Annals of Oncology Advance Access originally published online on December 1, 2005
Annals of Oncology 2006 17(3):457-460; doi:10.1093/annonc/mdj102
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
© 2005 European Society for Medical Oncology
Analysis of clinical decision-making in multi-disciplinary cancer teams
1 Department of Social Medicine, Canynge Hall, University of Bristol, Bristol, UK; 2 Clinical Sciences at South Bristol, University of Bristol, Bristol, UK
* Correspondence to: Dr J. M. Blazeby, Department of Social Medicine, Canynge Hall, Whiteladies Road, Clifton, Bristol BS8 2PR, UK. Tel: +44 117 9287231; E-mail: j.m.blazeby{at}bris.ac.uk
 |
Abstract |
|---|
 Top Abstract introductionmethodsresultsdiscussionReferences |
|---|
Management decisions for patients with cancer are frequently taken within the context of a multi-disciplinary team (MDT). There is little known, however, about decision-making at team meetings and whether MDT decisions are all implemented. This study evaluated team decision-making in upper gastrointestinal cancer. Consecutive MDT treatment decisions were recorded for patients with oesophageal, gastric, pancreatic and peri-ampullary tumours. Implementation of MDT decisions was investigated by examining hospital records. Where decisions were implemented it was recorded as concordant and discordant if the decision changed. Reasons for changes in MDT decisions were identified. 273 decisions were studied and 41 (15.1%) were discordant (not implemented), (95% confidence interval 11.1–20.0%). Looking at the reasons for discordance, 18 (43.9%) were due to co-morbid health issues, 14 (34.2%) related to patient choice and 8 (19.5%) decisions changed when more clinical information was available. For one discordant decision, the reason was not apparent. Discordant decisions were more frequent for patients with pancreatic or gastric carcinoma as compared to oesophageal cancer (P = 0.001). Results show that monitoring concordance between MDT decisions and final treatment implementation is useful to inform team decision-making. For upper gastrointestinal cancer, MDTs require more information about co morbid disease and patient choice to truly optimize the implementation of multi-disciplinary expertise.
Key words: decisions, co-morbid health, multi-disciplinary teams, patient choice
|
introduction |
|---|
|
TopAbstractintroductionmethodsresultsdiscussionReferences |
|---|
Increasing specialisation and complexity of knowledge has led to the introduction of multi-disciplinary teams (MDTs) for the management of patients with cancer [1
, 2]. In the United Kingdom, this model has been adopted for delivery of cancer services and site-specific specialist teams meet regularly to discuss patients and make treatment decisions. Teams are constituted according to standard national guidance and for upper gastrointestinal cancer key members include surgeons, oncologists, gastroenterologists, radiologists, pathologists and specialist nurses [3]. Periodical peer review of cancer services audits MDT constitution and other processes, to ensure they have a coordinated infrastructure, but currently, detailed evaluation of the clinical effectiveness of team working and the quality of team decisions is not undertaken [4, 5].
Factors that influence treatment decisions in upper gastro intestinal cancer include disease stage, co-morbid health status and patient preferences. At MDT meetings, there is detailed radiology and pathology review and discussion of patient's clinical details. Consensus agreement is then reached after consideration of available therapeutic options [1]. Multi-disciplinary teams decisions are then shared with the patient and a final treatment plan agreed. Assessing the quality of decision processes within MDTs is not possible with a prospective interventional study because MDT meetings have become established practice. A proposed method to evaluate MDT treatment decisions is to investigate if MDT decisions are actually implemented, by anticipating that MDT decisions made under the best circumstances with relevant information and experts available will lead to treatment decisions that are implemented in almost 100% of situations. This study tested this hypothesis by examining concordance between MDT decisions and treatment implementation in the setting of an upper gastrointestinal cancer MDT. The study also investigated reasons for changes in MDT decisions.
|
methods |
|---|
|
TopAbstractintroductionmethodsresultsdiscussionReferences |
|---|
Consecutive upper gastro intestinal MDT meetings held at Bristol Royal Infirmary were prospectively studied between October 2003 and March 2004. The MDT meeting at Bristol Royal Infirmary has referrals from the Avon, Somerset and Wiltshire Cancer Network, including United Bristol Healthcare Trust, North Bristol Trust (Frenchay and Southmead Hospitals), Royal United Hospital, Bath, East Somerset Trust (Yeovil District Hospital), Taunton and Somerset NHS Trust (Musgrove Park Hospital) and Weston Area Healthcare Trust (Weston Super Mare Hospital). Patients are referred to the MDT once a diagnosis has been made and the information is made available to the MDT from clinicians and specialist nurses from the satellite hospitals. The MDT in Bristol makes treatment decisions for all referrals, but only patients requiring major cancer resection undergo surgery in Bristol. Where other forms of treatment are required (e.g. chemotherapy) this is administered most frequently by the referring hospital. Final treatment decisions for new patients with oesophageal, gastric, pancreatic and peri-ampullary cancer were recorded because standard referral pathways and protocols are used in this MDT for these disease sites. Excluded were decisions about recurrent disease, rare tumours, primary and secondary liver tumours and decisions for further investigations. Patients with a second primary cancer were also excluded. Clinical information, age, gender, stage and diagnostic disease group were also recorded. Two independent researchers examined hospital and pathology records, oncology prescription charts and endoscopy records to obtain the final treatment that patients had received. MDT treatment decisions were compared with final treatments received and classified as (a) concordant (MDT decision the same as treatment received), or (b) discordant (MDT decision different to treatment received). Where decisions were discordant, the hospital's notes were examined in full and reasons for a change in management plan identified and classified as: patient's choice, co-morbid health issues, new clinical information unavailable to the MDT or ‘no apparent reason’. Where co-morbid health issues were recorded as the reason for a change in treatment decision, this included all medical conditions such as pre-existing cardiopulmonary disease that might preclude a patient from major surgery, chemotherapy or radiotherapy. Meetings were held to discuss the final categories of discordance and reasons for changes in treatment plan, when the two researchers did not reach similar conclusions.
data analyses
It was calculated that a sample size of 300 decisions would allow estimation of a 10% risk of discordance with acceptable precision (standard error 1.7%). The proportion of decisions changed was estimated with an exact binomial confidence interval. A multivariate logistic regression model, with all clinical variables (age, sex, MDT decision and diagnostic disease group) included as covariates, was used to estimate the independent effect of each of these variables on the odds of discordance.
|
results |
|---|
|
TopAbstractintroductionmethodsresultsdiscussionReferences |
|---|
Records of 300 MDT decisions were included, but 27 had to be excluded because a more detailed examination of their clinical information showed that they did not meet the inclusion criteria. 273 patients were therefore studied and information on final treatment was available for all but two decisions. The clinical details and treatments decisions are shown in Table 1. More treatment decisions were palliative in intent than potentially curative (55% vs. 45%), representing the referral practice within the cancer network. Most treatment decisions were for oesophageal and gastric cancers.
|
Of the 271 MDT decisions, 41 (15.1%, 95% confidence interval 11.1% to 20.0%) were not implemented (discordant). Discordance almost always arose from patients receiving a more conservative treatment than that originally planned: 14 patients recommended for curative treatment received palliative treatment and 25 patients recommended for an active palliative treatment ultimately received best supportive care.
Investigations into the reasons for discordance showed that 18 (43.9%) were due to patient co-morbid health issues, 14 (34.2%) related to patient choice, 8 (19.5%) decisions changed when more clinical information was available (e.g. metastatic disease discovered at surgery) and for one discordant decision, the reason was not apparent. Multivariate analysis showed that diagnosis was a more important reason for not following the MDTs recommendation compared to being female or of older age (Table 2).
|
|
discussion |
|---|
|
TopAbstractintroductionmethodsresultsdiscussionReferences |
|---|
Multi-disciplinary teams are considered central to the delivery of high quality cancer care and treatment decision-making is a key function. This study shows that 15.1% of treatment decisions made at the upper gastrointestinal MDT meetings at United Bristol Healthcare Trust were not implemented (95% confidence intervals 11.1% to 20.0%). Reasons for MDT decisions changing were mostly related to lack of information concerning patients' wishes or co-morbid disease and only eight decisions changed because unexpected metastatic disease was discovered at surgery. It is therefore proposed that monitoring concordance between MDT treatment decisions and final treatment implementation is an informative way of evaluating MDT decisions. It is also proposed that where MDT treatment decisions are not implemented that finding out the reasons for changing the management plan will subsequently inform the MDT of areas that need further attention.
The most common reason for an MDT decision being changed was where patients' co-morbid health status had not been sufficiently considered at the meeting. Co-morbid health status is critical to decision-making for major upper gastrointestinal surgery, where operative mortality risks are high and increase with decreasing general health [6]. Consideration of general health is part of the standard discussion at the upper gastrointestinal MDT, although integration of detailed methods of preoperative risk assessment into daily clinical practise are unusual [7, 8]. A more systematic approach to assessment of health risks and inclusion of data into the multi-disciplinary meetings would allow time for medical optimisation, fully informed MDT decision-making and provision of risk-adjusted informed consent. Methods for standardising co-morbid health for patients with head and neck cancer have been developed and this model may be able to be translated into other cancer sites [9]. The importance of detailed inclusion of co-morbid health status within other cancer site MDT meetings will vary and also be related to the nature of treatment [10, 11]. Where treatment involves major surgery (e.g. gynaecological, head and neck and gastro-intestinal tumours) or radical chemoradiation treatment, accurate assessment of co-morbid disease conditions is particularly important and should be given full consideration [7, 12]. For other conditions (e.g. superficial bladder cancer) the information may be less relevant.
Team decisions were also not implemented because the MDT had not fully considered patients' wishes and once these were discovered at the out patient consultation a different treatment path was agreed. Assessing patients' preferences for treatment is relevant to all cancer sites and there is evidence that although patients' consider oncologists or surgeons' recommendations important, other factors also influence treatment choice, particularly in patients with advanced disease and limited life expectancy [11, 13, 14]. Whether including patients' preferences is feasible or informative at MDT meetings warrants further research. It may be difficult when the focus of the MDT tends to be on significant clinical factors such as grade and stage of tumour. This is likely to pose new challenges for doctors [15].
In this study, there were eight patients in whom surgical resection was intended, who did not undergo resection because unexpected metastatic disease was discovered at laparotomy. Despite extensive staging investigations for upper gastrointestional cancer, there will always be a small proportion of cases where unexpected peritoneal disease or locally advanced tumours are only found at laparotomy. Monitoring the rate at which this occurs is a useful tool to assess accuracy of radiological, endoscopic and laparoscopic staging procedures and will provide quality assurance data to the MDT.
Team working represents a potentially powerful lever for change in healthcare and the need to develop high performing teams is widely acknowledged. Systems for evaluating effectiveness of teams, however, are immature and methods to monitor performance, team working and outcome are required. There is a need to explore further whether the lack of concordance between MDT treatment decisions and treatment implementation found here is evident elsewhere. It seems essential to develop standardised methods to allow the inclusion of co-morbidity data and patient choice into MDT meetings, if decisions are to truly optimize multi-disciplinary expertise and patient consultation.
|
Acknowledgements |
|---|
J.M.B. is supported by a UK MRC Clinician Scientist Award. We thank Professors D. Alderson and B. Hassan (University of Bristol), Mr C. P. Barham, Dr M. Callaway, Miss N. Coates, Mrs S. Hodges, Mrs M. D. Finch-Jones, Dr R. Jones, Dr M. Moorhen, Dr J. Virjee, Mrs J. Witherstone (United Bristol Healthcare Trust), Mr C. P. Armstrong, Ms I. Battiwalla, Dr E. Loveday, Miss S. Norton, Mr M. Thompson, (North Bristol Trust), Mr A. Gough, Mrs K. Low (Weston Super Mare Hospital), Mr R. Krysztopik, (Royal United Hospital Bath), Miss M. Cudbill (Musgrove Park Hospital, Taunton) and all members of the upper gastrointestinal cancer MDT in Bristol Royal Infirmary for allowing us to study the MDT meetings.
Received for publication September 13, 2005. Revision received November 7, 2005. Accepted for publication November 8, 2005.
|
References |
|---|
|
TopAbstractintroductionmethodsresultsdiscussionReferences |
|---|
1. Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer. Gut 2002; 50 (Suppl 5): v1–23.
2. The NHS Cancer Plan. 2000. London, Department of Health, PO Box, 777, London SE1 6XH. UK. The NHS Plan and Services.
3. Executive NHS. Improving outcomes in upper gastro-intestinal cancers. The Manual 2001. London, Department of Health, PO Box, 777, London SE1 6XH, UK.
4. Haward RA. Using service guidance to shape the delivery of cancer services: experience in the UK. Br J Cancer 2003; 89 (Suppl 1): S12–S14.
5. Borrill CS, West MA, Shapiro D, Rees A. Team working and effectiveness in health care. Br J Health Care Manage 2000; 6: 364–371.
6. McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro-oesphageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. Br Med J 2003; 327: 756–761.
7. Bartels HE, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer. Br J Surg 1998; 85: 840–844.[CrossRef][ISI][Medline]
8. Zafirellis KD, Fountoulakis A, Dolan K, Dexter SP, Martin IG, Sue-Ling HM. Evaluation of POSSUM in patients with oesophageal cancer undergoing resection. Br J Surg 2002; 89: 1150–1155.[CrossRef][Medline]
9. Piccirillo JF, Lacy PD, Basu A, Spitznagel EL. Development of a new head and neck cancer-specific comorbidity index. Arch Otolaryngol Head Neck Surg 2002; 128: 1172–1179.
10. Read WL, Tierney RM, Page NC et al. Differential prognostic impact of comorbidity. J Clin Oncol 2004; 22: 3099–3103.
11. Jansen SJ, Otten W, Stiggelbout AM. Review of determinants of patients' preferences for adjuvant therapy in cancer. J Clin Oncol 2004; 22: 3181–3190.
12. Piccirillo JF, Creech CM, Zequeira R, Anderson S, Johnston AS. Inclusion of comorbidity into oncology data registries. J Reg Management 1999; 26: 66–70.
13. Voogt E, van der HA, Rietjens JA et al. Attitudes of patients with incurable cancer toward medical treatment in the last phase of life. J Clin Oncol 2005; 23: 2012–2019.
14. Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol 2003; 21: 1379–1382.
15. Say RE, Thomson R. The importance of patient preferences in treatment decisions—challenges for doctors. Br Med J 2003; 327: 542–545.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  F Kee, T Owen, and R Leathem Offering a prognosis in lung cancer: when is a team of experts an expert team? J. Epidemiol. Community Health, April 1, 2007; 61(4): 308 - 313. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Mileshkin and J. Zalcberg The multidisciplinary management of patients with cancer Ann. Onc., August 1, 2006; 17(8): 1337 - 1338. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||