Multidisciplinary Clinic Model Research Articles

Qualitative feedback from caregivers in a multidisciplinary pediatric neuromuscular clinic.

This study explored family satisfaction and perceived quality of care in a pediatric neuromuscular care clinic to assess the value of the multidisciplinary clinic (MDC) model in delivering coordinated care to children with neuromuscular disorders, such as cerebral palsy. Caregivers of 22 patients were administered a qualitative survey assessing their perceptions of clinic efficiency, care coordination, and communication. Surveys were audio-recorded and transcribed. Thematic analysis was completed using both deductive and inductive methods. All caregivers reported that providers adequately communicated next steps in the patient's care, and most reported high confidence in caring for the patient as a result of the clinic. Four major themes were identified from thematic analysis: Care Delivery, Communication, Care Quality, and Family-Centeredness. Caregivers emphasized that the MDC model promoted access to care, enhanced efficiency, promoted provider teamwork, and encouraged shared care planning. Caregivers also valued a physical environment that was suitable for patients with complex needs. This study demonstrated that caregivers believed the MDC model was both efficient and convenient for pediatric patients with neuromuscular disorders. This model has the potential to streamline medical care and can be applied more broadly to improve care coordination for children with medical complexity.

BI17 A novel multidisciplinary clinic for the management of cutaneous T-cell lymphoma

Abstract Mycosis fungoides cutaneous T-cell lymphoma (MF-CTCL) is a rare condition that can present diagnostic difficulty and challenging management as no standard pathway exists. Patients require haematology and dermatology involvement to ensure optimal management, and the British Association of Dermatologists guidelines suggest regional supranetwork skin MDT for the majority of patients. However, this distances patients and local clinicians from the decision-making process. We propose a multidisciplinary model that includes local dermatology and haematology teams with the assistance of a regional expert to evaluate all of a region’s patients with MF-CTCL to ensure appropriate staging and management. On review of our cohort of patients with MF-CTCL, there were 42 patients with only 50% staged. We proposed a day-long multidisciplinary clinic model that enabled all patients with MF-CTCL to attend the dermatology department to receive a teaching session by trained nurses, a 30-minute consultation with a dermatology consultant with direct access to a specialist haematology consultant and a regional cutaneous lymphoma specialist, and access to on-the-day blood tests and diagnostic biopsies if needed. Twenty-six patients attended the clinic; 22 were confirmed to have MF-CTCL, 21 of whom were appropriately staged on the day. Ninety-five per cent of patients said they felt ‘extremely involved and informed’ about their management and treatment decisions after the clinic (vs. 19% preclinic). Ninety-five per cent would recommend the clinic to a family or friend, and 90% would attend a similar clinic in the future. From a clinician perspective, the survey responses showed high value in having repeated exposure to patients with CTCL, understanding the management options for MF-CTCL, face-to-face discussions with the multidisciplinary team (MDT) and longer clinic appointments. In conclusion, we offer this MDT clinic model as an efficient means for delivering patient-centred management and care, continuing education to local referring clinicians and ensuring close working relationships between dermatology and haematology. We propose running this clinic annually to ensure that all patients with MF-CTCL have appropriate investigation, staging and management pathways. The success of the clinic has led the department to adopt this model in other areas such as inflammatory conditions.

Pivotal Role of Genetic Counselors in the Uptake of Germline Genetic Testing in Non-Metastatic Breast Cancer and the Impact of Testing on Surgical Decision Making.

Genetic testing is increasingly utilized in breast cancer patients; however, testing rates remain low. We aimed to evaluate the rate of genetic testing at a tertiary academic medical center utilizing a multidisciplinary clinic model including genetic counselor. A single-center retrospective chart review was performed on a cohort of newly diagnosed breast cancer patients from January 2018 through February 2019. Patients were reviewed for genetic screening eligibility, consultation with a genetic counselor, and test results. Final analysis included 426 patients. 261 (61.3%) were found to meet National Comprehensive Cancer Network guidelines for genetic testing, of which 178 patient (68.2%) underwent testing and 32 patients (12.3%) declined testing. Of the 165 not eligible for testing, 5 patients were tested. A total of 183 patients underwent testing and 116 (63.4%) had a negative result, 17 (9.3%) were positive for at least one gene mutation and 50 (27.3%) were identified to have a variant of unknown significance (VUS). There was a positive association between those patients who met with a genetic counselor and eligibility for testing (OR 31.1, 95% CI 16.0-60.5). Genetic testing result has become an increasingly important factor when defining optimal surgical treatment for breast cancer patients. Increasing the availability of genetic consultation for breast cancer patients can improve testing rates and patient selection.

With Current Safety and Efficacy Data, Should Statins Be Made Available as Nonprescription Over-the-Counter Drugs?

Statins inhibit the enzyme 3-hydroxy-3-methylglutaryl-coenzyme A reductase in the liver and reduce atherosclerotic cardiovascular disease (ASCVD) risk by enhancing low-density lipoprotein (LDL) clearance from the circulation. In this review, we discuss their efficacy, safety, and real-world utilization to make a case for reclassifying statins as nonprescription over-the-counter drugs to improve access and availability with the overarching goal of increasing statin utilization in patients most likely to benefit from this class of therapy. Statin efficacy for reducing risk in primary and secondary ASCVD prevention populations as well as their safety and tolerability has been thoroughly investigated in large-scale clinical trials over the past 3 decades. Despite the overwhelming scientific evidence, statins are underutilized even among those at the highest ASCVD risk. We propose a nuanced approach to use statins as nonprescription drugsthat leverages a multi-disciplinary clinical model. Itintegrates lessons learned from experiences outside the USA with a proposed Food and Drug Administration rule change that allows nonprescription drug products with an additional condition for nonprescription use.

Canada’s First Joint Oncology-Allergy Clinic: Successful Desensitization to Trastuzumab Following Severe Anaphylactic Reaction in Which Epinephrine Was Inappropriately Withheld

Recognition of anaphylaxis and differentiation from other infusion reactions in an oncology setting is imperative; epinephrine is the recommended treatment for anaphylaxis and should be administered immediately to patients in whom anaphylaxis is suspected. Trastuzumab has a potentially tremendous oncological benefit, and when hypersensitivity reactions occur, rechallenge with desensitization protocols has become more common. Oncology presents a unique situation in which repeat drug exposure after a serious adverse reaction is often warranted due to the mortality risk of untreated cancer-allergists can assist with both symptom assessment and risk mitigation. This case showcases successful desensitization in a 43-year-old female with locally advanced HER2-positive breast cancer following a severe anaphylactic reaction to trastuzumab, in which epinephrine was not administered. We report the establishment of the Medical Oncology and Allergy Clinic: Canada's first multidisciplinary clinic aimed at expediting the assessment and management of oncology patients with adverse drug reactions (including chemotherapy, contrast media, antimicrobials) and those with primary and acquired immunodeficiency. We propose this multidisciplinary clinic model as a treatment framework moving forward, with the goal of continuing first-line therapies in cancer patients who develop drug-hypersensitivity (i.e., through desensitization). This case highlights the unmet need for a multidisciplinary approach to the management of oncology patients who experience hypersensitivity reactions.

The Limb-Girdle Muscular Dystrophies

The limb-girdle muscular dystrophies (LGMDs) are a group of inherited muscle disorders with a common feature of limb-girdle pattern of weakness, caused by over 29 individual genes. This article describes the classification scheme, common subtypes, and the management of individuals with LGMD. Advances in genetic testing and next-generation sequencing panels containing all of the LGMD genes have led to earlier genetic confirmation, but also to more individuals with variants of uncertain significance. The LGMDs include disorders with autosomal recessive inheritance, which are often due to loss-of-function mutations in muscle structural or repair proteins and typically have younger ages of onset and more rapidly progressive presentations, and those with autosomal dominant inheritance, which can have older ages of presentation and chronic progressive disease courses. All cause progressive disability and potential loss of ability to walk or maintain a job due to progressive muscle wasting. Certain mutations are associated with cardiac or respiratory involvement. No disease-altering therapies have been approved by the US Food and Drug Administration (FDA) for LGMDs and standard treatment uses a multidisciplinary clinic model, but recessive LGMDs are potentially amenable to systemic gene replacement therapies, which are already being tested in clinical trials for sarcoglycan and FKRP mutations. The dominant LGMDs may be amenable to RNA-based therapeutic approaches. International efforts are underway to better characterize LGMDs, help resolve variants of uncertain significance, provide consistent and improved standards of care, and prepare for future clinical trials.

Embedded Psychiatric Services in a Multidisciplinary Amyotrophic Lateral Sclerosis Clinic: An Assessment of Patient Needs and Perceptions.

Amyotrophic lateral sclerosis (ALS) is often associated with a range of difficult neuropsychiatric symptoms and conditions, including depression, apathy, pseudobulbar affect, and frontotemporal dementia (FTD). Despite the potential role for psychiatrists in the treatment of ALS, they are not typically involved in the ALS clinical team. The investigators describe a quality improvement intervention providing embedded psychiatric services within a multidisciplinary clinic (MDC). A psychiatrist working within an ALS MDC evaluated patients (N=116) over a 1-year period. The clinic assessed the prevalence of neuropsychiatric symptoms and conditions in patients with ALS (depression, anxiety, pseudobulbar affect, and cognitive impairment, including FTD) using standardized screening methods. Fifty-five patients and 47 family members completed surveys about perceptions of their need for psychiatric care, their experience of meeting with a psychiatrist, and their desire for future access to psychiatric care. Prevalence rates for neuropsychiatric symptoms were 14.9% for depression, 11.3% for anxiety, 19% for cognitive impairment (including FTD, 8.6%), and 36.2% for pseudobulbar affect; 62.0% of patients were being prescribed at least one psychotropic medication. Both patients and family members reported that meeting with a psychiatrist was helpful, that the treatment provided was helpful, and that they would prefer continued availability of psychiatric services in the future. The presence of cognitive impairment and use of antidepressants increased the likelihood of patients reporting a benefit from psychiatric care. Patients with ALS report a benefit from increased access to psychiatric services. The inclusion of a psychiatrist within the ALS MDC model should be considered to improve quality of care for this patient population.

200. The effect of a multidisciplinary spine clinic on treatment rates and lead times to care

<h3>BACKGROUND CONTEXT</h3> Back pain is a leading cause of years lived with disability and economic burden, exceeding more than $20 billion in health care costs not including indirect costs such as absence from work and caregiving. The multifactorial nature of back pain leads to treatment modalities administered by a variety of specialists which are often disjointed. Multiple studies have found that patients receiving delayed physical therapy for lower back pain had higher medical-related costs from increased health service utilization as well as a reduced improvement in pain severity compared to early management. Uncoordinated health care delivery can exacerbate the physical and economic toll of the chronic condition, thus improvements in interdisciplinary, shared decision-making may improve outcomes. <h3>PURPOSE</h3> To assess whether a multidisciplinary spine clinic (MSC), consisting of orthopedic surgery, neurosurgery, pain medicine, and physiatry, alters interventional and noninterventional planning and treatment compared to a traditional unidisciplinary spine clinic (USC) including only orthopedic surgery. <h3>STUDY DESIGN/SETTING</h3> We conducted a retrospective cohort study with patients initially presenting for spine care to orthopedic surgeons at both the outpatient unidisciplinary spine clinic and multidisciplinary spine clinic in the Bronx, NY. <h3>PATIENT SAMPLE</h3> We included adult patients of age 18 years or older initially presenting to orthopedic surgeons for spine care at our institution from July 1, 2018 to June 30, 2019. Eligible patients were identified through a health care surveillance software package (Clinical Looking Glass) and EMR review. <h3>OUTCOME MEASURES</h3> Time to treatment recommendation, time to treatment, and rates of treatment recommendations were assessed, including physical therapy, injections, and surgery. <h3>METHODS</h3> Treatment rates were compared between MSC and USC using Pearson's chi-squared test logistic regression. Time to treatment recommendation and time to treatment were compared using log-rank test and Cox proportional hazard regression. All analyses were repeated for the propensity score (PS) matched subsample. <h3>RESULTS</h3> This study included 1,764 patients, with 692 at MSC and 1,072 at USC. Patients in MSC were more likely to be recommended injection when compared to USC (8.5% vs 5.4%, p=0.01). When adjusted for confounders, the likelihood of injection recommendation remained greater in MSC than USC (odds ratio [OR]=2.22, 95% CI: (1.39, 3.53), p=0.001). MSC was also associated with a shorter time to receiving injection recommendation vs USC (median: 21 vs 32 days, log-rank: p<0.001; hazard ratio [HR]=1.90, 95% CI: (1.25, 2.90), p=0.003). MSC was associated with a higher likelihood of injection treatment (OR=2.27, 95% CI: (1.39, 3.73), p=0.001) and shorter lead time (HR=1.98, 95% CI: (1.27, 3.09), p=0.003). PS-matched analyses yielded similar conclusions. <h3>CONCLUSIONS</h3> Care delivered at a multidisciplinary spine clinic was associated with a higher likelihood of recommending injection and a shorter lead time to injection administration when compared to a traditional unidisciplinary spine surgery clinic. Multidisciplinary clinics may facilitate coordinated care amongst different specialties resulting in increased utilization of less invasive treatment modalities while also improving care efficiency. The multidisciplinary clinic model is an important advancement in care delivery and communication, which can be used as a powerful method of improving patient outcomes as treatment guidelines evolve. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Care for Adolescents With Polycystic Ovary Syndrome: Development and Prescribing Patterns of a Multidisciplinary Clinic.

Based on updated guidelines and expressed patient needs, we created a multidisciplinary clinic including endocrinology, gynecology/adolescent medicine, dermatology, psychology, and nutrition to provide comprehensive care to adolescent girls with polycystic ovary syndrome (PCOS). We describe the patient population presenting to this clinic, and prescribing patterns when a multidisciplinary approach is used. Retrospective chart review. Tertiary care hospital. Female patients, aged 11-24 years, presenting for initial assessment in a multidisciplinary PCOS clinic. None. Medical history, physical examination findings, laboratory measurements and prescribed therapies. A total of 92 patients seen from 2014 to 2018 are described (age 15.9 years, range 11-24 years, body mass index 35.6 kg/m2, range 19.9-53.5). Metabolic syndrome features were common: 26% had a prediabetes hemoglobin A1c (>5.6%), 83% had a high-density lipoprotein (HDL) <50 mg/dL, 40% had a systolic blood pressure >120 mm Hg, and 43% had an alanine aminotransferase level of >30 U/L. Dermatologic findings included acne 93%, hirsutism 38%, acanthosis nigricans 85%, hidradenitis suppurativa 16%, and androgenic alopecia 2%. Of the patients, 33% had a diagnosis of depression or anxiety, 16% of patients had a diagnosis of obstructive sleep apnea, and an additional 59% had symptoms warranting a sleep study The most commonly prescribed medications were topical acne preparations (62%), followed by estrogen-containing hormonal therapy (56%) and metformin (40%). In adolescents with PCOS and obesity, metabolic, dermatologic, and psychologic co-morbidities are common. The use of a multidisciplinary clinic model including dermatology in addition to endocrinology, gynecology, psychology, and lifestyle experts provides care for most aspects of PCOS.

Telemedicinevisits in an established multidisciplinary central nervous system clinic for radiation oncology and neurosurgery (RADIANS) in a community hospital setting.

To determine the impact of telemedicine visits, compared to in-person visits, on patient satisfaction in an established community hospital-based multidisciplinary central nervous system (CNS) clinic. Telemedicine options - virtual visits and teleconferencing - wereintroduced in July 2020. Both radiation oncologist and neurosurgeon were simultaneously present for the telemedicine visit. Descriptive patient demographics, survey responses, and travel time and distance calculations were analyzed. Satisfaction score was compared topreviously published data. A total of twenty-five telemedicine visits (n=22 video; n=3 phone) were completed since July 2020.Patient demographicsareas follows: mean age was 59 years (range=22-81), women (9) and men (16),repeat telemedicine visits n=10,malignant CNS disease(17) and benign disease (5).Meanone-waydistance traveled was 165.07 miles (median=114; range=0.8-358).Meanroundtrip travel time wasestimated at5h 5min. Mean telemedicine visit duration was 15.3 mins (range=4-46). Mean patient satisfaction scorefor telemedicine visits was 4.84. Patients who opted for the telemedicine visits found them just as effective as in-person visits, saving time and travel costs as well as ensuring patient safety during the current COVID-19 pandemic. The telemedicine visitplatform facilitates the multidisciplinary clinic model and should be considered for more widespread utilization (Tab. 3, Fig. 1, Ref. 18).

981. Extended Adherence and Persistence to HIV PrEP in a Multidisciplinary PrEP Clinic

BackgroundMethods to identify and address barriers to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) persistence are needed to improve low PrEP persistence rates beyond 6 months. We evaluated PrEP adherence and persistence in a multidisciplinary clinic model with an integrated specialty pharmacist.MethodsWe conducted a single-center, retrospective, cohort study of patients initiating PrEP in the multidisciplinary Vanderbilt PrEP Clinic with prescriptions filled by Vanderbilt Specialty Pharmacy between 9/1/2016 and 3/31/2019. In this model, integrated clinical pharmacists manage PrEP access, affordability, and therapy monitoring. Clinical data were collected from the electronic health records and pharmacy claims data. Adherence was calculated from fill data using proportion of days covered (PDC). Persistence at 6, 12 and 18 months was measured using patient-reported discontinuation date or the date of the last fill plus the fill’s days’ supply for patients lost to follow-up. The Kaplan-Meier estimation method was used to estimate persistence probabilities.ResultsMost of the 63 patients included were male (97%), white (84%), commercially insured (94%) with a median age of 38 years, and men who have sex with men at high risk for acquiring HIV (97%); Table 1. The majority of patients with at least one follow-up visit (n=58) reported no adverse effects (78%), no missed doses (71%), and had a median PDC of 99% (IQR 97% – 100%). Persistence at 6, 12 and 18 months was 0.87 (95% confidence interval, CI, 0.80 – 0.96), 0.81 (95% CI 0.72 – 0.91), and 0.74 (95% CI 0.64 – 0.86), respectively; Figure 1. Of the 18 patients who discontinued PrEP, 9 discontinued due to perceived lack of risk for acquiring HIV, 6 were lost to follow up, 1 moved, transferring PrEP care to a new provider, 1 had worsening depression, and 1 had renal function decline.Table 1 Patient Characteristics Figure 1 Persistence on HIV PrEP ConclusionPatients receiving PrEP treatment in a multidisciplinary clinic with an integrated clinical pharmacist had high rates of adherence and persistence up to 18 months. Patients reported few side effects and reasons for therapy discontinuation were appropriate. Efforts to incorporate pharmacy support in managing PrEP patients could be beneficial in increasing patient adherence and persistence.Disclosures All Authors: No reported disclosures

Effect of Geriatric Assessment and Intervention on Overall Survival Among Older Adults with Hematologic Malignancies

Background: Older adults with hematologic malignancies have inferior survival outcomes due to multiple factors including under-treatment, drug toxicity, treatment discontinuation and concerns of frailty. However, aging is heterogeneous and chronological age is a poor indicator of underlying health. Standardizing the approach to identify frailty is an unmet need in malignant hematology. We have established a multi-disciplinary clinical model designed to identify frailty and develop personalized treatment based on objective measures of health. We have standardized a geriatric assessment (GA) model to identify vulnerability, frailty and geriatric syndromes. Here we report, the largest cohort to date, of older adults with hematologic malignancies (HM) depicting geriatric deficits and interventions with long-term clinical outcomes. Methods: From Feb 2016 to October 2019, 311 older adults with HM were evaluated in our multi-disciplinary Cancer and Aging Resiliency (CARE) clinic. The CARE clinic is a 7-member team prescriptively evaluating the following domains: pharmacy, audiology, psychosocial needs, nutrition, physical functioning, and cognition. Geriatric syndromes were documented by CARE physician. Referral to CARE clinic is recommended for patients 60 years of age or older but all referrals are accepted independent of age. Data was abstracted by retrospective chart review. Descriptive statistics for patient characteristics, frailty measures, and prescribed interventions in each of the GA domains were provided. Univariable and multivariable Cox models were fit to associate clinical factors with OS. OS by Rockwood Clinical Frailty Scale and deficits in activities of daily living (ADLs) was evaluated by Kaplan-Meier method. Correlation between number of geriatric syndromes, clinical frailty score, and deficits in ADLs and instrumental ADLs (IADLs) was also assessed. Results: Over the 42-month study period, 311 older adults with HM with a median age of 75.9 years were evaluated in CARE clinic. Key demographic features and the frequency of specific frailty measures are outlined in table 1.Geriatric interventions were common with 59% requiring 1-2 interventions and 34% requiring 3+ interventions. In univariable analysis, any degree of frailty by Clinical Frailty Scale (Hazard Ratio [HR]: 2.63, 95% Confidence Interval [CI]: 1.43-4.82, p &amp;lt;0.01) and increasing number of geriatric syndromes (HR:1.13, 95% CI: 1.00-1.27, p = 0.04) were associated with inferior OS. In both univariable and multivariable analyses, 10-year increase in age (multivariable HR: 2.05, 95% CI:1.44-2.91, p&amp;lt;0.01), deficit in ADL (multivariable HR: 2.60, 95% CI: 1.38-4.87, p&amp;lt;0.01), diagnosis of acute leukemia (multivariable HR: 4.53, 95% CI:1.91-10.78, p&amp;lt;0.01), and prescribed nutrition intervention (multivariable HR: 2.04, 95% CI: 1.32-3.15, p&amp;lt;0.01) were associated with inferior OS. Anemia was also associated with OS in both univariable and multivariable analysis (multivariable HR for 1 g/dL increase in hemoglobin: 0.79, 95% CI: 0.69-0.91, p&amp;lt;0.01). Additional variables for univariable and multivariable analyses are presented in table 2. There was significant correlation between the Clinical Frailty Scale and number of geriatric syndromes (Spearman correlation p &amp;lt; 0.01). The same was true of correlation between ADL or IADL deficits and Clinical Frailty Scale (p &amp;lt; 0.01 for both). OS by Clinical Frailty Scale and ADL deficit is pictured in figure 1. Discussion: The Clinical Frailty Scale is predictive of OS among older adults with HM. GA-directed intervention is warranted in the vast majority of older adults with HM. In univariable analysis, Clinical Frailty Scale, increasing age, anemia, high risk HM, and increasing geriatric syndromes are associated with inferior OS. In multivariable analysis, age, anemia, and high risk HM remain significant. Nutrition and physical function are key modifiable risk factors predictive of inferior OS. Prospective studies focusing on geriatric interventions are warranted in this population with an emphasis on modifiable risk factors. This demonstrated prognostic significance of both geriatric assessments and interventions in older adults with HM should give way to future improvements in OS, quality of life, and treatment tolerability through GA-directed intervention. Disclosures No relevant conflicts of interest to declare.

A comparison of two models of multidisciplinary lung cancer care within a community-based healthcare system.

36 Background: The Multidisciplinary Thoracic Oncology Conference (MTOC) model is easier to implement than the Multidisciplinary Clinic (MDC) model, but does not directly involve patients in decision-making. We compared the processes and outcomes of lung cancer care between patients discussed in a weekly MTOC versus those seen in a MDC. Methods: Prospective observational study of thoroughness of staging, stage confirmation (defined as biopsy of the stage-defining lesion), National Comprehensive Cancer Network guideline-concordant treatment, overall (OS) and event-free (EFS) survival of lung cancer patients in a community healthcare system’s MDC and MTOC from 2014-2019. We used the chi-square test and multivariable logistic regression to evaluate guideline-concordant treatment and stage confirmation; Kaplan-Meier curves and multivariable Cox regression were used to evaluate OS and EFS. We adjusted models for age, sex, race, insurance, smoking status, and histology. Results: 614 patients received care in MDC; 571 in MTOC. MDC patients were older (median age: 69 vs. 67); less likely to be active smokers (44% vs. 47%; p=0.03); more likely to have bimodal (98% v 95%, p=0.02) and trimodal staging (60% v 46%, p&lt;0.0001). The stage-confirmation rate (OR: 1.55; 95% CI: 1.22-1.96) and mediastinal stage confirmation rate (OR: 1.55; 95% CI: 1.23-1.95) were both significantly higher in MDC, even after adjustment (aOR: 1.60; 95% CI: 1.25-2.03); (aOR: 1.58, 95% CI: 1.25-2.00). A higher proportion of patients received guideline-concordant treatment in MDC than in MTOC (82% vs. 73%; OR: 1.63; 95% CI: 1.21-2.20) even after adjustment (aOR: 1.64; 95% CI: 1.20-2.24). However, MTOC patients had significantly better OS (p=0.03) and EFS (p=0.001) than MDC patients and a lower hazard of death (HR: 0.81; 95% CI: 0.67-0.98), even after adjusting for confounding variables (aHR: 0.79 95%CI: 0.66-0.95). Conclusions: Although the processes of lung cancer care delivery were better in MDC than in MTOC, survival was better in MTOC. Patient selection may have played a role in these survival differences. The MTOC model, as implemented, seems competitive with the MDC model and is worthy of further exploration as a more feasible model of multidisciplinary care. [Table: see text]

Predicting No Show in Voice therapy: Avoiding the Missed Appointment Cycle

Voice therapy plays a critical role in the treatment of voice disorders. Despite positive outcomes in patients who attend voice therapy, otolaryngologists, and speech-language pathologists continue to struggle with patient compliance. Previous studies evaluating the multidisciplinary clinic model have shown better completion, VHI-10 scores, and fewer cancelation and no-shows (NS). We sought to review our own patient experience to better identify factors that predict NS rates in voice therapy. A retrospective chart review of patients at a tertiary medical center were included if they had a scheduled appointment during a 6-month period that was cancelled or a NS. Charts were reviewed for age, gender, race, diagnosis, number of sessions attended, reason for discharge, and attending physician. NS percentage is calculated as a ratio of number cancellations to total number sessions scheduled. A multivariable general linear model was used to examine the association between NS and the listed covariates. The study included 146 patients mean (SD) age 52.7 (16.6), where 62% were female and 72.6% were white. There is evidence that not being seen in a multidisciplinary clinic is significantly associated with NS rates in voice therapy (χ2=4.09, P=0.0431). There is also evidence that non-white race is significantly associated with NS rates in voice therapy (χ2=11.76, P=0.0006). Data presented in this study further support the use of a multidisciplinary model to improve NS rates in voice therapy. The relationship between nonwhite patients and lower NS suggests another determining factor in nonadherence to voice therapy.

Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model.

Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc. We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data. Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement. This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.

Аутизм. Мультидисциплинарная оценка и терапия. Модель LADDERS

Autism Spectrum Disorder (ASD) is a developmental disorder characterized by impaired social interaction, delayed and disordered communication skills and isolated areas of interest. There is a growing appreciation that ASD is more complex than previously appreciate and in many cases, involves multiple organ systems beyond the brain. Those affected require intensive therapeutic services as well as skilled medical diagnosis and supervision. This paper describes a multidisciplinary clinical model in which the many services and interventions needed by ASD patients can be provided in a single site, reducing fragmentation of care and providing skilled diagnostic care and ongoing supervision.

RADIANS: A Multidisciplinary Central Nervous System Clinic Model for Radiation Oncology and Neurosurgery Practice

Radiation therapy for central nervous system disease commonly involves collaboration between Radiation Oncology and Neurosurgery. We describe our early experience with a multidisciplinary clinic model. In 2016, the novel RADIANS (RADIation oncology And NeuroSurgery) clinic model was initiated at a community hospital. Disease and treatment demographics were collected and analyzed. Patient satisfaction was assessed via a blinded survey questionnaire. Forty-two patients have been seen since the inception of RADIANS. The median age was 65; and the median patient distance from RADIANS was 42.7 miles (mean= 62.6; range= 0.7-285). Half of the patients traveled >50 miles to receive care, and >80% were seen for central nervous system metastases. Of the patients receiving radiation, 75% received stereotactic radiosurgery/stereotactic body radiation therapy. The mean overall satisfaction from 0 (not satisfied) to 5 (very satisfied) was 4.8. The RADIANS clinic model has proved viable and well-liked by patients in a community setting, with the majority of radiation therapy administered being stereotactic radiosurgery/stereotactic body radiation therapy rather than conventional fractionation.

Evolution of the Radiation Therapist Role in a Multidisciplinary Palliative Radiation Oncology Clinic

BackgroundPalliative radiation therapists (PRTs) have been integrated in varying capacities into outpatient palliative radiation therapy (RT) services across Canada for over 2 decades. At our institution, PRTs have developed an essential role over 11 years within a palliative radiation oncology (PRO) clinic that focuses on integrating symptom management with radiation oncology assessment for palliative RT. PRTs have had direct clinical, technical, research, and administrative involvement as the clinic evolved from a pilot in 2007 supporting one half-day per week to the current model of five full clinical days. MethodsUsing collaborative reflection, we explored the PRTs' experience and insight. Twelve PRTs who contributed to the PRO clinic for varying lengths of time from 2007 through to 2016 were invited to participate in the development of a collective expression of the PRT experience. Seven PRTs consented to completing an electronic survey consisting of fifteen open-ended questions regarding individual roles and perspectives relating to our PRO clinic. Survey answers were enhanced by semistructured interviews when needed for clarification. Responses were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service. Results/DiscussionFive respondents answered all of the questions. From the narratives, PRT roles and responsibilities were outlined and their insights and reflections included to contextualize clinical changes. Four phases of the clinic were identified and elucidated. Beginning in January 2007, three PRTs staffed a multidisciplinary clinical pilot one half-day per week for single-fraction, symptomatic bone metastases. The clinic has now evolved through various iterations to the current model with four PRTs sharing a “navigator” role with two registered nurses five full clinic days per week. The range of PRT experiences, responsibilities, and challenges encountered reflected specific clinical and operational conditions. ConclusionAs our clinical service model evolved from short-term pilot to fully integrated departmental service, so did the PRT role. PRTs contributing to RT as part of a multidisciplinary model support and advance nontraditional involvement in the holistic care of patients with advanced cancer.

Multidisciplinary Clinic Management of Head and Neck Cancer

ImportanceContemporary management of head and neck cancer involves professionals from multiple specializations. Streamlined care that reduces delays yet allows for comprehensive evaluation is needed.ObjectiveTo evaluate a single-day, single-appointment, multidisciplinary head and neck clinic model for reduction in treatment delay and comprehensiveness of care.Design, Setting, and ParticipantsA retrospective cohort analysis was conducted from June 1, 2015, to July 31, 2016, of outpatients at a single, academic medical center.All eligible outpatients seen in either the multiple-appointment, traditional clinic (n = 73) or the single-day multidisciplinary clinic (MDC) (n = 68) were included. Patients with new squamous cell carcinoma of the oropharynx, hypopharynx, sinonasal tract, and larynx, along with any mucosal site recurrence were eligible for the study.Main Outcomes and MeasuresPrimary outcomes were delays between tertiary clinic referral or first appointment and treatment initiation in the MDC compared with the traditional clinic. Secondary outcomes were complete evaluations prior to treatment, enrollment in trials and registries, and rate of patient leak, defined as initiating therapy and then transferring to another center before completion. Outcome selection and hypothesis generation were performed a priori.ResultsPatient factors and tumor characteristics were similar between the traditional clinic cohort (19 women and 54 men; mean [SD] age, 64.0 [10.2] years) and the MDC cohort (8 women and 60 men; mean [SD] age, 61.0 [8.9] years). The MDC cohort had significantly fewer instances of delay greater than 30 days from referral to treatment initiation (28 [41%] vs 43 [59%]) and first appointment to treatment initiation (7 [10%] vs 17 [23%]). Actual median days in these categories were significantly different between the 2 clinic types after the patients in the traditional clinic who saw only a surgeon before treatment initiation were excluded (MDC, 28 days vs traditional, 35 days; median difference, –5 days; 95% CI, –11 to –1).Conclusions and RelevanceCoordination of the management of head and neck cancer is complex. Treatment is time sensitive, and frequently clinician resources are limited. This MDC model was associated with improved efficiency and completeness of care.

The evolving radiation therapist role in a multidisciplinary palliative radiotherapy clinic.

158 Background: Radiation therapists (MRTT) have been integrated in varying capacities into outpatient palliative radiotherapy (PRT) services across Canada for nearly two decades. We explored the experience of our centre’s MRTTs who have developed an essential role over nine years, from supporting one half-day PRT clinic per week to five full days of clinical, technical, research, and administrative involvement. Methods: An electronic survey was distributed to all 12 MRTTs who contributed to the PRT program (2007-2016), which was later supplemented by in-person semi-structured interviews. Qualitative analysis of the responses was undertaken to discern common themes. These were contextualized within the operational changes to our multidisciplinary clinical model, from pilot to integrated service. Results: Among seven respondents (range of PRT-specific experience: 1-5 years), five answered all questions. From the narratives, three common themes emerged: responsibilities, challenges, and opportunities. Responsibilities identified included: PRT planning/delivery (cited 13 times), patient assessment (12), multidisciplinary collaboration (MDC) (8), research (8), navigation (7), clinic process innovation (5), administration (5), communication (4), and education (2). Challenges described included: lack of support (cited 10 times), lack of shared understanding (5), high workload (5), pushback from colleagues (3), and inadequate staffing (2). However, opportunities outnumbered challenges, in terms of evolution of involvement in MDC (cited 13 times), patient care (8), increased autonomy (6), professional growth (5), role variation (5), scope of practice expansion (2), and being the team’s key contact for referrals (2). The range of MRTT experiences, responsibilities and challenges encountered reflected specific PRT clinical and operational conditions. Conclusions: As our PRT service model has evolved from short-term pilot to fully integrated departmental service, so has the MRTT role. MRTTs contributing to PRT as part of a MDC model are supportive of advancing non-traditional involvement in the holistic palliative care of patients with advanced cancer.