mdt meetings: an idea whose time has gone? alastair j munro … · 2017. 3. 3. · process results...
TRANSCRIPT
MDT meetings: an idea whose time has gone?
Alastair J MunroDundee & St Andrews
Questions
• Why do we have MDT meetings?• What resources do MDT meetings consume?• What has been the impact of MDT meetings?• Are MDT meetings necessary, or can we
escape?
Why do we have mdt meetings?
• Prehistory– Cancer registry – Morbidity and Mortality Meetings– Grand Rounds– CPC– “Tumor Boards”– Combined clinics
• Calman Hine Report 1995• National Cancer Plan 2000• Postcode Lottery• Centralisation Paradox
WHAT RESOURCES DO MDTS CONSUME?
Breast CNS Colorectal CUPGynae H&N, Thyroid HBP LungSarcoma Melanoma Urology UGIHaematology
Total number 320,658Total patients for discussion per year (excluding NMSC)
62396
59784
69984
90476
33044
clinical oncol. radiologists pathologists surgeons etc. medical oncol.
total attendances p.a. by specialty
120540
329508
410850
267282
40584
clinical oncol. radiologists pathologists surgeons etc. medical oncol.
total mdt-asociated hours p.a. by specialty
0 5 10 15
surgeons
radiologists
pathologists
medical oncologists
clinical oncologists
% capacity % capacity (travel included)
Number of new patients per annum 320,658
MDT base cost £129.6m
MDT with an opportunity cost discounted by 75% £146.9m
Base cost per discussion £107
Average number of discussions per patient 4 (2.6 to 5.5)
Base cost per patient £428
Cost per patient with a discounted opportunity cost £485
WHAT HAS BEEN THE IMPACT OF MDT MEETINGS?
Colorectal MDT performance
• Rate of compliance with standards: 91% (median)
• Rate of “immediate risks” 8/165: 5%• Rate of serious concerns 55/165: 33%
immediate risks and serious concerns
o Lack of Clinical Oncology capacity, meaning that treatment decisions are taken without oncology input
o Difficulties of collection of robust clinical MDT data, due to resource issueso Anal cancer pathways outwith IOG agreed configurationso Lack of CNS capacity, impacting on workload and availability at significant
points in pathwayo Not all patients offered laparoscopic surgeryo Inequities in patient pathway and support across MDTs within the same
Trusto Impact of increased workload, including endoscopy capacity, theatre
capacity and surgical bedso Cancelation of MDT meetings due to MDT coordinator absenceo Surgeons not undertaking required 20 operative procedures with curative
intent
trus
t
10 20 30 40 50% respondents with stoma
PROMS 2015 survey
Public Health England Knowledge and Information Team (Northern & Yorkshire), University of Leeds, University of Southampton. Quality of Life of Colorectal Cancer Survivors in England. Report on a national survey of colorectal cancer survivors using Patient Reported Outcome Measures (PROMs). 2015.
0 10 20 30% respondents with stoma
Yorkshire and Humber SCN
West Midlands SCN
Wessex SCN
Thames Valley SCN
South West Coast SCN
South East Coast SCN
Northern England SCN
London SCN
Greater Manchester, Lancashire and S Cumbria SCN
East of England SCN
East Midlands SCN
Cheshire and Mersey SCN
data from colorectal PROMS survey 2015% with stoma by SCN
Public Health England Knowledge and Information Team (Northern & Yorkshire), University of Leeds, University of Southampton. Quality of Life of Colorectal Cancer Survivors in England. Report on a national survey of colorectal cancer survivors using Patient Reported Outcome Measures (PROMs). 2015.
E.J.A. Morris , P.J. Finan , K. Spencer , I. Geh , A. Crellin , P. Quirke , J.D. Thomas , S. Lawton , R. Adams , D. Sebag-Montefiore Morris EJA, et al., Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal
Cancer Across the English National Health Service, Clinical Oncology (2016), http://dx.doi.org/10.1016/j.clon.2016.02.002
NRT, no radiotherapy; SCRT-I, short-course radiotherapy with immediate surgery; SCRT-D, short-course radiotherapy with delayed surgery; LCCRT, long-course chemoradiotherapy; ORT, other radiotherapy; PORT, postoperative radiotherapy
“All these observed variations in radiotherapy usage were seen despite the routine weekly colorectal MDT meetings, which occur across the NHS, in which clinical and radiological staging investigations, including pelvic MRI, are reviewed to determine the selection of patients for preoperative treatment. MDTs are, therefore, adopting very different treatment strategies. How can this wide variation in radiotherapy usage be explained?”
Morris EJA, et al., Wide Variation in the Use of Radiotherapy in the Management of Surgically Treated Rectal Cancer Across the English National Health Service, Clinical Oncology (2016)
http://dx.doi.org/10.1016/j.clon.2016.02.002
How Indeed?
0.1
.2.3
.4.5
.6A
PER
rat
e
0 .25 .5 .75 1Preop XRT rate
size of symbol is proportional to number of resectionsTrust Level 2013 - 2014
From NBOCA data
.15
.2.2
5.3
.35
APE
R r
ate
.2 .3 .4 .5 .6Preop XRT rate
size of symbol is proportional to number of resectionsSCN Level 2013 - 2014
From NBOCA data
586 patients diagnosed with colorectal cancerJanuary 2006 to December 2007
411 (70.1%) with documented evidence of an implemented MDT recommendation
175 (29.9%) with no documented evidence of an implemented MDT recommendation
134 (76.6%) survived >6w41(23.4%) died within 6w of
diagnosis
76 (91.6%) recommendation made and its lack of implementation clearly documented
7 (8.4%) impossible to tell if a recommendation was made
44 no discernible reason5 patients refused treatment that was offered
13 patients were too unfit for the recommended treatment 1 never seen after MDT
13 lack of implementation was for reasons other than above
407 patients who survived >6w and who had documented
implementation of MDT recommendation:
175 (42.3%) to see oncologist30 (7.4%) to have chemotherapy or
radiotherapy42 (10.3%) for further investigations
92 (22.6%) for surgery7 (1.7%) for palliative care
61(15.0%) for follow up only
51 (38.1%) never discussed at MDT
83 (61.9%) discussed at MDT but no documented implementation
22(53.7%) no MDT discussion
19 (46.3%) discussed at MDT
4 (1%) died within 6w of diagnosis
175/586 (29.9%) – either not discussed at MDT or recommendation not
implemented
45/586 (7.7%) - died within 6 weeks of diagnosis
Early
A or B 213
C 135
Neoadjuvant 38
Total 386
Advanced Advanced or metastatic 200
Factors used in MVA (adjusted)
AgeGenderGrade
SiteIncome deprivation
Co-morbidity
Factors independently influencing discussion and
implementation
• Lower age• Dukes stage C or neoadjuvant• Survival >6w from diagnosis
0.00
0.25
0.50
0.75
1.00
surv
ivin
g fr
actio
n
0 12 24 36 48 60survival time (months)
MDT+ MDT-
Overall survival - all patients
Punadj <0.00001
0.00
0.25
0.50
0.75
1.00
surv
ivin
g fr
actio
n
0 12 24 36 48 60survival time (months)
MDT+ MDT-
Cause-specific survival - all patients
Punadj <0.00001HRadj = 0.73 (0.53 to 1.00)
0.00
0.25
0.50
0.75
1.00
surv
ivin
g fr
actio
n
0 12 24 36 48 60survival time (months)
MDT+ MDT-
Cause-specific survival - patients surviving >6w
Punadj = 0.0641HRadj = 1.00 (0.70 to 1.42)
0.00
0.25
0.50
0.75
1.00
surv
ivin
g fr
actio
n
0 12 24 36 48 60survival time (months)
MDT+ MDT-
Cause-specific survival - 'early' patients surviving >6w
Punadj = 0.1379HRadj = 1.85 (0.88 to 3.88)
0.00
0.25
0.50
0.75
1.00
surv
ivin
g fr
actio
n
0 12 24 36 48 60survival time (months)
MDT+ MDT-
Cause-specific survival - 'advanced' patients surviving >6w
Punadj = 0.0604HRadj = 0.89 (0.58 to 1.36)
Du
Lordan
McDermid
Munro
Palmer
Ye
Stud
y
-1 -.5 0 .5LnHR OS adjusted
supp. Figure 2
advantage from MDT discussion disadvantage from MDT discussion
ARE MDT MEETINGS NECESSARY, OR CAN WE ESCAPE?
Problem Proposal Intended effect
Costs Restrict face-to-face MDT discussions to complex or unusual problems
Decrease the direct and indirect costs
Limited evidence for effectiveness Randomised controlled trials using a step wedge design,
Demonstrate relative effectiveness of different models
Recruitment to clinical trials and adherence to guidelines
Electronically mediated system would automatically capture information and make suggestions
Improved recruitment to clinical trials and adherence to guidelines.
Clinicians lack confidence
Use suitable gating mechanisms for referral to discourage the abuse of the MDT process by lazy clinicans
Ensure that the MDT is not a refuge for shirkers
Limited educational value Automatic capture of high-quality data generates an electronic archive of knowledge and experience: an educational resource.
An archive for each team that can be used for education and audit.
Medico-legal ambiguities Clarify the medico-legal position by insisting that the MDT process results in a recommendation, not a decision.
Ensure that MDTs operate within an appropriate legal framework
Committees for impersonalised medicine:
A web-based system would permit contributions from clinicians who actually know the patient
Better representation of patients views
Unnecessary delay Discussions could take place at any timeReduction in the interval between diagnosis and starting definitive treatment
Flurry of emails following each MDT.
The emails (or other electronic communication) would be part of the MDT process Flexibility
Ritual and disengagement
Discussion is less likely to become formulaic: audit trail and the Hawthorne effect.
Discussions become more open and varied
Primary care excluded A more flexible web-based system would allow GPs instant access to, and (potentially) participation in, discussion.
There would be greater involvement of primary care
Problems
• Conspicuous consumption of resources• The Flying Dutchman syndrome• Repeat business• Decisive atrophy & sloth• Delay• Neither world enough nor time
THE LIGHT-BULB HAS TO WANT TO CHANGE