The anatomy of clinical decision-making in multidisciplinary cancer meetings

Abstract

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs’ input and their corresponding surgical input into case reviews.

How multidisciplinary are multidisciplinary case reviews in cancer care? Feasibility analysis of a theory-driven team decision-making fidelity framework

“…Hence the case reviews were led either by surgeons, oncologists, or both (surgeons and oncologists), and to a lesser extent surgeons and CNSs where the nurse presented the case and contributed to the discussion, but the surgeon led the discussion and made the decision. This finding is supported by previous studies showing asymmetries in participation with surgeons and oncologists most commonly contributing to case reviews [10][11][12][13][14][15][16][17][18].…”

“…Asymmetries in participation and suboptimal sharing of information between team members in the meetings are of particular concern since complete patient profile (esp. patient comorbidities, psychosocial aspects and views on treatment options) and input by all core disciplines are needed for the MDT to reach a recommendation in the meeting and subsequently implement it [12][13][14][15][19][20].…”

“…So far the research on MDTs points to poor implementation of MDT decision-making [10-18].Asymmetries in participation and suboptimal sharing of information between team members in the meetings are of particular concern since complete patient profile (esp. patient comorbidities, psychosocial aspects and views on treatment options) and input by all core disciplines are needed for the MDT to reach a recommendation in the meeting and subsequently implement it [12][13][14][15][19][20].With an estimated cost of MDT meetings at £100 million a year [21], inefficient or insufficient communication and decision-making at the point of the meeting may inadvertently add to the existing pressures, such as frequency/durations of meetings (esp. for large teaching hospitals [22] workload [23], financial pressures [24], and complexity of care pathway for patients [25].…”

Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: an overview and synthesis of the available literature

“… 30 , 31 , 27 A more recent study showed that a complete patient profile (including, the biomedical aspects of the disease, as well as the information on patients’ co-morbidities, their psychosocial aspects, and views on treatment options), and input into the discussion by all core disciplines (including, the nurses’) are essential for the team to formulate a treatment recommendation for a patient. 18 , 32 And the need for a higher level information on patient comorbidities and nursing input may actually be indicators of more complex discussions 18 and validates the inclusion of specialist cancer nurses in the core membership of the MDMs.…”

“…For instance, in MDMs, decision-making process, team working and interactions, leadership (including chairing), team climate, treatment implementation, team ability to reach a care plan on a first case-presentation, and also waiting times, appropriate use of resources including technologies, as well as patient and health care professional satisfaction with care and quality of life, could be further examined. 15 , 16 , 18 Periodic survival evaluation of the population as a whole as well as prospective longitudinal studies of treatment implementation may also be useful indicators of team effectiveness. 19 …”