Are MDTs effective?

Although the proposed benefits of MDT working feature prominently in the policy documents described above, when MDTs were initially rolled out at a national level there was no real evidence of their effectiveness (Taylor et al., 2010). Since then,

‘effectiveness’ has been measured in a number of different ways, and there is now a vast body of literature that addresses the issue. Studies have looked at the impact of MDTs on patient outcomes, cost effectiveness, and the quality of decision

making.

Patient outcomes

Evidence of the effectiveness of MDTs in terms of patient outcomes is currently limited (Coory et al., 2008, Croke and El-Sayed, 2012), although it is growing (Kesson et al., 2012, Prades et al., 2014). One of the reasons for the ongoing debate is the challenge of evaluating effectiveness against outcomes such as survival. In part, this is because patient outcomes are affected by a much wider range of factors than MDT decision making alone (Sevdalis and Green, 2014). It also reflects the fact that there is no longer scope in the UK to conduct a randomised control study with a separate ‘non-MDT’ control group, because MDTs are mandatory within cancer services (Taylor et al., 2010, Sevdalis and Green, 2014).

Cost effectiveness

Given the number of healthcare professionals involved, MDT meetings are by nature an expensive resource. It has been estimated that they cost the NHS around

£50 million per year, based on preparation time alone (Taylor et al., 2010). A more recent study of 52 MDT meetings across 14 different tumour types at an NHS Trust in London assessed the overall cost of MDT meetings, based on attendance of key professionals and overhead costs (e.g. heating, lighting and information technology support) (De Ieso et al., 2013). Costs were shown to range from £3,912 per MDT meeting for a melanoma MDT, to £8,490 per meeting for a Gynaecology MDT.

These costs did not include the time required for core members to prepare for the

34 MDT (particularly pathologists and radiologists who are required to review material in advance).

A crucial question however is whether this investment is cost effective. Even if MDT meetings are an expensive resource, if they improve decision making and save healthcare professionals time in the long run by bringing together all the individuals necessary for making a treatment plan, these costs may well be justified. At

present, however, the findings from existing studies are inconsistent and a systematic review of the literature has concluded that concrete evidence of cost effectiveness is lacking (Ke et al., 2013).

Quality of decision making

Despite the challenges relating to measuring patient outcomes and gaps in the evidence base relating to cost effectiveness, there is a strong and growing body of evidence that MDT meetings can positively influence clinical decision making and treatment recommendations (Croke and El-Sayed, 2012, van Hagen et al., 2013, Rao et al., 2014, Ung et al., 2014, Leff et al., 2015, Schmidt et al., 2015). Benefits that have been documented include better team performance after case discussion (Kee et al., 2007), improved adherence to clinical guidelines, more accurate diagnoses (Lamb et al., 2011b, Pillay et al., 2016), and increased screening rates for clinical trials (McNair et al., 2008).

Nonetheless, echoing the findings of the National Cancer Peer Review Programme (NHS England, 2015), studies of decision making in MDT meetings have shown that there is wide variation between teams against measures of effectiveness. An

extensive number of studies have used proxy measures of decision quality to assess the effectiveness of MDT meetings. This includes the ability of teams to reach a decision the first time a patient is discussed in an MDT meeting. This is used as a measure of decision quality on the basis that delays to treatment as a result of a failure to make a diagnosis or treatment decision can have a negative impact on patient outcomes (Stalfors et al., 2007). Reported rates of effectiveness against this

35 measure in different cancer specialities range from 48 per cent to 74 per cent (Lamb et al., 2011b).

Similarly, implementation rates of decisions made in MDT meetings have been used as a proxy for effective team decision making (Raine et al., 2014a, Raine et al., 2014b). This measure is used on the basis that decisions are more likely to be implemented if all relevant clinical and non-clinical information has been taken into account when the decision is made. There is also considerable variation between teams in different cancer specialities in decision implementation rates. These differences are apparent across hospital trusts in England, and internationally, with implementation rates ranging from 72 per cent to 97 per cent of decisions made (Blazeby et al., 2006, Goolam-Hossen et al., 2011, English et al., 2012, Rajan et al., 2013, Raine et al., 2014b, Ung et al., 2014, Schmidt et al., 2015). Common reasons cited for non-implementation of decisions relate to a lack of information about patient centred factors such as patient treatment preference and comorbidities (Blazeby et al., 2006, Raine et al., 2014b, Ung et al., 2014, Schmidt et al., 2015, Stairmand et al., 2015). It has been suggested that this may reflect time pressures or limited multidisciplinary input, particularly from nurse specialists (Taylor et al., 2013). However, some of the variation is also likely to reflect differences in

measurement, reflecting more or less stringent definitions of implementation (Ung et al., 2014).

To summarise, the variety of outcome measures that have been used to determine whether or not MDTs are effective means that the literature is heterogeneous. As a result, published reviews, including four systematic reviews, have been unable to make a definitive judgement about whether or not MDTs are genuinely effective (Coory et al., 2008, Lamb et al., 2011b, Croke and El-Sayed, 2012, Ke et al., 2013, Prades et al., 2014). Nonetheless, there is a strong body of evidence that suggests that MDTs do positively influence clinical decision making, even if this does not extend to certainty about improvements in patient outcomes. What is also clear however, is that there is still a considerable degree of variation between MDTs.

36 2.2.2 Decision making in MDT meetings

Understanding this variation is key to supporting improvements in MDT meetings (Lamb et al., 2014a). As a result, a number of researchers have explored the

decision making process in cancer MDTs in order to understand why some are more effective than others. A series of standardised tools and checklists have been

developed to assess the component parts of the MDT decision making process.

These have been used to score a range of teamwork behaviours including

leadership, multidisciplinary participation, and the presentation of different types of information during the meeting (Lamb et al., 2011d, Lamb et al., 2011e, Lamb et al., 2012b, Taylor et al., 2012a, Taylor et al., 2012b, Lamb et al., 2013b, Harris et al., 2014, Jalil et al., 2014, Harris et al., 2016). This reflects a growing consensus about the features of an effective MDT meeting (Taylor and Ramirez, 2009, Lamb et al., 2012a, Lamb et al., 2014a, Raine et al., 2015). A number of these tools have already been validated (Lamb et al., 2011d, Lamb et al., 2012b, Lamb et al., 2013a, Jalil et al., 2014, Shah et al., 2014), although some require further testing to confirm validity and reliability (Taylor et al., 2012a, Harris et al., 2014, Harris et al., 2016).

Application of these tools has deepened our understanding of decision making processes in cancer MDT meetings in a number of important ways. First, they have demonstrated that participation in MDT meetings varies by professional group.

CNSs have been shown to participate less frequently in MDT meetings than medical or surgical team members, despite having an important contribution to make (Lamb et al., 2011b, Lamb et al., 2011d, Lamb et al., 2011e, Taylor et al., 2012a, Jalil et al., 2014).

Secondly, evaluation of MDT meetings using these tools has also raised issues about the extent to which patient centred information is shared during decision making. A study of decision making in a colorectal cancer MDT (using the cMDT-MODe

checklist¹) found that presentation of information relating to patient preferences or

1 cMDT-MODe: the Colorectal Multidisciplinary Team Metric for Observation of Decision-Making is a validated assessment tool for measuring the quality of contributions made by professional groups

37 psychosocial factors was poor in comparison to information on biomedical factors (Shah et al., 2014). In addition, an observational study of ten bowel cancer teams (using a tool called ‘MDT OARS’²) found that none of the teams under study took patient centred factors (including demography, comorbidities, psychosocial needs or preferences) into account in all patient discussions. Instead, the majority of teams took these factors into account in less than half of the cases they discussed (Taylor et al., 2012a). Furthermore, there is some evidence that although teams generally have good insight into their performance, they can over-estimate how patient centred they are (Lamb et al., 2011d).

Data collected using these checklists have also more recently been used to

investigate the influence of key factors in the decision making process on the ability of MDTs to reach a decision (Soukup et al., 2016a). Analysis of data collected from four cancer MDTs using the MDT-MODe checklist suggests that patient centred information can influence the MDT decision making process in different ways.

Notably, while teams were more likely to make decisions in cases where psychosocial factors were mentioned, they were less likely to do so when

information about comorbidities was shared. Similarly, nursing input during MDT discussion was associated with reducing the ability of the team to reach a decision (Soukup et al., 2016a). One of the most likely explanations for these findings is that mention of comorbidities and nursing input reflect greater case complexity, which makes it more difficult for a decision to be reached (Soukup et al., 2016a).

However, these tools have been designed to capture data on numerical scales (typically ranging from 1 to 5 or 1 to 10). As a result, they do not provide rich detail about the way in which different professional groups interact and participate in discussions. In addition, by focusing attention on decision making processes at the

and the quality of information shared during the MDT. It is based on a modified surgical observation tool.

2 MDT-OARS: the Multidisciplinary Team Observational Assessment Rating Scale measures 15 observable elements of teamwork, based on characteristics of effective MDTs identified in a UK national survey of over 2000 MDT members.

38 level of the MDT meeting, there has as yet been little consideration of what is different about those cases where CNSs do contribute to discussion and when patient centred information is shared. There is scope therefore to further explore the complexity of the decision making process in the MDT meeting.

2.2.3 The participation of different professional groups in MDT meetings