Benjamin W. Lamb

Quality of Care Management Decisions by Multidisciplinary Cancer Teams: A Systematic Review

BackgroundFactors that affect the quality of clinical decisions of multidisciplinary cancer teams (MDTs) are not well understood. We reviewed and synthesised the evidence on clinical, social and technological factors that affect the quality of MDT clinical decision-making.MethodsElectronic databases were searched in May 2009. Eligible studies reported original data, quantitative or qualitative. Data were extracted and tabulated by two blinded reviewers, and study quality formally evaluated.ResultsThirty-seven studies were included. Study quality was low to medium. Studies assessed quality of care decisions via the effect of MDTs on care management. MDTs changed cancer management by individual physicians in 2–52% of cases. Failure to reach a decision at MDT discussion was found in 27–52% of cases. Decisions could not be implemented in 1–16% of cases. Team decisions are made by physicians, using clinical information. Nursing personnel do not have an active role, and patient preferences are not discussed. Time pressure, excessive caseload, low attendance, poor teamworking and lack of leadership lead to lack of information and deterioration of decision-making. Telemedicine is increasingly used in developed countries, with no detriment to quality of MDT decisions.ConclusionsTeam/social factors affect management decisions by cancer MDTs. Inclusion of time to prepare for MDTs into team-members’ job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel would address some of the current shortcomings. These improvements ought to be considered at national policy level, with the ultimate aim of improving cancer care.

Information transfer and communication in surgery: a systematic review.

Objectives:We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care. Background:Communication breakdowns are a common cause of surgical errors and adverse events. Data Sources:Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography. Study Selection:Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review. Data Extraction:Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations. Results:Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes. Conclusions:ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Teamwork and Team Decision-making at Multidisciplinary Cancer Conferences: Barriers, Facilitators, and Opportunities for Improvement

BackgroundAnecdotally, multidisciplinary cancer conferences (MCCs) do not always function optimally. MCC members’ experiences with and attitudes toward MCCs are explored, and barriers to and facilitators of effective team-working are identified.MethodsA total of 19 semistructured interviews were conducted with surgeons, oncologists, nurses, and administrators. Interviews explored participants’ opinions on MCC attendance, information presentation, case discussion, leadership, team decision-making, and possible improvements to MCC meetings.ResultsNonattendance was associated with not having protected time to attend the MCC. Contributions to MCC discussions were unequal among the participants, and patient-centered information was ignored. Good leadership was necessary to foster inclusive case discussion. Members were positive about MCCs, but protected time, improved case selection, and working in a more structured way were possible improvements.ConclusionsResults are consistent with previous research: Members of the MCC are positive about the benefits of MCCs, although improving the way MCCs work is a goal.

Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool

Aim Team performance is important in multidisciplinary teams (MDTs), but no tools exist for assessment. Our objective was to construct a robust tool for scientific assessment of MDT performance. Materials and methods An observational tool was developed to assess performance in MDTs. Behaviours were scored on Likert scales, with objective anchors. Five MDT meetings (112 cases) were observed by a surgeon and a psychologist. The presentation of case history, radiological and pathological information, chairs effectiveness, and contributions to decision-making of surgeons, oncologists, radiologists, pathologists and clinical nurse specialists (CNSs) are analysed via descriptive statistics, a comparison of average scores (Mann–Whitney U) to test interobserver agreement and intraclass correlation coefficients (ICCs) to further assess interobserver agreement and learning curves. Results Contributions of surgeons, chairs effectiveness, presentation of case history and radiological information were rated above average (p≤0.001). Contributions of histopathologists and CNS were rated below average (p≤0.001), and others average. The interobserver agreement was high (ICC=0.70+) for presentation of radiological information, and contribution of oncologists, radiologists, pathologists and CNSs; adequate for case history presentation (ICC=0.68) and contribution of surgeons (ICC=0.69); moderate for chairperson (ICC=0.52); and poor for pathological information (ICC=0.31). Average differences were found only for case-history presentation (p≤0.001). ICCs improved significantly in assessment of case history, and Oncologists, and ICCs were consistently high for CNS, Radiologists, and Histopathologists. Conclusions Scientific observational metrics can be reliably used by medical and non-medical observers in cancer MDTs. Such robust assessment tools provide part of a toolkit for team evaluation and enhancement.

Improving Decision Making in Multidisciplinary Tumor Boards: Prospective Longitudinal Evaluation of a Multicomponent Intervention for 1,421 Patients

BACKGROUND Due to its complexity, cancer care is increasingly being delivered by multidisciplinary tumor boards (MTBs). Few studies have investigated how best to organize and run MTBs to optimize clinical decision making. We developed and evaluated a multicomponent intervention designed to improve the MTBs ability to reach treatment decisions. STUDY DESIGN We conducted a prospective longitudinal study during 16 months that evaluated MTB decision making for urological cancer patients at a university hospital in London, UK. After a baseline period, MTB improvement interventions (eg, MTBs checklist, MTB team training, and written guidance) were delivered sequentially. Outcomes measures were the MTBs ability to reach a decision, the quality of information presentation, and the quality of teamwork (as assessed by trained assessors using a previously validated observational assessment tool). The efficacy of the intervention was evaluated using multivariate analyses. RESULTS There were 1,421 patients studied between December 2009 and April 2, 2011. All outcomes improved considerably between baseline and intervention implementation: the MTBs ability to reach a decision rose from 82.2% to 92.7%, quality of information presentation rose from 29.6% to 38.3%, and quality of teamwork rose from 37.8% to 43.0%. The MTBs ability to reach a treatment decision was related to the quality of available information (r = 0.298; p < 0.05) and quality of teamwork within the MTB (r = 0.348; p < 0.05). The most common barriers to reaching clinical decisions were inadequate radiologic information (n = 77), inadequate pathologic information (n = 51), and inappropriate patient referrals (n = 21). CONCLUSIONS Multidisciplinary tumor board-delivered treatment is becoming the standard for cancer care worldwide. Our intervention is efficacious and applicable to MTBs and can improve decision making and expedite cancer care.

Framework for incorporating simulation into urology training

Study Type – Therapy (case series)

Management of non-muscle invasive bladder cancer: A comprehensive analysis of guidelines from the United States, Europe and Asia

Bladder cancer is the 8th most common cancer with 74,000 new cases in the United States in 2015. Non-muscle invasive bladder cancer (NMIBC) accounts for 75% of all bladder cancer cases. Transurethral resection and intravesical treatments remain the main treatment modality. Up to 31-78% of cases recur, hence the need for intensive treatment and surveillance protocols which makes bladder cancer one of the most expensive cancers to manage. The purpose of this review is to compare contemporary guidelines from Europe, (European Association of Urology), the United States (National Comprehensive Cancer Network), the United Kingdom (National Institute for Health and Care Excellence), Japan (Japanese Urological Association) and the International Consultation on Bladder Cancer (ICUD). We compare and contrast the different guidelines and the evidence on which their recommendations are based.

How do nurses make decisions

Judgement and decision-making are important facets of healthcare providers’ professional skills and identity, including both physicians (Croskerry and Norman, 2008) and nurses (Traynor et al., 2010). Judgement is typically defined as weighing up different options; decision-making involves choosing a specific course of action to follow (Jacklin et al., 2009). Recent holistic, ‘systemic’ approaches to the quality and safety of care provision have defined efficacious judgement and decision-making as key ‘nontechnical’ skills—i.e., skills that go beyond clinical knowledge and technical competence (Undre et al., 2009; Yule et al., 2006). Nursing judgement and decision-making, therefore, contribute significantly to the safety and quality of patient care, but can present nurses with challenges— some of them common to decision-making across all of healthcare (e.g., how to integrate intuition and evidence, how not to fall prey to a number of biases known to affect human judgement), others specific to the nursing profession (e.g., how to integrate nursing decision-making with that of physicians in a manner that streamlines care and minimises frictions) (Croskerry and Norman, 2008; Traynor et al., 2010). Despite their importance, these skills are underresearched—within nursing and across healthcare specialties. A number of reasons explain this. First of all, capturing such skills is not necessarily straightforward. It typically involves a multidisciplinary approach, and methodologies that span various disciplines, including psychology, sociology, and ethnography. Second, nursing judgement and decision-making are often only ‘visible’ in retrospect, when something has gone wrong in the care of a patient, which is retrospectively attributed to ‘erroneous judgement’ (e.g., not calling a physician to review a patient). Third, individual nurses’ decisions are thought to be driven primarily by protocols and occasions where this does not apply are treated as exceptions to the rule (Manias and Street, 2000). Taken together with a lack of training modules that specifically address such skills, nurses’ decision processes are often treated as a mysterious ‘black box’. Modern nursing research, however, is starting to address these issues. Through a number of international studies, many of them published in this journal, certain

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes.

OBJECTIVES To report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). METHODS AND MATERIALS A total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS). RESULTS Median follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5-45.4) for ORC; and 16.1 months (IQR: 11.2-27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed. CONCLUSION This study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

The cancer multi-disciplinary team from the co-ordinators’ perspective: results from a national survey in the UK

BackgroundThe MDT-Coordinators’ role is relatively new, and as such it is evolving. What is apparent is that the coordinator’s work is pivotal to the effectiveness and efficiency of an MDT. This study aimed to assess the views and needs of MDT-coordinators.MethodsViews of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators’ educational/training needs.Results265 coordinators responded to the survey. More than one third of the respondents felt that the job plan does not reflect their actual duties. It was reported that medical members of the MDT always contribute to case discussions. 66.9% of the respondents reported that the MDTs are chaired by Surgeons. The majority reported having training on data management and IT skills but more than 50% reported that they felt further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills.ConclusionsMDT-Coordinators’ role is central to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the resources and training available to MDT-coordinators can give them an opportunity to develop the required additional skills and contribute to improved MDT performance and ultimately cancer care. Finally, this study looks forward to the impact of the recent launch of a new e-learning training programme for MDT coordinators and discusses implications for future research.