Katrina F. Brown

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.

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.

Lay Vaccination Narratives on the Web Are They Worth Worrying About

The Internet allows us more access than ever before to the unadulterated anecdotes and opinions of our fellow laypeople. Our decisions—about health care or parenting, for example—were once based on advice from experts, plus perhaps testimonies from a small pool of friends and family, or a finite number of narratives filtered through the press or television. Now the proliferation of social networking and user-generated content in the age of Web 2.0 puts at our disposal a huge and often unmoderated bank of online material. Google searches in June 2011 for ‘‘health discussion forum’’ and ‘‘mothers discussion forum’’ yielded 310 million and 62 million hits, respectively—and we know that decision makers do access these online resources. What is less clear is whether, why, and exactly how lay narratives from online forums are associated with real-life decisions. In this issue of Medical Decision Making (MDM), Betsch and colleagues report an investigation of how lay narratives are used in decision making about vaccination. Using a fictional disease and vaccine context, a mock Internet bulletin board setup, and an undergraduate sample, the authors varied the relative frequency, emotionality, richness, and correlation with official risk estimates of narratives reporting vaccine adverse events and assessed perceived adverse event risk and vaccine uptake intention. Betsch and others found that a higher frequency of narratives reporting vaccine adverse events increased perceived vaccine risk and decreased vaccine uptake intention, that narrative frequency affected risk perception and uptake intention to a greater extent than did statistical information, and that emotionality in narratives increased risk perception, whereas richness had no impact.