Multidisciplinary Team Decision Research Articles

Abstract P4-07-22: Clinical decision support systems for multidisciplinary team decision-making in patients with solid cancer: an implementation model based on a scoping review

Abstract Background Clinical decision-making by multidisciplinary teams (MDTs) is getting more complex as treatment advice for the individual patient must be based on an increasing amount of patient and tumor characteristics, and scientific evidence on treatment efficacy. Clinical decision support systems (CDSSs) can make an important contribution to assist but also optimize MDT decision-making. However, implementation of CDSSs in clinical practice is challenging. Aim & methods The aim of our study is to set up a CDSSs implementation model for multidisciplinary decision-making in solid cancer. It is based on a scoping review of the currently reported CDSSs for MDT decision-making in solid cancers with identification of reported barriers and facilitators for implementation of these CDSSs. For this we systematically searched the Cochrane Library, MEDLINE (accessed through PubMed) and Scopus up to September 1st 2021. Results Of the 710 screened abstracts, 38 papers met the inclusion criteria (table 1). Sixteen different CDSSs were identified. For implementation of CDSSs, 87 barriers and 73 facilitators were reported. The reported barriers could be categorized in the same categories as those of the facilitators (a factor can be reported as a barrier if the factor is not addressed well, and as a facilitator if the factor is properly addressed). The most frequently reported barriers for CDSS implementation for MDT decision making mainly concerned CDSS maintenance (e.g. not incorporating guideline updates), loco-regional feasibility of the CDDS recommendation (e.g. no access to diagnostics or treatment), validity, not incorporating patient preference in decision making, data accuracy, noncoverage of certain patient subpopulations, lack of an information standard, usability, data availability and no interoperability of the CDSS with the electronic health record. The most frequently reported facilitators included, besides the categories as mentioned above, the category shared decision making (reporting of alternative treatment options) and technical skills (involvement of a computer scientist). Table 2 shows the most frequently reported categories of barriers and facilitators, and scores for each included study the number of reported barriers (B) and facilitators (F) in each category. Conclusion Based on the identified barriers and facilitators, we developed a CDSS implementation model to guide more successful CDSS integration in the clinical workflow to support MDTs (the model will be shown at the congress). The usability of this theoretical model should be explored in future studies. Table 1. Characteristics of 38 included articles Table 2. Overview of the most frequently reported categories of barriers and facilitators. For each included study the number of reported barriers (B) and facilitatiors (F) are scored for each category. Citation Format: Mathijs P. Hendriks, Kees C. Ebben, Janine A. Van Til, Agnes Jager, Sabine Siesling. Clinical decision support systems for multidisciplinary team decision-making in patients with solid cancer: an implementation model based on a scoping review [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-22.

Prescribing Exercise to Cancer Patients Suffering from Increased Bone Fracture Risk Due to Metastatic Bone Disease or Multiple Myeloma in Austria—An Inter- and Multidisciplinary Evaluation Measure

In the current absence of specific functional fracture risk assessment technology, the planning of physical exercise interventions for cancer patients suffering from increased bone fracture risk remains a serious clinical challenge. Until a reliable, solely technical solution is available for the clinician, fracture risk assessment remains an inter- and multidisciplinary decision to be made by various medical experts. The aim of this short paper is depicting how this challenge should be approached in the clinical reality according to Austrian experts in cancer rehabilitation, presenting the best-practice model in Austria. Following referral from the specialist responsible for the primary cancer treatment (oncologist, surgeon, etc.), the physiatrist takes on the role of rehabilitation case manager for each individual patient. Fracture risk assessment is then undertaken by specialists in radiology, orthopedics, oncology, and radiation therapy, with the result that the affected bone regions are classified as being at highly/slightly/not increased fracture risk. Following internal clearance, exercise planning is undertaken by a specialist in exercise therapy together with the physiatrist based on the individual's fracture risk assessment. In the case in which the patient shows exercise limitations due to additional musculoskeletal impairments, adjuvant physical modalities such as physiotherapy should be prescribed to increase exercisability. Exercise prescription for cancer patients suffering from increased fracture risk is an inter- and multidisciplinary team decision for each individual patient.

The management of non-diagnostic soft tissue tumour biopsies using a multi-disciplinary team approach: A 10-year retrospective review at a specialist sarcoma unit

Non-Diagnostic (ND) biopsies are occasionally encountered during the investigation of soft tissue sarcoma. We performed a retrospective review of all ND soft tissue biopsies discussed at our regional Multi-Disciplinary Team (MDT) meeting between 2004 & 2014 with the aim of establishing the incidence of ND biopsies, identifying predictive factors for repeat biopsies and evaluating the effectiveness of MDT decisions. We identified 80 ND out of 3233 biopsies. Diagnostic Yield (DY) was 97.5%, 76.0% and 77.8% for the first, second and third successive biopsy respectively. With an MDT approach utilising radiological and clinical information, the diagnostic success rate achieved was 98.5%, 82.0% and 77.8% for the first, second and third biopsies respectively. Malignant tumours (sarcoma & carcinoma) were 19 times more likely to undergo an increasing number of biopsies compared to benign lesions (p < 0.01), while repeat biopsies were less useful for suspected benign lesion. Although a repeat biopsy was only performed in 63% of cases, there were no patients originally diagnosed with a benign lesion that re-presented with the same lesion subsequently being malignant throughout the study period. Our study shows that a specialist MDT approach leads to high diagnostic rates and is a safe and effective method of preventing unnecessary, repeat biopsies where the initial biopsy is ND.

Impact of a Targeted Project for Shortening of Imaging Diagnostic Waiting Time in Patients with Suspected Oncological Diseases in Hungary

Background and Objectives: Medical imaging is a key element in the clinical workup of patients with suspected oncological disease. In Hungary, due to the high number of patients, waiting lists for Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were created some years ago. The Municipality of Budapest and Semmelweis University signed a cooperation agreement with an extra budget in 2020 (HBP: Healthy Budapest Program) to reduce the waiting lists for these patients. The aim of our study was to analyze the impact of the first experiences with the HBP. Material and Methods: The study database included all the CT/MRI examinations conducted at Semmelweis University with a referral diagnosis of suspected oncological disease within the first 13 months of the HBP (6804 cases). In our retrospective, two-armed, comparative clinical study, different components of the waiting times in the oncology diagnostics pathway were analyzed. Using propensity score matching, we compared the data of the HBP-funded patients (n = 450) to those of the patients with regular care provided by the National Health Insurance Fund (NHIF) (n = 450). Results: In the HBP-funded vs. the NHIF-funded patients, the time interval from the first suspicion of oncological disease to the request for imaging examinations was on average 15.2 days shorter (16.1 vs. 31.3 days), and the mean waiting time for the CT/MRI examination was reduced by 13.0 days (4.2 vs. 17.2 days, respectively). In addition, the imaging medical records were prepared on average 1.7 days faster for the HBP-funded patients than for the NHIF-funded patients (3.4 vs. 5.1 days, respectively). No further shortening of the different time intervals during the subsequent oncology diagnostic pathway (histological investigation and multidisciplinary team decision) or in the starting of specific oncological therapy (surgery, irradiation, and chemotherapy) was observed in the HBP-funded vs. the NHIF-funded patients. We identified a moderately strong negative correlation (r = -0.5736, p = 0.0350) between the CT/MR scans requested and the active COVID-19 case rates during the pandemic waves. Conclusion: The waiting lists for diagnostic CT/MR imaging can be effectively shortened with a targeted project, but a more comprehensive intervention is needed to shorten the time from the radiological diagnosis, through the decisions of the oncoteam, to the start of the oncological treatment.

Review of the role of MRI and 18 F-sodium fluoride PET/computed tomography in the characterisation of spinal bone metastases in a cohort of patients with breast cancer.

The purpose of the study was to compare the diagnostic accuracy and relative usefulness of MRI and 18 F-NaF (sodium fluoride) PET/computed tomography (CT) for detection of spinal bone metastases in a cohort of patients with high-risk breast cancer (BrCa). A retrospective study was conducted of patient and lesion-based analyses on 66 consecutive patients (median age, 62.5 years; age range, 33-91 years) who underwent Spinal MRI as well as 18 F-NaF PET-CT for restaging of newly diagnosed recurrent BrCa with no previous bone metastases. Both scans were performed within 20 days of each other. Review of prior images, clinical decisions, multi-disciplinary team discussions and decisions as well as follow-up information including scans and definitive tests was performed at least 12 months after the initial scans. Of the 66 patients reviewed, 26 patients had documented spinal bone metastases on one or both modalities, while 40 patients were considered bone disease free on both modalities and this was confirmed on follow-up. On lesion-based analysis, the findings of 18 F-NaF PET-CT and spinal MRI were concordant in 51 patients (77.3%). In the remaining patients, 18 F-NaF PET/CT detected more lesions in 4 patients (7.6%) and MRI detected more lesions in 10 patients (15.1%). Interestingly, there was a very high, 97 % concordance (64 patients) between spinal MRI and 18 F-NaF PET-CT when staging of spinal bone metastasis was taken into consideration. In one patient MRI identified two spinal bone metastases which were not seen on 18 F-NaF PET/CT; and, in one patient 18 F-NaF PET/CT showed few spinal bone metastases when no lesion was seen on MRI. Our study showed a high level of concordance between 18 F NaF PET-CT and spinal MRI within the setting of detection of bone lesions in the spine in a cohort of patients with high-risk BrCa. In our opinion, this high level of concordance negates the need to perform both tests although each test may be indicated for slightly different reasons. Further longitudinal studies across a longer duration and more centres may provide more definitive answers.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

IntroductionOptimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision. MethodsA prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed. ResultsOf 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea. ConclusionsAfter MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

OA19 A case of severe refractory lupus enteritis and nephritis that remitted with Obinutuzumab

Introduction/BackgroundSystemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost any organ system but gastrointestinal (GI) involvement is very rare. Obinutuzumab is a humanised type II anti-CD20 monoclonal antibody that is licensed to treat haematological malignancies. It has been used in a small number of SLE patients with secondary non-depletion non-response (2NDNR) to Rituximab and appears to be effective in lupus nephritis (LN) as outlined in the NOBILITY trial. We present a case of refractory lupus enteritis (LEn) and LN in a patient with 2NDNR to repeated Rituximab cycles that achieved remission with Obinutuzumab.Description/MethodA 19-year-old African woman was diagnosed with SLE in 2018 after presenting with polyarthritis without systemic involvement. Blood tests showed leucopenia, positive antinuclear antibody, anti-double-stranded DNA >200 IU/ml and hypocomplementaemia. Prednisolone and Methotrexate were commenced. However, one month later she presented to hospital with generalised abdominal pain, vomiting and diarrhoea. CT abdomen demonstrated significant small bowel wall thickening with mucosal hyperenhancement. Multidisciplinary team (MDT) input confirmed likely LEn. She was treated successfully with intravenous Methylprednisolone and Rituximab. Total parenteral nutrition was required for two weeks.Unfortunately, four further hospital admissions followed over the next six months due to GI symptoms, transient acute kidney injury and moderate proteinuria. Small bowel oedema persisted on MRI, three months after the CT. Renal biopsy demonstrated class 2 LN. Intravenous methylprednisolone helped and further Rituximab was given but she had infusion reactions. Six months later she re-presented with abdominal pain, synovitis and had nephrotic range proteinuria. She was treated again for LEn after gastroenterology input. Further Rituximab was given (MabThera instead of Truxima) but reactions still occurred and her B cells were non-deplete. Repeat renal biopsy confirmed class 4 LN and intravenous Cyclophosphamide (Euro-Lupus regimen) was commenced. This was repeated seven months later due to persisting high disease activity and proteinuria despite a short trial of intravenous Belimumab. However, she was admitted to hospital with colitis on CT after completing the second course of Cyclophosphamide. MDT decision was to treat with Obinutuzumab. Since commencing treatment eighteen months ago, her SLE has dramatically improved and she feels well for the first time. SLEDAI-2K score is 2 (16 pre-treatment), renal function has recovered with mild proteinuria. Anti-double-stranded DNA has reduced from >200 to 52.9 IU/ml and complements normalised. She remains on Prednisolone 5mg daily and Tacrolimus and a third maintenance dose of Obinutuzumab is planned.Discussion/ResultsLEn has been reported in only 0.2-5.8% of SLE cases. It is defined by the British Isles Lupus Assessment Group (BILAG 2004) by either vasculitis or inflammation of the small bowel supported by imaging or histology. Its pathogenesis is poorly understood but thought to be related to immune complex deposition and complement activation resulting in intestinal capillary leak and submucosal oedema. Symptoms are non-specific and a review by Janssens et al. (2013) suggested abdominal pain (97%), ascites (78%), nausea (49%), vomiting (42%) and diarrhoea (32%) were the most common symptoms in patients with LEn. They reported the ileum and jejunum were most commonly affected in LE (84% and 83% respectively), followed by colon (19%), duodenum (17%) and rectum (4%).Abdominal CT is considered to be the first line investigation and ‘classic’ radiological findings are bowel wall oedema (“target sign”), engorgement/increased number of mesenteric vessels (“comb sign”) and increased attenuation of the mesenteric fat (Ha et al. 2000, and Kim et al. 2006). These were all demonstrated on our patient’s initial CT abdomen which showed engorgement of the mesenteric vessels from the proximal jejunum to the proximal ileum.LEn seldom occurs in isolation and usually presents in the context of high disease activity and other systemic involvement. It is often responsive to glucocorticoids and bowel rest but further immunosuppression with Cyclophosphamide or Rituximab might be warranted in refractory cases as in our patient’s case.Obinutuzumab has been shown to be safe, effective and steroid-sparing in renal and non-renal SLE patients with 2NDNR to Rituximab from a case series of 9 patients by Arnold et al. (2022). This applied to LN in our patient and we believe this to be the first case where refractory LEn was treated successfully with Obinutuzumab.Key learning points/ConclusionAlthough very rare, have a high index of suspicion of LEn in SLE patients who present with GI symptoms and typical radiological findings.LEn often occurs with other systemic manifestations including LN and it is important to assess for these at the time of diagnosis of LEn.Obinutuzumab is an emerging treatment for severe SLE particularly 2NDNR to Rituximab and can improve both LN and LEn. We eagerly await results from the current REGENCY and ALLEGORY clinical trials which are assessing Obinutuzumab in renal and non-renal SLE patients respectively.

Long-term follow-up of surgical intervention pattern in pediatric low-grade gliomas: report from the German SIOP-LGG 2004 cohort.

Neurosurgical treatment is an integral part of the treatment algorithms for pediatric low-grade glioma (LGG), yet patterns of surgical procedures are rarely challenged. The objective of this study was to evaluate surgical treatment patterns in pediatric LGG. The German Societé Internationale d'Oncologie Pédiatrique (SIOP)-LGG 2004 cohort was analyzed to identify relevant patient and tumor characteristics associated with time to death, next surgery, number of resections, and radiological outcome. A total of 1271 patients underwent 1713 neurosurgical interventions (1 intervention in 947, 2 in 230, 3 in 70, and 4-6 in 24). The median age of the study population was 8.57 years at first surgery, and 46.1% were female. Neurofibromatosis type 1 (NF1) was found in 4.4%, and 5.4% had tumor dissemination. Three hundred fifty-four patients (27.9%) had chemotherapy and/or radiotherapy. The cumulative incidence of second surgery at 10 years was 26%, and was higher for infants, those with spinal and supratentorial midline (SML) tumors, and those with pilomyxoid astrocytomas. The hazard ratio for subsequent surgery was higher given dissemination and noncomplete initial resection, and lower for caudal brainstem and SML tumors. Among 1225 patients with fully documented surgical records and radiological outcome, 613 reached complete remission during the observation period, and 50 patients died. Patients with pilocytic astrocytoma had higher chances for a final complete remission, whereas patients with initial partial or subtotal tumor resection, dissemination, NF1, or primary tumor sites in the spinal cord and SML had lower chances. Neurosurgery is a key element of pediatric LGG treatment. In almost 50% of the patients, however, at least some tumor burden will remain during long-term follow-up. This study found that most of these patients reached a stable disease status without further surgeries. Multidisciplinary team decisions must balance the goal of complete resection, risk factors, repeated surgeries, and possible treatment alternatives in a wide range of heterogeneous entities. Procedural details and neurological outcome should be recorded to better assess their impact on long-term outcome.

Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients.

Simple SummaryA multispecialty discussion may represent a benefit for cancer patients in receiving the most updated pathway of cure. The aim of this study was to describe the activity of our multidisciplinary team (MDT) meeting on patients with colorectal liver metastases (CRLMs). Information about 847 consecutive CRLMs patients over an 11-year period was retrospectively collected. Their characteristics were analyzed, and the populations were compared based on received treatment.There is still debate over how reviewing oncological histories and addressing appropriate therapies in multidisciplinary team (MDT) discussions may affect patients’ overall survival (OS). The aim of this study was to describe MDT outcomes for a single cancer center’s patients affected by colorectal liver metastases (CRLMs). From 2010 to 2020, a total of 847 patients with CRLMs were discussed at our weekly MDT meeting. Patients’ characteristics and MDT decisions were analyzed in two groups: patients receiving systemic therapy (ST) versus patients receiving locoregional treatment (LRT). Propensity-score matching (PSM) was run to reduce the risk of selection bias. The median time from MDT indication to treatment was 27 (IQR 13–51) days. The median OS was 30 (95%CI = 27–34) months. After PSM, OS for patients undergoing LRT was 51 (95%CI = 36–64) months compared with 15 (95%CI = 13–20) months for ST patients (p < 0.0001). In this large retrospective study, the MDT discussions were useful in providing the patients with all available locoregional options.

Examining the Impact of Federal Specific Learning Disability Inclusionary Criteria on Multidisciplinary Team Decision Making When Using Response to Intervention

There are still many unanswered questions regarding the application of response to intervention (RTI) to making eligibility decisions for specific learning disabilities (SLD). Both U.S. federal regulations and research support that students identified with SLD using RTI should be deficient in both level of academic functioning and rate of growth in response to scientifically based instruction. To date, there is little research examining whether these eligibility criteria are predictive in identifying students with SLD by evaluation teams in schools. Two studies conducted in different U.S. states examined if level of academic performance and rate of improvement (ROI) using curriculum-based measurement in reading (CBM-R) predicted student eligibility for special education. Logistic regression results indicated that level of performance predicted special education eligibility across sites and that ROI did not. Implications for research and practice are discussed.

How do patients make decisions in the context of a multidisciplinary team: an ethnographic study of four head and neck cancer centres in the north of England

ObjectivesTo describe how patients are engaged with cancer decisions in the context of multidisciplinary team (MDT) and how MDT recommendations are operationalised in the context of a shared decision.DesignEthnographic qualitative study.SettingFour head and neck cancer centres in the north of England.ParticipantsPatients with a diagnosis of new or recurrent head and neck cancer; non-participant observation of 35 MDT meetings and 37 MDT clinics, informal interviews, and formal, semistructured interviews with 20 patients and 9 MDT staff members.MethodsEthnographic methods including non-participant observation of MDT meetings and clinic appointments, informal interviews, field notes and formal semistructured interviews with patients and MDT members.ResultsMDT discussions often conclude with a firm recommendation for treatment. When delivered to a patient in clinic, this recommendation is often accepted by the patient, but this response may result from the disempowered position in which they find themselves. While patient behaviour may thus appear to endorse clinicians’ views that a paternalistic approach is desired by patients (creating a ‘cycle of paternalism’), the rigidity of the MDT treatment recommendation can act as a barrier to discussion of options and the exploration of patient values.ConclusionsThe current model of MDT decision-making does not support shared decision-making and may actively undermine it. A model should be developed whereby the individual patient perspective has more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient. In order to achieve these objectives, a new model of MDT working is required.

Acute lower limb ischemia caused by vaccine-induced immune thrombotic thrombocytopenia: focus on perioperative considerations for 2 cases

BackgroundChAdOx1 nCoV-19 (AstraZeneca) and Ad26COV2.S (Johnson & Johnson/Janssen) adenoviral vector vaccines have been associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). Arterial thrombosis and acute limb ischemia have been described in a minority of patients with VITT. These patients usually need a revascularization, but they potentially are at a higher risk of complications. Optimal perioperative care of patients undergoing vascular surgery in acute VITT is unknown and important considerations in such context need to be described.Cases presentationsWe report 2 cases of VITT presenting with acute limb ischemia who needed vascular surgery and we describe the multidisciplinary team decisions for specific treatment surrounding the interventions. Both patients’ platelet counts initially increased after either intravenous immune globulin (IVIG) or therapeutic plasma exchange (TPE). None received platelet transfusion. They both received argatroban as an alternative to heparin for their surgery. Despite persistent positivity of anti-platelet factor 4 (PF4) antibodies and serotonin-release assay with added PF4 (PF4-SRA) in both patients, only one received a repeated dose of IVIG before the intervention. Per- and post-operative courses were both unremarkable.ConclusionIn spite of persistent anti-PF4 and PF4-SRA positivity in the setting of VITT, after platelet count improvement using either IVIG or TPE, vascular interventions using argatroban can show favorable courses. Use of repeated IVIG or TPE before such interventions still needs to be defined.

Evaluation of multidisciplinary team decisions in neuroendocrine neoplasms: Impact of expert centres.

To evaluate the impact of multidisciplinary team (MDT) meetings on the management of patients with neuroendocrine neoplasms (NENs). All newly referred gastro-entero-pancreatic (GEP)-NEN patients discussed from 1 April to 1 October 2017 in the MDT of seven European expert centres were prospectively included. The impact on patients' management was defined as a change in diagnosis, grade, stage or treatment. A total of 292 patients were included, mainly small intestinal (siNENs) (32%) and pancreatic NENs (28%), with distant metastases in 51%. Patients had received prior surgery in 43% of cases and prior medical treatment in 32%. A significant change occurred in 61% of NENs: 7% changes in diagnosis, 8% in grade and 16% in stage. The MDT recommended a new treatment for 51% of patients, mainly surgery (9%) or somatostatin analogues (20%). A significant change was most frequently observed in patients with Stage IV disease (hazard ratio [HR] 3.6, 95% confidence interval [CI]: 1.9-6.9 vs. Stage I) and G2 NENs (vs. G1, HR 2.1 95% CI: 1.2-3.8). NEN-dedicated MDT discussion in expert centres yields significant management changes in over 60% of patients and thus represents the gold standard for the management of these patients.

The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer.

Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p=0.08). Patients with poor performance status (PS>2; p<0.001), severe comorbidity (p<0.001), socio-economic deprivation (p=0.004), a positive predictive circumferential resection margin (p=0.005) and metastatic disease (p<0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p<0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p=0.05). The only prognostic factor identified in patients treated palliatively was performance status (p<0.001). Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.

Management of Malnutrition Based on Multidisciplinary Team Decision-Making in Chinese Older Adults (3M Study): A Prospective, Multicenter, Randomized, Controlled Study Protocol.

BackgroundIn hospital settings, malnutrition affects 30–50% of aged inpatients and is related to a higher risk of hospital complications and death. This study aims to demonstrate the effectiveness of a tailored optimum nutritional therapy in malnourished, elderly inpatients based on multidisciplinary team recommendations in hopes of decreasing the incidence of deleterious clinical outcomes.Methods and DesignThis trial will be a multicenter, open-label, randomized control trial conducted in the geriatric wards of at least five hospitals in five different regions. We aim to include 500 inpatients over the age of 60 with or at risk of malnutrition based on a Mini Nutritional Assessment Short-Form (MNA-SF) score of ≤ 11 points and the Global Leadership Initiative on Malnutrition with an expected length of stay of ≥ 7 days. Eligible inpatients will be randomized into a 1:1 ratio, with one receiving a multidisciplinary team intervention and the other receiving standard medical treatment or care alone. A structured comprehensive assessment of anthropometry, nutritional status, cognition, mood, functional performance, and quality of life will be conducted twice. These assessments will take place on the day of group allocation and 1 year after discharge, and a structured screening assessment for elderly malnutrition will be conducted at 3 and 6 months after discharge using the MNA-SF. The primary outcome will be nutritional status based on changes in MNA-SF scores at 3, 6 months, and 1 year. The secondary outcome will be changes in cognition, mood, functional status, length of hospital stay, and all-cause mortality 1 year after discharge.DiscussionGuided by the concept of interdisciplinary cooperation, this study will establish a multidisciplinary nutrition support team that will develop an innovative intervention strategy that integrates nutritional screenings, evaluations, education, consultation, support, and monitoring. Moreover, nutritional intervention and dietary fortification will be provided to hospitalized elderly patients with or at risk of malnutrition. The nutrition support team will formulate a clinical map for malnutrition in elderly patients with standardized diagnosis and treatment for malnutrition in this population.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [ChiCTR2200055331].

Buried bumper syndrome: improving patient outcomes using a structured multidisciplinary team (MDT) approach to management

IntroductionBuried bumper syndrome (BBS) is a complication seen in 2.4% of percutaneous endoscopic gastrostomy (PEG) tubes. We present a case series of 30 patients with BBS managed at a regional...

A Multidisciplinary Team Approach Is Highly Effective in the Management of Nondiagnostic Bone Tumour Biopsies: A 10-Year Retrospective Review at a Specialist Sarcoma Unit.

Nondiagnostic (ND) biopsies are frequently encountered during the investigation of bone tumours and can lead to treatment delay. We performed a retrospective review of all ND bone tumour biopsies discussed at our regional MDT meeting between 2004 and 2014 with the aim of establishing the incidence of ND biopsies, identifying any factors that could predict the requirement for repeat biopsies, and evaluating the effectiveness of multidisciplinary team (MDT) decisions. We identified 98 ND out of 4949 biopsies. Diagnostic yield (DY) was 98%, 76%, and 40% for the first, second, and third successive biopsy, respectively. With an MDT approach utilising radiological and clinical information, the diagnostic success rate achieved was 99%, 85%, and 80% for the first, second, and third biopsies, respectively. Although a repeat biopsy was only performed in 34% of cases, there were no patients originally diagnosed with a benign lesion that re-presented with the same lesion subsequently being malignant throughout the study period. Malignant primary bone tumours (p < 0.01) and malignant secondary tumours (p=0.02) were more likely to undergo repeat biopsy compared to benign and infective lesions. Upper limb (p=0.04) and lower limb (p=0.03) were more likely than pelvic and spinal tumours to undergo a repeat biopsy. Tumours of haematological origin frequently required multiple biopsies. Our study demonstrated that a specialist MDT approach leads to high diagnostic rates and is a safe and effective method of preventing unnecessary, repeat biopsies where the initial biopsy is ND.

Patient Harm and Institutional Avoidability of Out-of-Hours Discharge From Intensive Care: An Analysis Using Mixed Methods.

OBJECTIVES:Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night.DESIGN:This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged “probably avoidable” in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors–based functional analysis resonance method.SETTING:Three U.K. National Health Service hospitals, chosen to represent different hospital settings.SUBJECTS:Patients discharged from ICU, their families, and staff involved in their care.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available.CONCLUSIONS:We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.

Using guideline-based clinical decision support in oncological multidisciplinary team meetings: A prospective, multicenter concordance study.

BackgroundMultidisciplinary team meetings formulate guideline-based individual treatment plans based on patient and disease characteristics and motivate reasons for deviation. Clinical decision trees could support multidisciplinary teams to adhere more accurately to guidelines. Every clinical decision tree is tailored to a specific decision moment in a care pathway and is composed of patient and disease characteristics leading to a guideline recommendation.ObjectiveThis study investigated (1) the concordance between multidisciplinary team and clinical decision tree recommendations and (2) the completeness of patient and disease characteristics available during multidisciplinary team meetings to apply clinical decision trees such that it results in a guideline recommendation.MethodsThis prospective, multicenter, observational concordance study evaluated 17 selected clinical decision trees, based on the prevailing Dutch guidelines for breast, colorectal and prostate cancers. In cases with sufficient data, concordance between multidisciplinary team and clinical decision tree recommendations was classified as concordant, conditional concordant (multidisciplinary team specified a prerequisite for the recommendation) and non-concordant.ResultsFifty-nine multidisciplinary team meetings were attended in 8 different hospitals, and 355 cases were included. For 296 cases (83.4%), all patient data were available for providing an unconditional clinical decision tree recommendation. In 59 cases (16.6%), insufficient data were available resulting in provisional clinical decision tree recommendations. From the 296 successfully generated clinical decision tree recommendations, the multidisciplinary team recommendations were concordant in 249 (84.1%) cases, conditional concordant in 24 (8.1%) cases and non-concordant in 23 (7.8%) cases of which in 7 (2.4%) cases the reason for deviation from the clinical decision tree generated guideline recommendation was not motivated.ConclusionThe observed concordance of recommendations between multidisciplinary teams and clinical decision trees and data completeness during multidisciplinary team meetings in this study indicate a potential role for implementation of clinical decision trees to support multidisciplinary team decision-making.

Perspectives of Pharmacists on the Structure, Decision-Making, and Communication Practices of Multidisciplinary Cancer Teams in Alabama.

Introduction: A multidisciplinary team (MDT) approach within cancer care settings is increasingly being adopted to improve patient outcomes due to the rising complexity of diagnosis and treatment. This study aims to explore the perspective of pharmacists on the structure, decision-making process, and communication practices of cancer MDTs. Methods: A 25-item online questionnaire was distributed to oncology-related clinical pharmacists in Alabama. Data were analyzed using descriptive statistics. Results: A total of 15 pharmacists completed the survey. More than half of the respondents reported that MDT meetings were held mostly in person on a set schedule. While physicians primarily facilitated the meetings, patients and/or their caregivers were largely not invited to participate in them. The treating physician oversaw delivering and update to the patient and/or their caregivers after the MDT meetings. Most respondents indicated that positron emission and computed tomography were the most common sources of information available at initial case presentations. Overall, respondents strongly agreed that they felt comfortable sharing their opinions with others health professionals during MDT meetings. Conclusions: This study provides evidence that oncology pharmacists are involved in MDT decision-making processes and communications but suggests the need to promote conditions to further their participation.