- Email: [email protected]
Does every patient need to be discussed at a multidisciplinary team meeting?
Clinical Radiology 68 (2013) 780e784
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Does every patient need to be discussed at a multidisciplinary team meeting? N. Chinai a, F. Bintcliffe a, E.M. Armstrong b, J. Teape c, B.M. Jones c, K.B. Hosie a, * a
Department of Colorectal Surgery, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK Department of Radiology, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK c Department of Finance, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK b
article in formation Article history: Received 5 November 2012 Received in revised form 28 January 2013 Accepted 8 February 2013
AIM: To evaluate the clinical impact and cost-effectiveness of a multidisciplinary team (MDT) meeting in a large hospital in the UK. MATERIALS AND METHODS: A management plan for colorectal cancer patients was recorded by the supervising surgical consultant prior to the MDT meeting using the available clinical information and the available reports for imaging and histopathology. The recorded outcomes were then compared with the outcomes documented at the subsequent MDT meeting. The cost of the MDT meeting was calculated based on the salaries of individuals involved plus relevant overheads. A range of opportunity costs were considered, the most significant of which was the expenditure required to re-provide direct clinical care displaced by the MDT. RESULTS: Over a 3 month period a sample of 47 random cases were reviewed from the colorectal MDT. In three patients, there were significant differences between the preliminary consultant decision and the MDT recommendation: in one case management was changed based on further information about patient co-morbidity and performance status. In only one case was there a material alteration to a CT report, which altered management. The annual costs of running this colorectal local MDT alone were estimated at £162,734þ per annum with opportunity costs of at least twice that. CONCLUSION: The costs of MDT meetings are very high producing a small clinical impact. At a time of increasing financial and capacity pressure in healthcare systems, the use of scarce resources may be better deployed elsewhere. Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.
Introduction In the early 1990s, the EUROCARE study1,2 demonstrated poorer survival in the UK than in other European countries for most types of cancer. Following this publication, it was proposed that all patients with cancer should be seen by a
* Guarantor and correspondent: K.B. Hosie, Department of Colorectal Surgery, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford PL6 8DH, UK. Tel.: þ44 (0) 1752 202 082x39740. E-mail address: [email protected] (K.B. Hosie).
surgeon who specializes in their type of cancer and collaborates with colleagues in multidisciplinary teams (MDTs) that include diagnostic specialists and cancer nurse specialists.3 Fifteen years ago less than 20% of patients with cancer in England were managed by a specialist team.4 Current National Institute of Health and Clinical Excellence (NICE) guidance and peer-review recommendations are that 95e100% of patients should be discussed at a MDT meeting.5 MDTs aim to improve treatment standards by ensuring that all patients receive considered and homogeneous treatment and care from appropriately skilled professionals.
0009-9260/$ e see front matter Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.02.011
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
It is assumed that there is better continuity of care and the overall experience of cancer patients is enhanced by improved communication and decision-making. MDT meetings have been implemented in cancer care systems across most of Europe, the United States, and Australia. This development and widespread implementation of MDT meetings is not underpinned by high-quality evidence.6,7 The aim of the present study was to consider the clinical impact and cost-effectiveness of discussing all cancer patients at an MDT meeting.
Materials and methods At Derriford Hospital, the local colorectal MDT meeting occurs weekly, and the patient list is published 2 days prior to the meeting. Over a 3 month period, a sample of patients randomly chosen from the MDT meeting list were presented to any of the eight colorectal consultants with all the relevant background information, histopathological and/or radiological results, and documented future management of each patient’s condition available. At the subsequent MDT meeting, the outcomes were then recorded and compared with the previously documented recommendations. If a consultant was unavailable to discuss patient management before the MDT meeting, the outcomes for these patients were not included in the analysis. For the duration of this observational study, a single junior trainee Fiona Bintcliffe (F.B.) prepared the patient information for the MDT meeting. On receiving the MDT meeting patient list F.B. collated all the current clinical, radiology, and histopathology results (as they would be presented at the MDT meeting) on a computerized database, and presented this information to the named colorectal consultant in the 2 days preceding the meeting. The pre-MDT meeting management decisions were then documented on an independently maintained computerized database. Patients were only included if the trainee (F.B.) was able to discuss the case with the consultant surgeon prior to the MDT meeting. Patients who did not have documented pre- and post-MDT meeting recommendations were not analysed in this case series. To evaluate the cost of the MDT meetings, the direct and overhead costs were calculated based on established costing principles. Direct costs included salaries for core and extended members. Core members included consultants: surgeons (n ¼ 8), radiologists (n ¼ 2), pathologists (n ¼ 1), and oncologists (n ¼ 2). Extended members included nurse specialists (n ¼ 3), junior doctors, an MDT meeting coordinator, and administrative support. Overhead costs included the use of a specific room with appropriate IT facilities to view radiological images and histology slides (Table 1). Opportunity costs are represented by the clinics, theatre time, radiology or histopathology reporting, or other direct clinical care that otherwise might have been performed. Calculation of opportunity costs is somewhat subjective and dependent on the prevailing circumstances. For the purpose
781
of this study, three methods of calculation have been considered: (1) the cost of staff time providing direct clinical care at base rates; (2) the loss of income that could otherwise have been generated; and (3) the cost of Waiting List Initiative sessions at £250 per hour plus oncosts (£284.50).
Calculating direct costs (see Table 1) For the colorectal cancer MDT meetings at Derriford Hospital, the total cost of running a weekly MDT meeting was calculated as follows:
Salary costs Thirteen consultants across surgery, radiology, pathology, and oncology have more than 2 h per week included in their job plans (0.5e1 PA). These were calculated as per job plan at a representative average whole time equivalent rate of £113.443 per annum (Table 1). Cancer nurse specialists spend on average 3 h per week preparing for MDT meetings and completing post-MDT meeting paperwork. This represents a cost of £17,154 for the three cancer nurse specialists. Junior doctors at Derriford Hospital (specifically the registrars) prepare the brief on each patient for the MDT meeting. The registrars spends on average 3 h per week at an annual cost of £8363 preparing for the MDT meeting, and therefore, are unable to participate in any clinical or theatre sessions for that day. The MDT meeting coordinator spends 2e3 h per day preparing the agenda for each cancer MDT meeting, 1e1.5 hours at each cancer MDT meeting, and then up to 2 h postMDT meeting ensuring that the information is disseminated to the consultants and on the network MDT database. This equates to £8864 per annum. Administrative support has been calculated at £6648.
Overhead costs Overhead costs are shown in Table 1 and have been taken from reference costs return in 2011/2012.
Opportunity costs In the local environment, patient demand exceeds established capacity in all participating disciplines. Therefore, it is considered that the requirements to re-provide direct clinical care sessions at waiting list initiative rates represents the most appropriate method of calculating the opportunity costs of the MDT meetings. The cost of reproviding consultant input alone equates to £387,000 (Table 1).
Results Data for 47 patients were collected prospectively over a 3 month period and compared with the recorded outcomes at the MDT meetings. There was 94% concurrence between the management plan documented by each consultant prior to the MDT meeting and the recorded outcomes. In only three cases was there a difference of opinion. The first case was a
782
Table 1 Estimated costs of MDT. Direct Costs
Overheads MDT meeting room costs: heat, light, cleaning, capital charges etc. IT: PC, projector, whiteboard capital charges Corporate overheads Total Overheads Total MDT costs
Average preparation time per week (h)
Average participation time per week (h)
Average post-MDT time per week (h)
Total MDT commitment per week (h)
% WTE
Employment Cost p.a. (1 WTE)
MDT cost per participant
Total colorectal MDT meeting cost
WLI costs (Opportunity Costs)
£ 284.50
2 4 4.4 2 5
5.0% 10.0% 11.0% 5.0% 13.3%
113,443 113,443 113,443 113,443 42,884
5,672 11,344 12,479 5,672 5,718
45,377 22,689 12,479 11,344, 91,889 17,154
4,552 2,276 1,252 1,138
191,184 95,592 52,576 47,796 387,148
8 2 1 2 3
2
2 2 2 2 2
1
3
2
5
12.5%
66,905
8,363
8,363
4
0
2
2
5.0%
66,905
3,345
13,381
1
12.5
1.5
2
16
42.7%
20,774
8,864
8,864
12
0.5
0.5
1
2.7%
20,774
554
6,648
34
22.4
3.5
41.4
2 2.4
15.5
1
146,298
1,697
1,697
506
506
14,233
14,233 16,436 162,734
Staff costs include employers’ on-costs (pension/National Insurance). Consultant costs based on a representative 7 year consultant with 10 Programmed Activity (PA and ¼ 4 hours) contract, 7.5:2.5 Direct Clinical Care (DCC):Supporting Professional Activity (SPA), on call category A, high frequency and availability for MDT meeting 42/52 weeks per annum (p.a.) without backfill for annual leave. No allowance made for clinical excellence awards. Clinical nurse specialist costs based on representative mean of scale band 7, 37.5 h per week and availability for MDT meeting 46/52 weeks p.a. without backfill for annual leave. Specialist registrar costs based on representative mean of scale (point 4) band 2B intensity 40 h per week and availability for MDT meeting 46/52 weeks p.a. without backfill for annual leave. MDT meeting co-ordinator based on representative mean of scale band 3, 37.5 hours per week and availability for MDT 46/52 weeks p.a. without backfill for annual leave. Administrative costs based on representative mean of scale band 3 administrators, 37.5 h per week, 46 weeks p.a. without backfill for annual leave. MDT meeting room costs taken from Reference costs return 2011/12.
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
Consultants Colorectal surgery Radiology Pathology Oncology Clinical nurse specialists (band 7) Specialist registrar (prep) Specialist registrar (attendance) MDT meeting coordinator (band 3) Administrative support (band 3) Total direct costs
No
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
73-year-old woman referred with rectal bleeding and found to have four colonic polyps. Three of the four polyps were hyperplastic; however, one polyp in the ascending colon had a focus of poorly differentiated adenocarcinoma. The polyp had been completely excised endoscopically, and it was the consultant’s opinion that the patient be fully staged using computed tomography (CT), and undergo regular endoscopic and CT surveillance. The recommendation of the MDT meeting was that the patient be staged and then offered a right hemi-colectomy. The second case was a 71-year-old man who had undergone an anterior resection. Postoperative histology demonstrated a Dukes’ B moderately differentiated adenocarcinoma, and the preoperative CT examination demonstrated indeterminate lung nodules. Based on the information available, it was the consultant’s recommendation that the patient have clinical follow-up and a repeat CT examination of the chest in 3 months. At the MDT meeting, an addendum was added to the CT examination regarding the lung lesions, and it was recommended that the patient undergo a repeat CT examination of the chest immediately and be referred for adjuvant chemotherapy. In the third case of non-concurrence, a 78-year-old man on hormone therapy for primary prostate cancer had presented with a change of bowel habit. Endoscopy and histology demonstrated a rectal adenoma. It was the treating consultant’s recommendation that the patient be referred for consideration of palliative chemo-radiotherapy for the rectal lesion. However, after extensive discussion at the MDT meeting, it was felt that the lesion was more likely to be rectal invasion of a primary prostate carcinoma and the best course of treatment was to leave the adenoma and continue with hormone therapy for the primary prostate cancer. In light of patient co-morbidities, it was felt that the patient would not be suitable for chemoradiotherapy.
Discussion In this small series of treatment recommendations made within a colorectal cancer MDT meeting, 94% concurred with the treatment strategy outlined by the supervising colorectal surgeon. The management decisions that changed were in light of new clinical information made available at the MDT meeting in two cases. It can be argued that in both cases the management would have been ultimately decided by the oncologist. In the case of the cancer in the polyp, there remains some contention about the most appropriate management and, perhaps most importantly, the decision should be made with the patients themselves. Because the patient is not present, an MDT meeting may make treatment recommendations without a full picture of co-morbidity, mobility, comprehension, personal preference, and the wider psychosocial implications of any decision. Recent publications suggest that as many as 10e15% of MDT meeting recommendations made in the UK are not implemented.8,9 It is appreciated that the ability to extrapolate from the results of this observational case series is limited by the
783
small sample size and restriction to a single cancer specialty. Although limiting its external validity, the results demonstrate that the accepted belief that improvements in patient diagnosis and management processes are due specifically due to the introduction of MDT meetings is difficult to substantiate. Over the same time period, knowledge about cancer and available diagnostic and treatment options has evolved alongside organizational restructuring (e.g., centralization of processes, streamlining of the clinical pathway, introduction of evidence-based guidelines, and protocols of care). Together these make the interpretation of a causal link between the introduction of MDT meetings and improved clinical outcomes tenuous. The emphasis of MDT meetings is on collaborative decision-making where the core team members of relevant specialties participate, share their knowledge, and make collective evidence-based recommendations for patient management. The published empirical evidence to support the benefits of cancer MDT meetings is weak and limited, and therefore, it is paradoxical that individual clinical decisions must be based on evidence but overall organizational decisions, such as the mandating of MDT meetings for all patients are not based on similarly sound empirical evidence. The value of the MDT meeting in changing clinical practice in the UK has certainly been important and a number of accepted benefits are set out in Table 2. However, these benefits are difficult to quantify. Previous publications suggest that MDT meeting decisions concur with consultant opinion in 90% of cases, and when changed, tend to adopt a more conservative approach due to patient-related factors.9,10 In calculating the financial costs, the authors have deliberately underestimated the time involved and not included all the oncosts that would be incurred. Despite this, the costs are very significant and are of questionable justification when measured against clinical impact. Furthermore, the utility costs to patients of delayed management decisions due to MDT meetings often being unable to cope with the volume of patients allocated to each meeting have not been discussed. For a comprehensive multidisciplinary discussion for each patient, all clinical information (including endoscopy results), all imaging, and all histology must be reported and available to review. Due to the MDT meeting workload expanding more rapidly than the rate at which resources can be allocated away from routine work, this is not always possible, and often cases need to be brought back to a subsequent MDT meeting to discuss management. Table 2 Accepted benefits of the introduction of multidisciplinary team meetings.
Improved co-ordination and consistency of care Improved clinical outcomes Increased patient satisfaction and psychological wellbeing Improved communication between health professionals Educational opportunities for health professionals Support from a collegial environment Opportunities to improve audit Increased recruitment into clinical trials
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N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
The clinical results of this study cannot be generalized beyond this specific colorectal MDT, but can be validated by undertaking further audits of other teams with different working methods and at various stages of development and experience. However, given the time and resources that MDT working requires, a stronger evidence base is essential. In light of the now established guidelines for management of colorectal cancer, the MDT meeting guidelines should be reconsidered to allow more selected discussions of appropriate cases and, therefore, better use of scarce resources. Further research needs to be undertaken to assess the outcomes of MDT effectiveness. This should include clinical audits to examine whether team decisions influence better patient management and ultimately survival and patient audits to check whether the introduction of MDT meetings have enabled patients to be involved in decision-making by sharing adequate information on options discussed by the MDT. If the time spent in MDT meetings across all specialties was rationalized in a cost-effective way, the efficiency savings for the National Health Service (NHS) would be significant, and the time spent discussing difficult or controversial cases would be more appropriate, thus, hopefully, improving clinical outcomes.
References 1. Berrino F, Esteve J, Coleman MP. Basic issues in estimating and comparing the survival of cancer patients. IARC Sci Publ 1995:1e14. 2. Sant M, Capocaccia R, Verdecchia A, et al. Comparisons of colon-cancer survival among European countries: the Eurocare Study. Int J Cancer 1995;63:43e8. 3. Calman K, Hine D. A policy framework for commissioning cancer services: a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. Available at: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4071083; 1995 [last accessed January 2012]. 4. Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006;7:935e43. 5. Finan P, Smith J, Trivella M, Meulen J, Greenaway K, Yelland A. The National Bowel Cancer Audit Annual Report 2010. 2010. Available at: http://data.gov.uk/dataset/national-bowel-cancer-audit-annual-reports [last accessed January 2012]. 6. Tattersall MH. Multidisciplinary team meetings: where is the value? Lancet Oncol 2006;7:886e8. 7. Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: what is the evidence? BMJ 2010;340:c951. 8. Blazeby JM, Wilson L, Metcalfe C, et al. Analysis of clinical decisionmaking in multi-disciplinary cancer teams. Ann Oncol 2006;17:457e60. 9. Wood JJ, Metcalfe C, Paes A, et al. An evaluation of treatment decisions at a colorectal cancer multi-disciplinary team. Colorectal Dis 2008;10:769e72. 10. Sharma A, Sharp DM, Walker LG, Monson JR. Colorectal MDTs: the team’s perspective. Colorectal Dis 2008;10:63e8.
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Does every patient need to be discussed at a multidisciplinary team meeting? N. Chinai a, F. Bintcliffe a, E.M. Armstrong b, J. Teape c, B.M. Jones c, K.B. Hosie a, * a
Department of Colorectal Surgery, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK Department of Radiology, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK c Department of Finance, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK b
article in formation Article history: Received 5 November 2012 Received in revised form 28 January 2013 Accepted 8 February 2013
AIM: To evaluate the clinical impact and cost-effectiveness of a multidisciplinary team (MDT) meeting in a large hospital in the UK. MATERIALS AND METHODS: A management plan for colorectal cancer patients was recorded by the supervising surgical consultant prior to the MDT meeting using the available clinical information and the available reports for imaging and histopathology. The recorded outcomes were then compared with the outcomes documented at the subsequent MDT meeting. The cost of the MDT meeting was calculated based on the salaries of individuals involved plus relevant overheads. A range of opportunity costs were considered, the most significant of which was the expenditure required to re-provide direct clinical care displaced by the MDT. RESULTS: Over a 3 month period a sample of 47 random cases were reviewed from the colorectal MDT. In three patients, there were significant differences between the preliminary consultant decision and the MDT recommendation: in one case management was changed based on further information about patient co-morbidity and performance status. In only one case was there a material alteration to a CT report, which altered management. The annual costs of running this colorectal local MDT alone were estimated at £162,734þ per annum with opportunity costs of at least twice that. CONCLUSION: The costs of MDT meetings are very high producing a small clinical impact. At a time of increasing financial and capacity pressure in healthcare systems, the use of scarce resources may be better deployed elsewhere. Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.
Introduction In the early 1990s, the EUROCARE study1,2 demonstrated poorer survival in the UK than in other European countries for most types of cancer. Following this publication, it was proposed that all patients with cancer should be seen by a
* Guarantor and correspondent: K.B. Hosie, Department of Colorectal Surgery, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford PL6 8DH, UK. Tel.: þ44 (0) 1752 202 082x39740. E-mail address: [email protected] (K.B. Hosie).
surgeon who specializes in their type of cancer and collaborates with colleagues in multidisciplinary teams (MDTs) that include diagnostic specialists and cancer nurse specialists.3 Fifteen years ago less than 20% of patients with cancer in England were managed by a specialist team.4 Current National Institute of Health and Clinical Excellence (NICE) guidance and peer-review recommendations are that 95e100% of patients should be discussed at a MDT meeting.5 MDTs aim to improve treatment standards by ensuring that all patients receive considered and homogeneous treatment and care from appropriately skilled professionals.
0009-9260/$ e see front matter Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.crad.2013.02.011
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
It is assumed that there is better continuity of care and the overall experience of cancer patients is enhanced by improved communication and decision-making. MDT meetings have been implemented in cancer care systems across most of Europe, the United States, and Australia. This development and widespread implementation of MDT meetings is not underpinned by high-quality evidence.6,7 The aim of the present study was to consider the clinical impact and cost-effectiveness of discussing all cancer patients at an MDT meeting.
Materials and methods At Derriford Hospital, the local colorectal MDT meeting occurs weekly, and the patient list is published 2 days prior to the meeting. Over a 3 month period, a sample of patients randomly chosen from the MDT meeting list were presented to any of the eight colorectal consultants with all the relevant background information, histopathological and/or radiological results, and documented future management of each patient’s condition available. At the subsequent MDT meeting, the outcomes were then recorded and compared with the previously documented recommendations. If a consultant was unavailable to discuss patient management before the MDT meeting, the outcomes for these patients were not included in the analysis. For the duration of this observational study, a single junior trainee Fiona Bintcliffe (F.B.) prepared the patient information for the MDT meeting. On receiving the MDT meeting patient list F.B. collated all the current clinical, radiology, and histopathology results (as they would be presented at the MDT meeting) on a computerized database, and presented this information to the named colorectal consultant in the 2 days preceding the meeting. The pre-MDT meeting management decisions were then documented on an independently maintained computerized database. Patients were only included if the trainee (F.B.) was able to discuss the case with the consultant surgeon prior to the MDT meeting. Patients who did not have documented pre- and post-MDT meeting recommendations were not analysed in this case series. To evaluate the cost of the MDT meetings, the direct and overhead costs were calculated based on established costing principles. Direct costs included salaries for core and extended members. Core members included consultants: surgeons (n ¼ 8), radiologists (n ¼ 2), pathologists (n ¼ 1), and oncologists (n ¼ 2). Extended members included nurse specialists (n ¼ 3), junior doctors, an MDT meeting coordinator, and administrative support. Overhead costs included the use of a specific room with appropriate IT facilities to view radiological images and histology slides (Table 1). Opportunity costs are represented by the clinics, theatre time, radiology or histopathology reporting, or other direct clinical care that otherwise might have been performed. Calculation of opportunity costs is somewhat subjective and dependent on the prevailing circumstances. For the purpose
781
of this study, three methods of calculation have been considered: (1) the cost of staff time providing direct clinical care at base rates; (2) the loss of income that could otherwise have been generated; and (3) the cost of Waiting List Initiative sessions at £250 per hour plus oncosts (£284.50).
Calculating direct costs (see Table 1) For the colorectal cancer MDT meetings at Derriford Hospital, the total cost of running a weekly MDT meeting was calculated as follows:
Salary costs Thirteen consultants across surgery, radiology, pathology, and oncology have more than 2 h per week included in their job plans (0.5e1 PA). These were calculated as per job plan at a representative average whole time equivalent rate of £113.443 per annum (Table 1). Cancer nurse specialists spend on average 3 h per week preparing for MDT meetings and completing post-MDT meeting paperwork. This represents a cost of £17,154 for the three cancer nurse specialists. Junior doctors at Derriford Hospital (specifically the registrars) prepare the brief on each patient for the MDT meeting. The registrars spends on average 3 h per week at an annual cost of £8363 preparing for the MDT meeting, and therefore, are unable to participate in any clinical or theatre sessions for that day. The MDT meeting coordinator spends 2e3 h per day preparing the agenda for each cancer MDT meeting, 1e1.5 hours at each cancer MDT meeting, and then up to 2 h postMDT meeting ensuring that the information is disseminated to the consultants and on the network MDT database. This equates to £8864 per annum. Administrative support has been calculated at £6648.
Overhead costs Overhead costs are shown in Table 1 and have been taken from reference costs return in 2011/2012.
Opportunity costs In the local environment, patient demand exceeds established capacity in all participating disciplines. Therefore, it is considered that the requirements to re-provide direct clinical care sessions at waiting list initiative rates represents the most appropriate method of calculating the opportunity costs of the MDT meetings. The cost of reproviding consultant input alone equates to £387,000 (Table 1).
Results Data for 47 patients were collected prospectively over a 3 month period and compared with the recorded outcomes at the MDT meetings. There was 94% concurrence between the management plan documented by each consultant prior to the MDT meeting and the recorded outcomes. In only three cases was there a difference of opinion. The first case was a
782
Table 1 Estimated costs of MDT. Direct Costs
Overheads MDT meeting room costs: heat, light, cleaning, capital charges etc. IT: PC, projector, whiteboard capital charges Corporate overheads Total Overheads Total MDT costs
Average preparation time per week (h)
Average participation time per week (h)
Average post-MDT time per week (h)
Total MDT commitment per week (h)
% WTE
Employment Cost p.a. (1 WTE)
MDT cost per participant
Total colorectal MDT meeting cost
WLI costs (Opportunity Costs)
£ 284.50
2 4 4.4 2 5
5.0% 10.0% 11.0% 5.0% 13.3%
113,443 113,443 113,443 113,443 42,884
5,672 11,344 12,479 5,672 5,718
45,377 22,689 12,479 11,344, 91,889 17,154
4,552 2,276 1,252 1,138
191,184 95,592 52,576 47,796 387,148
8 2 1 2 3
2
2 2 2 2 2
1
3
2
5
12.5%
66,905
8,363
8,363
4
0
2
2
5.0%
66,905
3,345
13,381
1
12.5
1.5
2
16
42.7%
20,774
8,864
8,864
12
0.5
0.5
1
2.7%
20,774
554
6,648
34
22.4
3.5
41.4
2 2.4
15.5
1
146,298
1,697
1,697
506
506
14,233
14,233 16,436 162,734
Staff costs include employers’ on-costs (pension/National Insurance). Consultant costs based on a representative 7 year consultant with 10 Programmed Activity (PA and ¼ 4 hours) contract, 7.5:2.5 Direct Clinical Care (DCC):Supporting Professional Activity (SPA), on call category A, high frequency and availability for MDT meeting 42/52 weeks per annum (p.a.) without backfill for annual leave. No allowance made for clinical excellence awards. Clinical nurse specialist costs based on representative mean of scale band 7, 37.5 h per week and availability for MDT meeting 46/52 weeks p.a. without backfill for annual leave. Specialist registrar costs based on representative mean of scale (point 4) band 2B intensity 40 h per week and availability for MDT meeting 46/52 weeks p.a. without backfill for annual leave. MDT meeting co-ordinator based on representative mean of scale band 3, 37.5 hours per week and availability for MDT 46/52 weeks p.a. without backfill for annual leave. Administrative costs based on representative mean of scale band 3 administrators, 37.5 h per week, 46 weeks p.a. without backfill for annual leave. MDT meeting room costs taken from Reference costs return 2011/12.
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
Consultants Colorectal surgery Radiology Pathology Oncology Clinical nurse specialists (band 7) Specialist registrar (prep) Specialist registrar (attendance) MDT meeting coordinator (band 3) Administrative support (band 3) Total direct costs
No
N. Chinai et al. / Clinical Radiology 68 (2013) 780e784
73-year-old woman referred with rectal bleeding and found to have four colonic polyps. Three of the four polyps were hyperplastic; however, one polyp in the ascending colon had a focus of poorly differentiated adenocarcinoma. The polyp had been completely excised endoscopically, and it was the consultant’s opinion that the patient be fully staged using computed tomography (CT), and undergo regular endoscopic and CT surveillance. The recommendation of the MDT meeting was that the patient be staged and then offered a right hemi-colectomy. The second case was a 71-year-old man who had undergone an anterior resection. Postoperative histology demonstrated a Dukes’ B moderately differentiated adenocarcinoma, and the preoperative CT examination demonstrated indeterminate lung nodules. Based on the information available, it was the consultant’s recommendation that the patient have clinical follow-up and a repeat CT examination of the chest in 3 months. At the MDT meeting, an addendum was added to the CT examination regarding the lung lesions, and it was recommended that the patient undergo a repeat CT examination of the chest immediately and be referred for adjuvant chemotherapy. In the third case of non-concurrence, a 78-year-old man on hormone therapy for primary prostate cancer had presented with a change of bowel habit. Endoscopy and histology demonstrated a rectal adenoma. It was the treating consultant’s recommendation that the patient be referred for consideration of palliative chemo-radiotherapy for the rectal lesion. However, after extensive discussion at the MDT meeting, it was felt that the lesion was more likely to be rectal invasion of a primary prostate carcinoma and the best course of treatment was to leave the adenoma and continue with hormone therapy for the primary prostate cancer. In light of patient co-morbidities, it was felt that the patient would not be suitable for chemoradiotherapy.
Discussion In this small series of treatment recommendations made within a colorectal cancer MDT meeting, 94% concurred with the treatment strategy outlined by the supervising colorectal surgeon. The management decisions that changed were in light of new clinical information made available at the MDT meeting in two cases. It can be argued that in both cases the management would have been ultimately decided by the oncologist. In the case of the cancer in the polyp, there remains some contention about the most appropriate management and, perhaps most importantly, the decision should be made with the patients themselves. Because the patient is not present, an MDT meeting may make treatment recommendations without a full picture of co-morbidity, mobility, comprehension, personal preference, and the wider psychosocial implications of any decision. Recent publications suggest that as many as 10e15% of MDT meeting recommendations made in the UK are not implemented.8,9 It is appreciated that the ability to extrapolate from the results of this observational case series is limited by the
783
small sample size and restriction to a single cancer specialty. Although limiting its external validity, the results demonstrate that the accepted belief that improvements in patient diagnosis and management processes are due specifically due to the introduction of MDT meetings is difficult to substantiate. Over the same time period, knowledge about cancer and available diagnostic and treatment options has evolved alongside organizational restructuring (e.g., centralization of processes, streamlining of the clinical pathway, introduction of evidence-based guidelines, and protocols of care). Together these make the interpretation of a causal link between the introduction of MDT meetings and improved clinical outcomes tenuous. The emphasis of MDT meetings is on collaborative decision-making where the core team members of relevant specialties participate, share their knowledge, and make collective evidence-based recommendations for patient management. The published empirical evidence to support the benefits of cancer MDT meetings is weak and limited, and therefore, it is paradoxical that individual clinical decisions must be based on evidence but overall organizational decisions, such as the mandating of MDT meetings for all patients are not based on similarly sound empirical evidence. The value of the MDT meeting in changing clinical practice in the UK has certainly been important and a number of accepted benefits are set out in Table 2. However, these benefits are difficult to quantify. Previous publications suggest that MDT meeting decisions concur with consultant opinion in 90% of cases, and when changed, tend to adopt a more conservative approach due to patient-related factors.9,10 In calculating the financial costs, the authors have deliberately underestimated the time involved and not included all the oncosts that would be incurred. Despite this, the costs are very significant and are of questionable justification when measured against clinical impact. Furthermore, the utility costs to patients of delayed management decisions due to MDT meetings often being unable to cope with the volume of patients allocated to each meeting have not been discussed. For a comprehensive multidisciplinary discussion for each patient, all clinical information (including endoscopy results), all imaging, and all histology must be reported and available to review. Due to the MDT meeting workload expanding more rapidly than the rate at which resources can be allocated away from routine work, this is not always possible, and often cases need to be brought back to a subsequent MDT meeting to discuss management. Table 2 Accepted benefits of the introduction of multidisciplinary team meetings.
Improved co-ordination and consistency of care Improved clinical outcomes Increased patient satisfaction and psychological wellbeing Improved communication between health professionals Educational opportunities for health professionals Support from a collegial environment Opportunities to improve audit Increased recruitment into clinical trials
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The clinical results of this study cannot be generalized beyond this specific colorectal MDT, but can be validated by undertaking further audits of other teams with different working methods and at various stages of development and experience. However, given the time and resources that MDT working requires, a stronger evidence base is essential. In light of the now established guidelines for management of colorectal cancer, the MDT meeting guidelines should be reconsidered to allow more selected discussions of appropriate cases and, therefore, better use of scarce resources. Further research needs to be undertaken to assess the outcomes of MDT effectiveness. This should include clinical audits to examine whether team decisions influence better patient management and ultimately survival and patient audits to check whether the introduction of MDT meetings have enabled patients to be involved in decision-making by sharing adequate information on options discussed by the MDT. If the time spent in MDT meetings across all specialties was rationalized in a cost-effective way, the efficiency savings for the National Health Service (NHS) would be significant, and the time spent discussing difficult or controversial cases would be more appropriate, thus, hopefully, improving clinical outcomes.
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