Improving Oncological MDTs: A Systematic Review and Call to Action
Response to Walraven et al.
Comment on paper by Walraven et al. (1) Factors influencing the quality and functioning of oncological multidisciplinary team meetings: results of a systematic review.
We read the article by Walraven et al. (1) with great interest and support the findings and framework of this systematic review in highlighting domains in detail. Their work will help improve both the efficiency and efficacy of multi-disciplinary team meeting (MDTM) discussions. Thus, we recognise these key factors in our local MDTM work but also note that there are several difficulties MDT administrators and chairs have in implementing changes.
Currently, there is no gold standard scale for an MDTM chair to assess the performance of their MDT. This makes it difficult to use evidence-based performance markers to compare between different MDTMs. Currently, one of the most comprehensive tools to assess MDT performance is MDT-MODE II (2), however, there are no data verifying the tool’s assessment criteria against patient clinical or economic outcomes.
The quality of data presented at different MDTs varies enormously from short verbal summaries to comprehensive data for formal evaluation by the participants. As far as we are aware, there are no trials or interventions assessing different approaches to MDTMs. For example, if the discussion is more effective when participants look at high-quality summary data or if they look at the electronic health record more comprehensively. In a field which puts such high emphasis on treatment evidence, there are few studies analysing the communication methods which underpin clinical decision-making. We appreciate it may be difficult to conduct cluster randomised trials for differing approaches to MDTs but these would be helpful to guide change.
Without having standardised qualitative measures to gauge the effectiveness of MDTMs, it is not possible to effectively run analyses to assess the clinical and cost-effectiveness of MDTMs (3). In our practice, we have commonly observed online MDTMs involving more than 30-40 clinical staff over the course of a meeting, while the main substance of discussions involves <6 individuals. Some staff attend in the background while doing other duties waiting to advocate for a patient. Meanwhile, business leaders often identify that overall productivity is higher when people attend meetings only for when they are engaging in the discussion (4,5) but this is not commonly practised in hospitals. Decision fatigue is highlighted in various studies (6) and is made worse by poorly structured MDTMs. These factors challenge the utility of MDTMs in their current form, and software applications should optimise the efficiency of these workflows and provide stronger audit data.
Whilst most MDTs attempt to stream their cases into simple/benign and malignant, they are often subsumed by the many cases that could be decided simply and without the need for discussion by multiple healthcare professionals. Thus, once a mature MDT has a good dataset of prior decisions and outcomes, many of the simpler cases could be decided using artificial intelligence or algorithms, leaving adequate time for discussion of the complex cases. Despite this, the issue surrounding MDTM optimisation is a workflow issue and the differences in workflow and the clinical decision-making process, which relies on modalities such as imaging and risk scores, should not vary significantly.
A mature MDTM team may have a greater risk acceptance compared to a less mature team. No one has determined how to allow people who take risks to be positively highlighted in metric and scoring systems. How do we evaluate those that take appropriate risk versus those that continually take a conservative approach? Some MDTs only use risk scores to make decisions, however, risk scores are not all-encompassing of patient and clinician characteristics. Personalisation is necessary to contextualise a risk score and risk factor.
Additionally, the personality of a chair and the confidence they convey to others can sway an MDTM’s appetite for risk management or dissuade from it. The ability of a good chair to be able to invite debate is particularly important as a measure of the maturity of an MDTM. Most MDTM chairs do not undergo formal training in risk management, data science or statistical methods to be able to evaluate their own MTDM nor are data scientists guiding the performance of an MDTM. Such factors are also needed to evolve MDTMs to become data-driven decision-making meetings which can also flex to patient and clinician preferences after risk evaluation.
Authors.
Dr. Kevin Moore (Co-Founder, CMO)
Dr. Ameet Bakhai (Research Lead, CSO)
Dara Vakili (Product Manager).
References:
1. Walraven et al. See above.
2. Lamb BW, Wong HWL, Vincent C, Green JSA, Sevdalis N. Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool. BMJ Qual Saf. 2011 Oct;20(10):849–56.
3. Ke KM, Blazeby JM, Strong S, Carroll FE, Ness AR, Hollingworth W. Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature. Cost Eff Resour Alloc. 2013 Apr 4;11(1):7.
4. Gallo A. The Condensed Guide to Running Meetings. Harvard Business Review [Internet]. 2015 Jul 6 [cited 2022 Aug 31]; Available from: https://hbr.org/2015/07/the-condensed-guide-to-running-meetings
5. Plan a better decision meeting | McKinsey [Internet]. [cited 2022 Aug 31]. Available from: https://www.mckinsey.com/business-functions/people-and-organizational-performance/our-insights/want-a-better-decision-plan-a-better-meeting
6. Wihl J, Rosell L, Frederiksen K, Kinhult S, Lindell G, Nilbert M. Contributions to Multidisciplinary Team Meetings in Cancer Care: Predictors of Complete Case Information and Comprehensive Case Discussions. J Multidiscip Healthc. 2021 Sep 4;14:2445–52.
Salutare Group LTD, 1110 Elliott Court, Coventry Business Park, Herald Avenue, Coventry, CV5 6UB, UK.
Imperial College London, South Kensington Campus, London SW7 2AZ, UK. Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK .