Isla Wallace

Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study

Objective Multidisciplinary team (MDT) meetings are assumed to produce better decisions and are extensively used to manage chronic disease in the National Health Service (NHS). However, evidence for their effectiveness is mixed. Our objective was to investigate determinants of MDT effectiveness by examining factors influencing the implementation of MDT treatment plans. This is a proxy measure of effectiveness, because it lies on the pathway to improvements in health, and reflects team decision making which has taken account of clinical and non-clinical information. Additionally, this measure can be compared across MDTs for different conditions. Methods We undertook a prospective mixed-methods study of 12 MDTs in London and North Thames. Data were collected by observation of 370 MDT meetings, interviews with 53 MDT members, and from 2654 patient medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation, whether their preferences and other clinical/health behaviours were mentioned) and MDT features (as measured using the ‘Team Climate Inventory’ and skill mix) on the implementation of MDT treatment plans. Results The adjusted odds (or likelihood) of implementation was reduced by 25% for each additional professional group represented at the MDT meeting. Implementation was more likely in MDTs with clear goals and processes and a good ‘Team Climate’ (adjusted OR 1.96; 95% CI 1.15 to 3.31 for a unit increase in Team Climate Inventory (TCI) score). Implementation varied by disease category, with the lowest adjusted odds of implementation in mental health teams. Implementation was also lower for patients living in more deprived areas (adjusted odds of implementation for patients in the most compared with least deprived areas was 0.60, 95% CI 0.39 to 0.91). Conclusions Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care.

Diversion of opioid maintenance treatment medications and predictors for diversion among Finnish maintenance treatment patients

BACKGROUND Diversion (i.e. selling or giving away) of opioid maintenance treatment (OMT) medications is a challenge that concerns many units providing OMT worldwide and tools for prevention are needed. The object of this study was to examine the prevalence and predictors for diversion of the OMT medications buprenorphine-naloxone (BNX) and methadone (MET) among Finnish OMT patients. METHODS A cross-sectional study was conducted among all Finnish OMT patients of whom 60% (n=1508) participated. The data were collected by anonymous questionnaires distributed through all OMT units in Finland. To evaluate predictors for diversion, we used binominal regression analysis with unadjusted and adjusted ORs. Selling and/or giving away of OMT medication was used as a dependent variable and explanatory variables were gender, age, duration of OMT, type of OMT medication and dose, dispensation method of OMT medication, place of residence and intravenous use of any intoxicating drugs during the past six months. RESULTS Of all 1508 respondents, 7% (n=100) had sold and 12% (n=169) had given their OMT medication to others, 57% for money and 23% in exchange for other drugs. In multivariate analysis, predictors associated with diversion were BNX as OMT medication (OR 2.76, 95% CI 1.76-4.33), low (<9.0mg/day) BNX dose (OR 1.74, 95% CI 1.01-2.98), intravenous use of intoxicating drugs during the past six months (OR 4.48, 95% CI 3.13-6.43) and increasing length of OMT (OR 1.01, 95% CI 1.01-1.02). Age, place of residence or unsupervised pharmacy distribution of BNX were not associated with diversion. CONCLUSIONS In order to reduce diversion, more interventions are needed to support patients to stop concurrent substance abuse. Increasing control measures, for example, increased supervision, are unlikely to prevent diversion. Given that sub-optimal dosing of BNX increases the risk of diversion, more attention should be paid to providing patients with an optimal medical dose.

Use of a formal consensus development technique to produce recommendations for improving the effectiveness of adult mental health multidisciplinary team meetings

BackgroundMultidisciplinary team (MDT) meetings are the core mechanism for delivering mental health care but it is unclear which models improve care quality. The aim of the study was to agree recommendations for improving the effectiveness of adult mental health MDT meetings, based on national guidance, research evidence and experiential insights from mental health and other medical specialties.MethodsWe established an expert panel of 16 health care professionals, policy-makers and patient representatives. Five panellists had experience in a range of adult mental health services, five in heart failure services and six in cancer services. Panellists privately rated 68 potential recommendations on a scale of one to nine, and re-rated them after panel discussion using the RAND/UCLA Appropriateness Method to determine consensus.ResultsWe obtained agreement (median ≥ 7) and low variation in extent of agreement (Mean Absolute Deviation from Median of ≤1.11) for 21 recommendations. These included the explicit agreement and auditing of MDT meeting objectives, and the documentation and monitoring of treatment plan implementation.ConclusionsFormal consensus development methods that involved learning across specialities led to feasible recommendations for improved MDT meeting effectiveness in a wide range of settings. Our findings may be used by adult mental health teams to reflect on their practice and facilitate improvement. In some other contexts, the recommendations will require modification. For example, in Child and Adolescent Mental Health Services, context-specific issues such as the role of carers should be taken into account. A limitation of the comparative approach adopted was that only five members of the panel of 16 experts were mental health specialists.

Factors associated with non-adherence and misuse of opioid maintenance treatment medications and intoxicating drugs among Finnish maintenance treatment patients

BACKGROUND The intravenous (IV) use of opioid maintenance treatment (OMT) medications and other intoxicating drugs among OMT patients is a challenge for many OMT units and affects treatment outcomes. The aim of this study is to examine factors associated with IV use of OMT medications and other intoxicating drugs among Finnish OMT patients. METHODS A cross-sectional study was conducted among all Finnish OMT patients of whom 60% (n=1508) participated. The data were collected by anonymous questionnaire. Binominal regression analysis with unadjusted and adjusted ORs was conducted to evaluate predictors for IV use. FINDINGS Factors associated with the injection of a patients own OMT medication were: being treated with buprenorphine-naloxone (BNX) (OR 2.60, p=0.005) with a low dose (<9.0mg/day; OR 5.70, p<0.001) and being treated in a health-care centre (OR 2.03, p=0.029). Factors associated with the injection of illicit OMT medications were: being treated with BNX (OR 5.25, p<0.001) with a low dose (<9.0mg/day; OR 2.89, p=0.017), lack of psychosocial support (OR 2.62, p<0.001) and concurrent use of psychotropic medications from illicit sources (OR 4.28, p<0.001). Associated factors for the injection of other intoxicating drugs were: concurrent use of illicit drugs (OR 1.72, p=0.015), psychotropic medications from illicit sources (OR 4.78, p<0.001) and from a doctor (OR 1.93, p=0.004). CONCLUSIONS More effort should be made to reduce concurrent injecting use during OMT. This may be done by addressing concurrent substance use orders more effectively, by ensuring that patients receive an optimal BNX dose and by providing more psychosocial support.

Patient experience of MDT care and decision-making

Purpose – The purpose of this paper is to explore physical and mental health patients’ experience of multidisciplinary team (MDT) care and decision making in order to highlight factors underlying effective care and to identify areas in which patient experience could be improved. Design/methodology/approach – Totally, 12 MDTs within the North Thames area participated; the authors recruited 13 patients from physical health MDTs and seven patients from mental health MDTs. The authors conducted semi-structured interviews with each participant and thematically analysed the transcripts. Findings – The study found a marked contrast in patient experience: physical health patients emphasised their faith in the judgement of MDT clinicians, described experiencing high quality care and expressed a strong preference not to attend MDT meetings; mental health patients highlighted a range of negative experiences, were frequently sceptical about their diagnosis, and expressed a desire to have greater involvement in the de...

PP45 Developing Recommendations to Improve the Effectiveness of Multidisciplinary Team Meetings for Patients with Chronic Diseases

Background Multidisciplinary team meetings (MDMs) have been endorsed by the Department of Health as the core model for managing chronic diseases. It is believed that MDMs ensure higher quality decision making and improved outcomes. However, the evidence underpinning the development of MDMs is not strong and the degree to which MDMs have been absorbed into clinical practice varies widely across conditions and settings. We conducted a large mixed-methods study of multidisciplinary teams in chronic diseases to examine and explore determinants of effective decision making. We applied a transparent and explicit consensus development method to develop recommendations, based on our results, to improve MDM decision making and effectiveness. Methods We collected qualitative and quantitative data from 12 multidisciplinary teams (gynaecological, skin and haematological cancers, mental health, memory clinics and heart failure). Data included non-participant observation of 370 MDMs and follow up of medical records, 53 interviews with healthcare professionals and 20 patient interviews. We triangulated these datasets to increase the internal validity and consistency of our findings. Over the course of successive analytic meetings we identified patterns of convergence to develop a coherent framework for understanding our findings. Based on this analysis we derived a series of potential recommendations for discussion and rating by an expert consensus development panel including policy makers, healthcare professionals and patient representatives. Results Issues for discussion by the consensus panel included: whether or not patients should attend MDMs; how patient perspectives can be best represented; determining which patients, and indeed whether all patients should be included for discussion; suggestions for improvements in MDM processes, including the structure and co-ordination of MDMs; whether functions such as teaching and emotional support for team members have a valid role in the MDM, and if so, how best to incorporate them. The issue of how to incorporate multi-morbidity in disease specific MDMs was also considered. Conclusion We have conducted the largest study of its kind in this area and the first to examine and compare MDMs for different chronic diseases. In addition, the use of a diverse range of qualitative and quantitative data allowed an unprecedented breadth and depth of data to be explored. This produced wide ranging, important and feasible recommendations to improve the effectiveness of MDMs which, the data suggest are generalisable to different patient groups.

OP92 Improving the Effectiveness of Multidisciplinary Team Meetings for Patients with Chronic Diseases: Assessing the Predictors of Decision Implementation

Background Department of Health policy states that health care for chronic diseases should be delivered through multidisciplinary team meetings (MDMs). It is known that multidisciplinary teams should include certain features (for example commitment to leadership) to be effective. But additional factors need to be considered: e.g. the context in which MDMs operate, group decision processes, and patient related factors such as their preferences and socio-demographic characteristics. There is, therefore, a need for research on MDMs to identify factors that promote effective MDM decision-making in terms of decision implementation. We report on a study, unique in its size and scope, making its results applicable across the NHS. Methods We undertook an observational study of 370 MDMs in 12 different teams (gynaecological, skin and haematological cancers, mental health, heart failure and memory clinics) in the North Thames area. Analyses used random effects logistic regression models, allowing for MDM clustering, to investigate the influence of MDM and patient related factors on decision implementation. Decision implementation and patient demographics were ascertained from medical records. The MDM characteristics examined were Team Climate Score, disease type, team skill-mix (Adjusted Teachman’s Index and number of professional categories represented), and whether defined co-morbidities and patient preferences were considered. The patient characteristics examined were age, gender and Index of Multiple Deprivation (IMD) score. Results We will present descriptive analyses on 6053 discussions of 3184 patients. For example, discussions on 17% of patients led to no decision. Decision implementation ranged from 67% (Mental Health) to 79% (Memory Clinics). Reasons for non-implementation will be presented. We will present the results of logistic regression on the patient and MDM related factors associated with decision implementation, including the extent to which patient related factors, for example their socio-economic circumstances, were associated with implementation. We will also describe the patient and MDM related factors associated with patient preferences being taken into account. Conclusion We address recent calls for empirical research on MDM decision-making in routine practice to understand how and under what conditions MDMs produce effective decisions, as well as methods to effectively obtain and consider patient preferences. As the largest study of its kind in this area, and the first to examine and compare MDMs for different chronic diseases, this study enables identification of factors associated with good outcomes that are generalisable across healthcare.