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

BACKGROUND: Evidence-based tools are necessary for scientifically improving the way MTBs work. Such tools are available but can be difficult to use. This study aimed to develop a robust observational assessment tool for use on cancer multidisciplinary tumor boards (MTBs) by health care professionals in everyday practice. METHODS: A retrospective cross-sectional observational study was conducted in the United Kingdom from September 2015 to July 2016. Three tumor boards from three teaching hospitals were recruited, with 44 members overall. Six weekly meetings involving 146 consecutive cases were video-recorded and scored using the validated MODe tool. Data were subjected to reliability and validity analysis in the current study to develop a shorter version of the MODe. RESULTS: Phase 1, a reduction of the original items in the MODe, was achieved through two focus group meetings with expert assessors based on previous research. The 12 original items were reduced to 6 domains, receiving full agreement by the assessors. In phase 2, the six domains were subjected to item reliability, convergent validation, and internal consistency testing against the MODe-Lite global score, the MODe global score, and the items of the MODe. Significant positive correlations were evident across all domains (p < 0.01), indicating good reliability and validity. In phase 3, feasibility and high inter-assessor reliability were achieved by two clinical assessors. Six domains measuring clinical input, holistic input, clinical collaboration, pathology, radiology, and management plan were integrated into MODe-Lite. CONCLUSIONS: As an evidence-based tool for health care professionals in everyday practice, MODe-Lite gives cancer MTBs insight into the way they work and facilitates improvements in practice.

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

BACKGROUND: Multidisciplinary team (MDT)-driven cancer care is a mandatory UK national policy, widely used globally. However, few studies have examined how MDT members make decisions as a team. We report a single-centre prospective study on team working within breast cancer MDT. METHODS: This was a prospective observational study of 10 breast MDT meetings (MDM). Trained clinical observer scored quality of presented information and disciplinary contribution to case reviews in real time, using a validated tool, namely Metric for the Observation of Decision-Making. Data were analysed to evaluate quality of team working. RESULTS: Ten MDMs were observed (N = 346 patients). An average of 42 patients were discussed per MDM (range: 29-51) with an average 3 min 20 s (range: 31 s-9 min) dedicated to each patient. Management decision was made in 99% of cases. In terms of contribution to case reviews, breast care nurses scored significantly (p < 0.05) lower (M = 1.79, SD = 0.12) compared to other team members (e.g. surgeons, M = 4.65; oncologists, M = 3.07; pathologists, M = 4.51; radiologists, M = 3.21). Information on patient psychosocial aspects (M = 1.69, SD = 0.68), comorbidities (M = 1.36, SD = 0.39) and views on treatment options (M = 1.47, SD = 0.34) was also significantly (p < 0.05) less well represented compared to radiology (M = 3.62, SD = 0.77), pathology (M = 4.42, SD = 0.49) and patient history (M = 3.91, SD = 0.48). CONCLUSION: MDT evaluation via direct observation in a meeting is feasible and reliable. We found consistent levels of quality of information coverage and contribution within the team, but certain aspects could be improved. Contribution to patient review resides predominantly with surgeons, while presented patient information is largely of biomedical nature. These findings can be fed to cancer MDTs to identify potential interventions for improvement.

A computational model of ureteral peristalsis and an investigation into ureteral reflux.

The aim of this study is to create a computational model of the human ureteral system that accurately replicates the peristaltic movement of the ureter for a variety of physiological and pathological functions. The objectives of this research are met using our in-house fluid-structural dynamics code (CgLes-Y code). A realistic peristaltic motion of the ureter is modelled using a novel piecewise linear force model. The urodynamic responses are investigated under two conditions of a healthy and a depressed contraction force. A ureteral pressure during the contraction shows a very good agreement with corresponding clinical data. The results also show a dependency of the wall shear stresses on the contraction velocity and it confirms the presence of a high shear stress at the proximal part of the ureter. Additionally, it is shown that an inefficient lumen contraction can increase the possibility of a continuous reflux during the propagation of peristalsis.

Multidisciplinary cancer team meeting structure and treatment decisions: a prospective correlational study.

BACKGROUND: Anecdotally, organizational factors appear to have an effect on the quality of decision-making in the multidisciplinary team (MDT) meeting. We assess the effect of the number of team-members present, number and order of cases, and the timing of meetings on the process of decision-making in MDT meetings. METHODS: Between December 2009 and January 2010, data were prospectively collected on treatment decisions, meeting characteristics, quality of information, and teamworking for all cases discussed at a London-based MDT meeting. Variables measured using a validated assessment tool (MDT MODe) and correlational analyses were performed. RESULTS: Treatment decisions were reached in 254 of 298 (85%) cases. Cases toward the end of meetings were associated with lower rates of decision-making, information quality, and teamworking (r = -0.15 to -0.37). Increased number of cases per meeting and team members in attendance were associated with better information and teamworking (r = 0.29-0.43). More time per case was associated with improved teamworking (r = 0.16). A positive correlation was obtained between ability to reach decisions and improved information and teamworking (r = 0.36-0.54; all P ≤ 0.001). CONCLUSIONS: Organizational factors related to the structure of the MDT meeting are associated with variation in the likelihood of reaching a treatment decision. Further research is required to establish causation and to modify such factors in order to improve the quality of cancer care.

Facilitators and barriers to teamworking and patient centeredness in multidisciplinary cancer teams: findings of a national study.

BACKGROUND: Multidisciplinary teams (MDTs) are the standard means of making clinical decisions in surgical oncology. The aim of this study was to explore the views of MDT members regarding contribution to the MDT, representation of patients' views, and dealing with disagreements in MDT meetings-issues that affect clinical decision making, but have not previously been addressed. METHODS: Responses to open questions from a 2009 national survey of MDT members about effective MDT working in the United Kingdom were analyzed for content. Emergent themes were identified and tabulated, and verbatim quotes were extracted to validate and illustrate themes. RESULTS: Free-text responses from 1,636 MDT members were analyzed. Key themes were: (1) the importance of nontechnical skills, organizational support, and good relationships between team members for effective teamworking; (2) recording of disagreements (potentially sharing them with patients) and the importance of patient-centered information in relation to team decision making; (3) the central role of clinical nurse specialists as the patient's advocates, complementing the role of physicians in relation to patient centeredness. CONCLUSIONS: Developing team members' nontechnical skills and providing organizational support are necessary to help ensure that MDTs are delivering high-quality, patient-centered care. Recording dissent in decision making within the MDT is an important element, which should be defined further. The question of how best to represent the patient in MDT meetings also requires further exploration.

Developing and testing TEAM (Team Evaluation and Assessment Measure), a self-assessment tool to improve cancer multidisciplinary teamwork.

BACKGROUND: Cancer multidisciplinary teams (MDTs) are well established worldwide and are an expensive resource yet no standardised tools exist to measure performance. We aimed to develop and test an MDT self-assessment tool underpinned by literature review and consensus from over 2000 UK MDT members about the "characteristics of an effective MDT." METHODS: Questionnaire items relating to all characteristics of MDTs (particularly Leadership and Chairing; Teamworking and Culture; Patient-centred care; Clinical decision-making process; and Organisation and administration during meetings) were developed by an expert panel. Acceptability, feasibility and psychometric properties were tested by online completion of the questionnaire by 23 MDTs from 4 UK NHS Trusts followed by interviews with 74 team members including members from all teams and nonresponders. 10 of the MDTs also completed questionnaires that directly translated each characteristic to an item (for the five domains above) to test content validity. RESULTS: A total of 47 items were created, each rated for agreement on a 5-point scale. A total of 329 (52 %) of 637 team members completed the questionnaire, including representation from medical, nursing and clerical MDT members. Responses correlated well with domain-specific questionnaires (r > 0.67, p = 0.01), most domain-scales had acceptable internal consistency (Cronbach alpha > 0.60), and good item discrimination (majority of items r < 0.20). Team members were positive about its value. CONCLUSIONS: Self-assessment of team performance using this tool may support MDT development.

Multidisciplinary team working across different tumour types: analysis of a national survey.

BACKGROUND: Using data from a national survey, this study aimed to address whether the current model for multidisciplinary team (MDT) working is appropriate for all tumour types. PATIENTS AND METHODS: Responses to the 2009 National Cancer Action Team national survey were analysed by tumour type. Differences indicate lack of consensus between MDT members in different tumour types. RESULTS: One thousand one hundred and forty-one respondents from breast, gynaecological, colorectal, upper gastrointestinal, urological, head and neck, haematological and lung MDTs were included. One hundred and sixteen of 136 statements demonstrated consensus between respondents in different tumour types. There were no differences regarding the infrastructure for meetings and team governance. Significant consensus was seen for team characteristics, and respondents disagreed regarding certain aspects of meeting organisations and logistics, and patient-centred decision making. Haematology MDT members were outliers in relation to the clinical decision-making process, and lung MDT members disagreed with other tumour types regarding treating patients with advanced disease. CONCLUSIONS: This analysis reveals strong consensus between MDT members from different tumour types, while also identifying areas that require a more tailored approach, such as the clinical decision-making process, and preparation for and the organisation of MDT meetings. Policymakers should remain sensitive to the needs of health care teams working in individual tumour types.

Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC.

BACKGROUND: The quality of decision-making in cancer multidisciplinary team (MDT) meetings is variable, which can result in suboptimal clinical decision making. We developed MDT-QuIC, an evidence-based tool to support clinical decision making by MDTs, which was evaluated by key users. METHODS: Following a literature review, factors important for high-quality clinical decision making were listed and then converted into a preliminary checklist by clinical and safety experts. Attitudes of MDT members toward the tool were evaluated via an online survey, before adjustments were made giving rise to a final version: MDT-QuIC. RESULTS: The checklist was evaluated by 175 MDT members (surgeons = 38, oncologists = 40, specialist nurses = 62, and MDT coordinators = 35). Attitudes toward the checklist were generally positive (P < 0.001, 1-sample t test), although nurses were more positive than other groups regarding whether the checklist would improve their contribution in MDT meetings (P < 0.001, Mann-Whitney U test). Participants thought that the checklist could be used to prepare cases for MDT meetings, to structure and guide case discussions, or as a record of MDT discussion. Regarding who could use the checklist, 70% thought it should be used by the MDT chair, 54% by the MDT coordinator, and 38% thought all MDT members should use it. CONCLUSION: We have developed and validated an evidence-based tool to support the quality of MDT decision making. MDT members were positive about the checklist and felt it may help to structure discussion, improve inclusivity, and patient centeredness. Further research is needed to assess its effect on patient care and outcomes.

Quality improvement in multidisciplinary cancer teams: an investigation of teamwork and clinical decision-making and cross-validation of assessments.

PURPOSE: Teamworking and clinical decision-making are important in multidisciplinary cancer teams (MDTs). Our objective is to assess the quality of information presentation and MDT members' contribution to decision-making via expert observation and self-report, aiming to cross-validate the two methods and assess the insight of MDT members into their own team performance. MATERIALS AND METHODS: Behaviors were scored using (i) a validated observational tool employing Likert scales with objective anchors, and (ii) a 29-question online self-report tool. Data were collected from observation of 164 cases in five MDTs, and 47 surveys from MDT members (response rate 70%). Presentation of information (case history, radiological, pathological, comorbidities, psychosocial, and patients' views) and quality of contribution to decision-making of MDT members (surgeons, oncologists, radiologists, pathologists, nurses, and MDT coordinators) were analyzed via descriptive statistics and the Jonckheere-Terpstra test. Correlation between observational and self-report assessments was assessed with Spearman's correlations. RESULTS: Quality of information presentation: Case histories and radiology information rated highest; patients' views and comorbidities/psychosocial issues rated lowest (observed: Z = 14.80, P ≤ 0.001; self-report: Z = 3.70, P < 0.001). Contribution to decision-making: Surgeons and oncologists rated highest, nurses and MDT coordinators rated lowest, and others in between (observed: Z = 20.00, P ≤ 0.001; self-report: Z = 8.10, P < 0.001). Correlations between observational and self-report assessments: Median Spearman's rho = 0.74 (range = 0.66-0.91; P < 0.05). CONCLUSIONS: The quality of teamworking and clinical decision-making in MDTs can reliably be assessed using observational and self-report metrics. MDT members have good insight into their own team performance. Such robust assessment methods could provide the basis of a toolkit for MDT team evaluation and improvement.

Decision making in surgical oncology.

Decisions in surgical oncology are increasingly being made by multi-disciplinary teams (MDTs). Although MDTs have been widely accepted as the preferred model for cancer service delivery, the process of decision making has not been well described and there is little evidence pointing to the ideal structure of an MDT. Performance in surgery has been shown to depend on non-technical skills, such as decision making, as well as patient factors and the technical skills of the healthcare team. Application of this systems approach to MDT working allows the identification of factors that affect the quality of decision making for cancer patients. In this article we review the literature on decision making in surgical oncology and by drawing from the systems approach to surgical performance we provide a framework for understanding the process of decision making in MDTs. Technical factors that affect decision making include the information about patients, robust ICT and video-conferencing equipment, a minimum dataset with expert review of radiological and pathological information, implementation and recording of the MDTs decision. Non-technical factors with an impact on decision making include attendance of team members at meetings, leadership, teamwork, open discussion, consensus on decisions and communication with patients and primary care. Optimising these factors will strengthen the decision making process and raise the quality of care for cancer patients.

The measurement of psychological distress in men being investigated for the presence of prostate cancer.

High levels (>50%) of anxiety are reported in patients undergoing screening for prostate cancer, which may affect health-related quality of life. We aimed to determine the level and prevalence of anxiety and depression and to identify those aspects of the diagnostic pathway that induce the most stress in men being investigated for prostate cancer. A total of 159 prostate-specific antigen-unscreened men undergoing a transrectal ultrasound-guided biopsy of the prostate (TRUS-B) completed two questionnaires, prior to their biopsy and before receiving results, containing the Hospital Anxiety and Depression Scale (HADS) and a 10-point Visual Analogue Scale (VAS). Median scores and prevalence of anxiety (4-5, 4-7%) and depression (1-2, 1.4%) respectively were low for both questionnaires. Waiting for biopsy results received the highest median VAS score (6) and was the most stressful event in 65% of men. There is a low incidence of clinically significant anxiety and depression in men being investigated for prostate cancer but questionnaires such as HADS identify patients with psychological distress who may benefit from early counselling. Uncertainty about the future while awaiting biopsy results after TRUS-B seems to be the most stressful event in patients' lives and minimizing this wait should help optimize patient care.

An investigation into the spatial relationship between prostate intraepithelial neoplasia and cancer.

The distribution of high grade prostate intraepithelial neoplasia (PIN) and cancer was analysed in 18 separate areas from 89 radical prostatectomy specimens that had been sectioned and digitally imaged. When the occurrence of each type of pathology was summated a predilection was demonstrated for both pathologies in the apex of the prostate and a linear relationship was found between the frequency of cancer and high grade PIN (r(2)=0.744, P<0.05). This relationship was strongest at the apex (r(2)=0.621, P<0.005), lower in the midgland (r(2)=0.828, P<0.05) and bordered on significance at the base (r(2)=0.621, P<0.063). These results support the theory that cancer could obliterate high grade PIN as it over grows the areas once occupied by PIN.Prostate Cancer and Prostatic Diseases (2001) 4, 97-100

Prevalence of prostatic intra-epithelial neoplasia (PIN) in biopsies from hospital practice and pilot screening: clinical implications.

As high grade PIN is commonly associated with concomitant cancer, current literature recommends re-biopsy of patients with high grade PIN. This paper describes the prevalence of high grade prostatic intra-epithelial neoplasia (PIN) from three independent clinical settings, reported by a single pathologist (MCP). High grade PIN was diagnosed in biopsies from 131 of the 1205 (11%) of patients in whom cancer was suspected in hospital practice, 42 of the 202 (20%) asymptomatic men screened for prostate cancer and 29 of the 118 (25%) patients presenting with prostatism in a case finding study. Re-biopsy on this scale has major clinical and cost implications. However, from a literature review, there is evidence to suggest that the risk of concomitant cancer with high grade PIN may be stratified according to serum PSA. This opinion should be tested prospectively.