinary teams: lessons learned from the Anglian Germ Cell Cancer Collaborative Group

Shamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisation of treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients, streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement.

Gaps and Overlaps in Cancer Multidisciplinary Team Communication: Analysis of Speech

Guided by the principles of conversation analysis, we examined the communication practices used to negotiate levels of participation in cancer multidisciplinary team meetings and their implications for patient safety. Three cancer teams participated. Thirty-six weekly meetings were video recorded, encompassing 822 case reviews. A cross-section was transcribed using Jefferson notation. We found a low frequency of gaps between speakers (3%), high frequency of overlaps (24%), and no-gaps-no-overlaps (73%), suggesting fast turn transitions. Securing a turn to speak is challenging due to a systematic reduction in turn-taking opportunities. We contribute to group research with the development of a microlevel methodology for studying multidisciplinary teams.

GP experience and understandings of providing follow-up care in prostate cancer survivors in England

Survival times for prostate cancer have increased substantially, meaning more survivors will be discharged to General Practitioners' (GP) services. The detection of recurrence and monitoring of symptoms and long-term side-effects in prostate cancer survivors requires the active involvement of GPs in their follow-up care. In order to address this, the transition and discharge from hospital to primary care must be managed effectively. The objective of this study was to examine the preparedness, concerns and experiences of GPs in relation to their role in providing follow-up care to prostate cancer survivors. Purposive sampling was used to recruit GPs with experience in providing care to prostate cancer survivors. Twenty semi-structured telephone interviews were conducted with GPs across England. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Participants described their current role in the follow-up pathway, a number of challenges and barriers in assuming this role, and potential ways to resolve these and improve their involvement. They expressed a range of views about their preparedness and willingness to take over follow-up care after discharge for this group of patients. GPs had reservations about workload, lack of resources, expertise and deficiencies in communication with hospitals. Findings from this study suggest that GPs will be ready to take over the follow-up care of prostate cancer survivors if better information, additional training and adequate resources are provided and communication lines with hospital specialists are clear. Understanding the issues faced by GPs and overcoming identified barriers to providing follow-up care to prostate cancer survivors will provide the insight necessary to make the process of transferring care from secondary to primary teams a more straightforward task for all stakeholders.

Assessing the current state of quality improvement training in urology in the UK: Findings from the General Medical Council 2018 trainee survey

Objective:

The General Medical Council (GMC) of the UK has identified the need to support doctors through education in safety and quality improvement (QI) methods. This study reports findings from the GMC annual survey of 2018 from urology trainees regarding the state of QI training and their training needs.

Material and methods:

We designed a set of four questions to assess how QI methods are being taught nationally, and inserted them in the 2018 annual GMC trainee survey for urology. This is a cross-sectional study assessing the current state of QI training and mentoring received by trainees, and their self-assessed ability and confidence in completing a QI project as part of training requirements. Data were statistically analysed in Stata 15 stratified by Local Education Training Boards (LETBs)/Deanery and by specialty trainee level (ST3–7).

Results:

In total, 270 responses were received from urology trainees. Data showed significant variation across the country. Responses from ST3–7 trainees ranged from 5–20% on completing more than three QI projects, while 7–58% replied that they had done none. Across all ST grades, 40% of trainees stated they had not undertaken QI, whereas 0–27% reported they had not received any mentoring on QI to date. There was significant variation across training regions too: 11–74% of trainees answered that they have received training in QI methods, and 58–100% responded that they were confident in undertaking QI projects. Across all LETBs, 1–3% responded that they uploaded projects on national websites for dissemination; finally, a range of 0–18% stated they had completed more than three projects.

Conclusion:

This is the first national snapshot of QI training for the entire urology specialty in the UK. The study demonstrates wide variation in QI training and activity undertaken by trainees, and shows a lack of systematic implementation of QI education across training regions.

Level of evidence:

2c

A measure of case complexity for streamlining workflow in multidisciplinary tumor boards: Mixed methods development and early validation of the MeDiC tool

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.

Prescription switching: Rationales and risks

BACKGROUND

Therapeutic drug switching is commonplace across a broad range of indications and, within a drug class, is often facilitated by the availability of multiple drugs considered equivalent. Such treatment changes are often considered to improve outcomes via better efficacy or fewer side effects, or to be more cost-effective. Drug switching can be both appropriate and beneficial for several reasons; however, switching can also be associated with negative consequences.

AIM

To consider the impact of switching in two situations: the use of statins as a well-studied example of within-class drug switching, and gonadotropin-releasing hormone (GnRH)-targeting drug switching as an example of cross-class switching.

RESULTS

With the example of statins, within-class switching may be justified to reduce side effects, although the decision to switch is often also driven by the lower cost of generic formulations. With the example of GnRH agonists/antagonists, switching often occurs without the realisation that these drugs belong to different classes, with potential clinical implications.

CONCLUSION

Lessons emerging from these examples will help inform healthcare practitioners who may be considering switching drug prescriptions.

Pilot implementation and evaluation of a national quality improvement taught curriculum for urology residents: Lessons from the United Kingdom

BACKGROUND

We report the immediate educational impact of a previously developed quality improvement (QI) curriculum for UK urology residents.

MATERIALS AND METHODS

Prospective pre/post-training evaluation, using the Kirkpatrick framework: residents' QI knowledge, skills and attitudes were assessed via standardized assessments. We report descriptive/inferential statistics and scales psychometric analyses.

RESULTS

Ninety-eight residents from across the UK provided full datasets. Scale reliability was good (Cronbach-alphas = 0.485-0.924). Residents' subjective knowledge (Mpre = 2.71, SD = 0.787; Mpost = 3.97, SD = 0.546); intentions to initiate QI (Mpre = 3.65, SD = 0.643; Mpost = 4.09, SD = 0.642); attitudes towards doing QI (Mpre = 3.67, SD = 0.646; Mpost = 4.11, SD = 0.591); attitudes towards QI at work (Mpre = 3.80, SD = 0.511; Mpost = 4.00, SD = 0.495); and attitudes towards influencing QI (Mpre = 3.65, SD = 0.482; Mpost = 3.867, SD = 0.473) all improved post-training (all ps < 0.0001). Objective knowledge remained stable (58%-59%, p > 0.05). Residents' satisfaction was high.

CONCLUSIONS

Our novel QI training is educationally sound and feasible to deliver. Longitudinal evaluation and scalability are planned.

An Integrated Literature Review of Time-on-Task Effects With a Pragmatic Framework for Understanding and Improving Decision-Making in Multidisciplinary Oncology Team Meetings

Multidisciplinary oncology team meetings (MDMs) or tumor boards, like other MDMs in healthcare, facilitate the incorporation of diverse clinical expertise into treatment planning for patients. Decision-making (DM) in relation to treatment planning in MDMs is carried out repeatedly until all patients put forward for discussion have been reviewed. Despite continuing financial pressure and staff shortages, the workload of cancer MDMs, and therefore meeting duration continue to increase (up to 5 h) with patients often receiving less than 2 min of team input. This begs the question as to whether the current set-up is conducive to achieve optimal DM, which these multi-specialty teams were set out to achieve in the first place. Much of what it is known, however, about the effects of prolonged cognitive activity comes from various subfields of science, leaving a gap in applied knowledge relating to complex healthcare environments. The objective of this review was thus to synthesize theory, evidence and clinical practice in order to bring the current understanding of prolonged, repeated DM into the context of cancer MDMs. We explore how and why time spent on a task affects performance in such settings, and what strategies can be employed by cancer teams to counteract negative effects and improve quality and safety. In the process, we propose a pragmatic framework of repeated DM that encompasses the strength, the process and the cost-benefit models of self-control as applied to real-world contexts of cancer MDMs. We also highlight promising research avenues for closing the research-to-practice gap. Theoretical and empirical evidence reviewed in this paper suggests that over prolonged time spent on a task, repeated DM is cognitively taxing, leading to performance detriments. This deterioration is associated with various cognitive-behavioral pitfalls, including decreased attentional capacity and reduced ability to effectively evaluate choices, as well as less analytical DM and increased reliance on heuristics. As a short to medium term improvement for ensuring safety, consistently high quality of care for all patients, and the clinician wellbeing, future research and interventions in cancer MDMs should address time-on-task effects with a combination of evidence-based cognitive strategies. We propose in this review multiple measures that range from food intake, short breaks, rewards, and mental exercises. As a long term imperative, however, capacity within cancer services needs to be reviewed as well as how best to plan workforce development and service delivery models to achieve population coverage whilst maintaining safety and quality of care. Hence the performance detriments that arise in healthcare workers as a result of the intensity (time spent on a task) and complexity of the workload require not only more research, but also wider regulatory focus and recognition.

Do multidisciplinary cancer care teams suffer decision-making fatigue: an observational, longitudinal team improvement study

OBJECTIVE

The objective of this study was to examine effectiveness of codesigned quality-improving interventions with a multidisciplinary team (MDT) with high workload and prolonged meetings to ascertain: (1) presence and impact of decision-making (DM) fatigue on team performance in the weekly MDT meeting and (2) impact of a short meeting break as a countermeasure of DM fatigue.

DESIGN AND INTERVENTIONS

This is a longitudinal multiphase study with a codesigned intervention bundle assessed within team audit and feedback cycles. The interventions comprised short meeting breaks, as well as change of room layout and appointing a meeting chair.

SETTING AND PARTICIPANTS

A breast cancer MDT with 15 members was recruited between 2013 and 2015 from a teaching hospital of the London (UK) metropolitan area.

MEASURES

A validated observational tool (Metric for the Observation of Decision-making) was used by trained raters to assess quality of DM during 1335 patient reviews. The tool scores quality of information and team contributions to reviews by individual disciplines (Likert-based scores), which represent our two primary outcome measures.

RESULTS

Data were analysed using multivariate analysis of variance. DM fatigue was present in the MDT meetings: quality of information (M=16.36 to M=15.10) and contribution scores (M=27.67 to M=21.52) declined from first to second half of meetings at baseline. Of the improvement bundle, we found breaks reduced the effect of fatigue: following introduction of breaks (but not other interventions) information quality remained stable between first and second half of meetings (M=16.00 to M=15.94), and contributions to team DM improved overall (M=17.66 to M=19.85).

CONCLUSION

Quality of cancer team DM is affected by fatigue due to sequential case review over often prolonged periods of time. This detrimental effect can be reversed by introducing a break in the middle of the meeting. The study offers a methodology based on 'team audit and feedback' principle for codesigning interventions to improve teamwork in cancer care.

Development and implementation of a national quality improvement skills curriculum for urology residents in the United Kingdom: A prospective multi-method, multi-center study

BACKGROUND

Surgical quality improvement (QI) is a global priority. We report the design and proof-of concept testing of a QI skills curriculum for urology residents.

METHODS

'Umbrella review' of QI curricula (Phase-1); development of draft QI curriculum (Phase-2); curriculum review by Steering Committee of urologists (Attendings & Residents), QI and medical education experts and patients (Phase-3); proof-of-concept testing (Phase-4).

RESULTS

Phase-1: Six systematic reviews were identified of 4332 search hits. Most curricula are developed/evaluated in the USA; use mixed teaching methods (incl. didactic, QI exercises & self-reflection); and introduce core QI techniques (e.g., Plan-Do-Study-Act). Phase-2: curriculum drafted. Phase-3: the curriculum was judged to represent state-of-the-art, relevant QI training. Stronger patient involvement element was incorporated. Phase-4: the curriculum was delivered to 43 urology residents. The delivery was feasible; the curriculum implementable; and a knowledge-skills-attitudes evaluation approach successful.

CONCLUSION

We have developed a practical QI curriculum, for further evaluation and national implementation.

Implementation of guidelines for multidisciplinary team management of pregnancy in women with pre-existing diabetes or cardiac conditions: results from a UK national survey

Abstract

Background

Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes.

Methods

National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance.

Results

One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists.

Conclusions

The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1609-9) contains supplementary material, which is available to authorized users.

CanWalk: a feasibility study with embedded randomised controlled trial pilot of a walking intervention for people with recurrent or metastatic cancer

OBJECTIVES

Walking is an adaptable, inexpensive and accessible form of physical activity. However, its impact on quality of life (QoL) and symptom severity in people with advanced cancer is unknown. This study aimed to assess the feasibility and acceptability of a randomised controlled trial (RCT) of a community-based walking intervention to enhance QoL in people with recurrent/metastatic cancer.

DESIGN

We used a mixed-methods design comprising a 2-centre RCT and nested qualitative interviews.

PARTICIPANTS

Patients with advanced breast, prostate, gynaecological or haematological cancers randomised 1:1 between intervention and usual care.

INTERVENTION

The intervention comprised Macmillan's 'Move More' information, a short motivational interview with a recommendation to walk for at least 30 min on alternate days and attend a volunteer-led group walk weekly.

OUTCOMES

We assessed feasibility and acceptability of the intervention and RCT by evaluating study processes (rates of recruitment, consent, retention, adherence and adverse events), and using end-of-study questionnaires and qualitative interviews. Patient-reported outcome measures (PROMs) assessing QoL, activity, fatigue, mood and self-efficacy were completed at baseline and 6, 12 and 24 weeks.

RESULTS

We recruited 42 (38%) eligible participants. Recruitment was lower than anticipated (goal n=60), the most commonly reported reason being unable to commit to walking groups (n=19). Randomisation procedures worked well with groups evenly matched for age, sex and activity. By week 24, there was a 45% attrition rate. Most PROMs while acceptable were not sensitive to change and did not capture key benefits.

CONCLUSIONS

The intervention was acceptable, well tolerated and the study design was judged acceptable and feasible. Results are encouraging and demonstrate that exercise was popular and conveyed benefit to participants. Consequently, an effectiveness RCT is warranted, with some modifications to the intervention to include greater tailoring and more appropriate PROMs selected.

TRIAL REGISTRATION NUMBER

ISRCTN42072606.

Predictors of Treatment Decisions in Multidisciplinary Oncology Meetings: A Quantitative Observational Study

BACKGROUND

In many healthcare systems, treatment recommendations for cancer patients are formulated by multidisciplinary tumor boards (MTBs). Evidence suggests that interdisciplinary contributions to case reviews in the meetings are unequal and information-sharing suboptimal, with biomedical information dominating over information on patient comorbidities and psychosocial factors. This study aimed to evaluate how different elements of the decision process affect the teams' ability to reach a decision on first case review.

METHODS

This was an observational quantitative assessment of 1045 case reviews from 2010 to 2014 in cancer MTBs using a validated tool, the Metric for the Observation of Decision-making. This tool allows evaluation of the quality of information presentation (case history, radiological, pathological, and psychosocial information, comorbidities, and patient views), and contribution to discussion by individual core specialties (surgeons, oncologists, radiologists, pathologists, and specialist cancer nurses). The teams' ability to reach a decision was a dichotomous outcome variable (yes/no).

RESULTS

Using multiple logistic regression analysis, the significant positive predictors of the teams' ability to reach a decision were patient psychosocial information (odds ratio [OR] 1.35) and the inputs of surgeons (OR 1.62), radiologists (OR 1.48), pathologists (OR 1.23), and oncologists (OR 1.13). The significant negative predictors were patient comorbidity information (OR 0.83) and nursing inputs (OR 0.87).

CONCLUSIONS

Multidisciplinary inputs into case reviews and patient psychosocial information stimulate decision making, thereby reinforcing the role of MTBs in cancer care in processing such information. Information on patients' comorbidities, as well as nursing inputs, make decision making harder, possibly indicating that a case is complex and requires more detailed review. Research should further define case complexity and determine ways to better integrate patient psychosocial information into decision making.

The anatomy of clinical decision-making in multidisciplinary cancer meetings: A cross-sectional observational study of teams in a natural context

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled "Holistic and Clinical inputs" (patient views, psychosocial aspects, patient history, comorbidities, oncologists', nurses', and surgeons' inputs), "Radiology" (radiology results, radiologists' inputs), "Pathology" (pathology results, pathologists' inputs), and "Meeting Management" (meeting chairs' and coordinators' inputs). A negative cross-loading was observed from surgeons' input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs' input and their corresponding surgical input into case reviews.

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

OBJECTIVE

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

DESIGN

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

SETTING

Study 2 included 10 cancer MDMs in England.

PARTICIPANTS

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

INTERVENTION

None.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Preventing ‘same-day’ cancellations in elective urological surgery: Are different strategies needed for inpatient, day case and procedural admissions?

Background:

Late surgical cancellations adversely impact patients and efficient use of hospital resources. Non-clinical reasons have a cancellation rate of 0.77%, but when including clinical reasons this rate rises to 13%–15%.1–4

Objectives:

The objectives of this article are to identify reasons for cancellations of elective urological procedures at a single centre across different procedure types and to make recommendations for prevention.

Methods:

Rates and reasons for late cancellation of urological surgery were retrospectively audited for the period April 2009 to April 2012. For each cancellation, reasons were classified: Patient-related, Facility-related, Work-up, Change in medical condition, Process-related, Miscellaneous.

Results:

During the study period, 9039 elective operations were reviewed to find 2804 cancellations: 580, 450, 1774 (rates = 15.6%, 21.7% and 29.3%) for inpatient, day case and procedure-room cases, respectively. Thirty per cent of inpatient cancellations were due to process-related factors, and 35% due to change in medical condition, of which 78% were urinary tract infection (UTI). Patient-related factors accounted for the majority (52%) of day case and procedural cancellations.

Conclusions:

Causes for cancellations vary according to procedure type, suggesting tailored strategies are needed for prevention. Change in medical condition caused similar rates of cancellation across procedure type (35%, 28% and 25%). Inpatient procedures were prone to process-related cancellations especially over-run theatre sessions. Patient surveys and reminders closer to time of operation, improvements in preoperative UTI detection and treatment and further process mapping is recommended to identify exact reasons behind and decrease cancellations.

Management of pregnant and postnatal women with pre-existing diabetes or cardiac disease using multi-disciplinary team models of care: a systematic review

BACKGROUND

More women with an increased risk of poor pregnancy outcome due to pre-existing medical conditions are becoming pregnant. Although clinical care provided through multi-disciplinary team (MDT) working is recommended, little is known about the structure or working practices of different MDT models, their impact on maternal and infant outcomes or healthcare resources. The objectives of this review were to consider relevant international evidence to determine the most appropriate MDT models of care to manage complex medical conditions during and after pregnancy, with a specific focus on pre-existing diabetes or cardiac disease in high income country settings.

METHODS

Quantitative and qualitative evidence of MDT models of care for the management of pregnant/postnatal women with pre-existing diabetes and cardiac disease was considered. A search of the literature published between January 2002 - January 2014 was undertaken. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Given limited primary and secondary research evidence, guidelines and opinion papers were included. Two independent reviewers conducted critical appraisal of included papers.

RESULTS

Nineteen papers were included from UK, Canada, USA, the Netherlands and Singapore. No studies were found which had compared MDT models for pregnant/postnatal women with pre-existing diabetes or cardiac disease. Two small retrospective studies reported better outcomes for women with cardiac disease if an MDT approach was used, although evidence to support this was limited. Due to study heterogeneity it was not possible to meta-analyse data. No evidence was identified of MDT management in the postnatal period or impacts of MDT working on healthcare resources.

CONCLUSIONS

Despite widespread promotion of MDT models of care for pregnant and postnatal women with pre-existing diabetes or cardiac disease, there is a dearth of primary evidence to inform structure or working practices or beneficial impact on maternal and infant outcomes or healthcare resources. Primary research into if or how MDT models of care improve outcomes for women with complex pregnancies is urgently needed.

Psychological distress in out-patients undergoing flexible cystoscopy for the investigation of bladder cancer

Objectives:

Flexible cystoscopy can cause patients significant psychological distress, especially when utilised in the diagnostic pathway for suspected bladder cancer. We aimed to assess the prevalence of general anxiety and depression, as well as procedure-related worry and pain in patients undergoing local anaesthetic flexible cystoscopy and to determine whether these conditions occur more frequently in subsets of the population.

Patients and methods:

Patients referred for flexible cystoscopy were invited to participate. Patients were asked to complete a questionnaire containing the Hospital Anxiety and Depression Scale (HADS), a worry score and a question regarding the most stressful event in the diagnostic pathway. Following the procedure patients were also asked to complete a pain score.

Results:

A total of 175 patients participated in the study. The prevalence of significant anxiety was 15% and depression 3.5%. This was higher in younger, female and unmarried patients. Procedure-related worry and pain were generally low.

Conclusions:

We found the prevalence of anxiety and depression in patients undergoing flexible cystoscopy to be raised compared to a similar cohort of patients undergoing TRUS-guided prostate biopsy. We have identified subgroups more likely to experience these symptoms and have also identified the sections of the diagnostic pathway that are most likely to cause anxiety and depression. By doing this we can target those patients who are more likely to suffer during the diagnostic process and aim to improve their experience. We can also implement targeted changes to the pathway to reduce the impact it may have on patients’ mental health.

Management of Node-Positive Bladder Cancer After Neoadjuvant Chemotherapy and Radical Cystectomy: A Survey of Current UK Practice

INTRODUCTION

Because of the lack of published evidence, this study was done to explore the decisions and rationale of uro-oncology consultants regarding the treatment of patients with muscle-invasive bladder cancer who have positive lymph nodes after radical cystectomy (RC) and neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

An electronic survey was sent to UK pelvic cancer centers regarding: (1) choice of NAC regimen; (2) indications for reimaging; (3) choice and indication of adjuvant chemotherapy (AC) for patients with nodal disease after NAC and RC; (4) choice and indication of chemotherapy regimen if disease continues to progress in patients with advanced bladder cancer; and (5) guidelines used by those surveyed.

RESULTS

Consultant uro-oncologists from 77% of UK pelvic cancer centers responded, who treated a median of 13 patients per year with NAC before RC. Three cycles of gemcitabine and cisplatin was the most common NAC regimen, with 93% and 67% respondents giving it for downstaging of cN1- and cN2- and 3-positive patients, respectively. Forty-five percent would not give AC after NAC and RC in patients with positive lymph nodes. The patient's performance status, followed by response to NAC were key factors in dictating the use of AC. In the presence of disease progression, 46% of participants would use a taxane. Fifty-two percent of responders do not follow any guidelines.

CONCLUSION

In the United Kingdom, the treatment of patients with nodal disease after NAC and RC is variable. There is little evidence on which to base the management of such patients. The creation of national and international guidelines might help clinicians to optimize care for these patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Quantifying the risk of malignancy in patients with visible haematuria presenting to the emergency department

Introduction:

Visible haematuria (VH) is a very common presentation to the emergency department (ED). In an outpatient setting, 18%−24% of such patients have been shown to have an underlying malignancy. The aim of this study is to determine the malignancy rates of patients presenting acutely to ED and whether the degree of bleeding or presence of clots is a higher risk factor for cancer.

Method:

We retrospectively collected data from adult patients (>18 years) presenting to ED with VH for a six-month period. Diagnostic outcomes after one year were assessed.

Results:

Our study population has 96 patients (male = 77, female = 19) with a mean age of 68 years (SD = 20.2). Twenty-eight patients (29%) had haematuria with clots. Twenty-five patients (26%) had a new diagnosis of malignancy, and 10 had a known diagnosis of malignant disease. Bladder cancer was the most commonly found malignancy, in 17 patients (15 new diagnoses), while prostate cancer was second with 14 cases (six new). Renal cancer two, testicular one and colorectal one accounted for the other new malignancies diagnosed following presentation. All but one patient with cancer were male. Although most malignancies were found in patients over 70 years old, the two youngest patients were in their 30s. The incidence of malignancy appears to increase in patients who have urinary blood clots (58%), p = 0.08.

Conclusion:

A third of patients presenting to ED with VH will have a urological cancer. Patients with VH and clots have a significantly higher incidence of malignancy. We recommend expedited referral of all such patients to a urologist.

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

Background

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

Methods

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

Results

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

Conclusion

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

Cancer patients' perspectives on multidisciplinary team working: an exploratory focus group study

This qualitative, focus-group study explores what patients understand about the multidisciplinary team (MDT) in cancer care. Participants were positive towards MDT working, and by strengthening the role of nurses in MDT decision-making, the representation of patients' interests can be improved.

Initial experience of intravesical gemcitabine for patients with high-risk superficial transitional cell carcinoma of the bladder following BCG failure

This study reports the use of intravesical gemcitabine in managing patients with high-risk bladder cancer, refractory to Bacillus Calmette-Guerin (BCG). Patients were given gemcitibine; treatment response was evaluated by fluorescence-cystoscopy biopsy and urine cytology. Time to reoccurrence increased with instillation time.

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.

Simulation of the upper urinary system

The ureter and its peristalsis motions have long been of significant interest in biomechanics. In this article we review experimental, theoretical, and numerical studies of the behavior of the ureter together with its mechanical properties, emphasizing studies that contain information of importance in building a virtual simulation tool of the complete ureter that includes its complex geometry, nonlinear material properties, and interaction with urine flow. A new technique to model the contraction of a ureter, which directly applies wall forces to model pacemaker activities, is presented. The required further steps to capture the full complex movement of the peristalsis are discussed, aiming to construct a computational platform that will provide a reliable tool to assist in the investigation and design of material devices (stents) for the renal system.