at SciVerse ScienceDirect

Clinical Radiology 68 (2013) 780e784

Contents lists available

Clinical Radiology

journal homepage: www.cl in icalradiologyonl ine.net

Does every patient need to be discussedat a multidisciplinary team meeting?N. Chinai a, F. Bintcliffe a, E.M. Armstrong b, J. Teape c, B.M. Jones c, K.B. Hosie a,*

aDepartment of Colorectal Surgery, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UKbDepartment of Radiology, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UKcDepartment of Finance, Derriford Hospital, Plymouth Hospitals NHS Trusts, Derriford, UK

article information

Article history:Received 5 November 2012Received in revised form28 January 2013Accepted 8 February 2013

* Guarantor and correspondent: K.B. Hosie,Surgery, Derriford Hospital, Plymouth Hospitals8DH, UK. Tel.: þ44 (0) 1752 202 082x39740.

E-mail address: kenneth.hosie@nhs.net (K.B. H

0009-9260/$ e see front matter Crown Copyright �http://dx.doi.org/10.1016/j.crad.2013.02.011

AIM: To evaluate the clinical impact and cost-effectiveness of a multidisciplinary team (MDT)meeting in a large hospital in the UK.MATERIALS AND METHODS: A management plan for colorectal cancer patients was recorded

by the supervising surgical consultant prior to the MDT meeting using the available clinicalinformation and the available reports for imaging and histopathology. The recorded outcomeswere then compared with the outcomes documented at the subsequent MDT meeting. Thecost of the MDT meeting was calculated based on the salaries of individuals involved plusrelevant overheads. A range of opportunity costs were considered, the most significant ofwhich was the expenditure required to re-provide direct clinical care displaced by the MDT.RESULTS: Over a 3 month period a sample of 47 random cases were reviewed from the

colorectal MDT. In three patients, there were significant differences between the preliminaryconsultant decision and the MDT recommendation: in one case management was changedbased on further information about patient co-morbidity and performance status. In only onecase was there a material alteration to a CT report, which altered management. The annualcosts of running this colorectal local MDT alone were estimated at £162,734þ per annum withopportunity costs of at least twice that.CONCLUSION: The costs of MDT meetings are very high producing a small clinical impact. At

a time of increasing financial and capacity pressure in healthcare systems, the use of scarceresources may be better deployed elsewhere.

Crown Copyright � 2013 Published by Elsevier Ltd on behalf of The Royal College ofRadiologists. All rights reserved.

Introduction

In the early 1990s, the EUROCARE study1,2 demonstratedpoorer survival in the UK than in other European countriesfor most types of cancer. Following this publication, it wasproposed that all patients with cancer should be seen by a

Department of ColorectalNHS Trusts, Derriford PL6

osie).

2013 Published by Elsevier Ltd on

surgeon who specializes in their type of cancer and col-laborates with colleagues in multidisciplinary teams(MDTs) that include diagnostic specialists and cancer nursespecialists.3 Fifteen years ago less than 20% of patients withcancer in England were managed by a specialist team.4

Current National Institute of Health and Clinical Excel-lence (NICE) guidance and peer-review recommendationsare that 95e100% of patients should be discussed at a MDTmeeting.5

MDTs aim to improve treatment standards by ensuringthat all patients receive considered and homogeneoustreatment and care from appropriately skilled professionals.

behalf of The Royal College of Radiologists. All rights reserved.

N. Chinai et al. / Clinical Radiology 68 (2013) 780e784 781

It is assumed that there is better continuity of care and theoverall experience of cancer patients is enhanced byimproved communication and decision-making.

MDT meetings have been implemented in cancer caresystems across most of Europe, the United States, andAustralia. This development and widespread implementa-tion of MDT meetings is not underpinned by high-qualityevidence.6,7 The aim of the present study was to considerthe clinical impact and cost-effectiveness of discussing allcancer patients at an MDT meeting.

Materials and methods

At Derriford Hospital, the local colorectal MDT meetingoccurs weekly, and the patient list is published 2 days priorto the meeting. Over a 3 month period, a sample of patientsrandomly chosen from the MDT meeting list were pre-sented to any of the eight colorectal consultants with all therelevant background information, histopathological and/orradiological results, and documented futuremanagement ofeach patient’s condition available.

At the subsequent MDT meeting, the outcomes werethen recorded and compared with the previously docu-mented recommendations. If a consultant was unavailableto discuss patient management before the MDT meeting,the outcomes for these patients were not included in theanalysis.

For the duration of this observational study, a single ju-nior trainee Fiona Bintcliffe (F.B.) prepared the patientinformation for the MDT meeting. On receiving the MDTmeeting patient list F.B. collated all the current clinical,radiology, and histopathology results (as they would bepresented at the MDT meeting) on a computerized data-base, and presented this information to the named colo-rectal consultant in the 2 days preceding the meeting. Thepre-MDT meeting management decisions were then docu-mented on an independently maintained computerizeddatabase. Patients were only included if the trainee (F.B.)was able to discuss the case with the consultant surgeonprior to the MDT meeting. Patients who did not havedocumented pre- and post-MDT meeting recommenda-tions were not analysed in this case series.

To evaluate the cost of the MDT meetings, the direct andoverhead costs were calculated based on establishedcosting principles. Direct costs included salaries for core andextended members. Core members included consultants:surgeons (n ¼ 8), radiologists (n ¼ 2), pathologists (n ¼ 1),and oncologists (n ¼ 2). Extended members included nursespecialists (n ¼ 3), junior doctors, an MDT meeting co-ordinator, and administrative support. Overhead costsincluded the use of a specific room with appropriate IT fa-cilities to view radiological images and histology slides(Table 1).

Opportunity costs are represented by the clinics, theatretime, radiology or histopathology reporting, or other directclinical care that otherwise might have been performed.Calculation of opportunity costs is somewhat subjective anddependent on the prevailing circumstances. For the purpose

of this study, three methods of calculation have beenconsidered: (1) the cost of staff time providing direct clin-ical care at base rates; (2) the loss of income that couldotherwise have been generated; and (3) the cost of WaitingList Initiative sessions at £250 per hour plus oncosts(£284.50).

Calculating direct costs (see Table 1)

For the colorectal cancer MDT meetings at DerrifordHospital, the total cost of running a weekly MDT meetingwas calculated as follows:

Salary costsThirteen consultants across surgery, radiology, pathol-

ogy, and oncology have more than 2 h per week included intheir job plans (0.5e1 PA). These were calculated as per jobplan at a representative average whole time equivalent rateof £113.443 per annum (Table 1).

Cancer nurse specialists spend on average 3 h per weekpreparing for MDT meetings and completing post-MDTmeeting paperwork. This represents a cost of £17,154 forthe three cancer nurse specialists.

Junior doctors at Derriford Hospital (specifically theregistrars) prepare the brief on each patient for the MDTmeeting. The registrars spends on average 3 h per week atan annual cost of £8363 preparing for theMDTmeeting, andtherefore, are unable to participate in any clinical or theatresessions for that day.

The MDT meeting coordinator spends 2e3 h per daypreparing the agenda for each cancer MDT meeting, 1e1.5hours at each cancer MDT meeting, and then up to 2 h post-MDTmeeting ensuring that the information is disseminatedto the consultants and on the network MDT database. Thisequates to £8864 per annum. Administrative support hasbeen calculated at £6648.

Overhead costsOverhead costs are shown in Table 1 and have been taken

from reference costs return in 2011/2012.

Opportunity costsIn the local environment, patient demand exceeds

established capacity in all participating disciplines. There-fore, it is considered that the requirements to re-providedirect clinical care sessions at waiting list initiative ratesrepresents the most appropriate method of calculating theopportunity costs of the MDT meetings. The cost of re-providing consultant input alone equates to £387,000(Table 1).

Results

Data for 47 patients were collected prospectively over a 3month period and comparedwith the recorded outcomes attheMDTmeetings. Therewas 94% concurrence between themanagement plan documented by each consultant prior tothe MDT meeting and the recorded outcomes. In only threecases was there a difference of opinion. The first case was a

Table 1Estimated costs of MDT.

Direct Costs No Averagepreparationtime perweek (h)

Averageparticipationtime perweek (h)

Averagepost-MDTtime perweek (h)

Total MDTcommitmentper week (h)

% WTE EmploymentCost p.a.(1 WTE)

MDTcost perparticipant

TotalcolorectalMDTmeetingcost

WLI costs(OpportunityCosts)

£ 284.50

ConsultantsColorectal surgery 8 2 2 5.0% 113,443 5,672 45,377 4,552 191,184Radiology 2 2 2 4 10.0% 113,443 11,344 22,689 2,276 95,592Pathology 1 2.4 2 4.4 11.0% 113,443 12,479 12,479 1,252 52,576Oncology 2 2 2 5.0% 113,443 5,672 11,344, 91,889 1,138 47,796Clinical nurse

specialists (band 7)3 2 2 1 5 13.3% 42,884 5,718 17,154 387,148

Specialist registrar(prep)

1 3 2 5 12.5% 66,905 8,363 8,363

Specialist registrar(attendance)

4 0 2 2 5.0% 66,905 3,345 13,381

MDT meetingcoordinator (band 3)

1 12.5 1.5 2 16 42.7% 20,774 8,864 8,864

Administrativesupport (band 3)

12 0.5 0.5 1 2.7% 20,774 554 6,648

Total direct costs 34 22.4 15.5 3.5 41.4 146,298

OverheadsMDT meeting roomcosts: heat, light,cleaning, capitalcharges etc.

1,697 1,697

IT: PC, projector,whiteboard capitalcharges

506 506

Corporate overheads 14,233 14,233Total Overheads 16,436Total MDT costs 162,734

Staff costs include employers’ on-costs (pension/National Insurance). Consultant costs based on a representative 7 year consultant with 10 Programmed Activity (PA and ¼ 4 hours) contract, 7.5:2.5 DirectClinical Care (DCC):Supporting Professional Activity (SPA), on call category A, high frequency and availability for MDT meeting 42/52 weeks per annum (p.a.) without backfill for annual leave. No allowancemade for clinical excellence awards. Clinical nurse specialist costs based on representative mean of scale band 7, 37.5 h per week and availability for MDTmeeting 46/52 weeks p.a. without backfill for annualleave. Specialist registrar costs based on representative mean of scale (point 4) band 2B intensity 40 h per week and availability for MDT meeting 46/52 weeks p.a. without backfill for annual leave. MDTmeeting co-ordinator based on representative mean of scale band 3, 37.5 hours per week and availability for MDT 46/52 weeks p.a. without backfill for annual leave. Administrative costs based onrepresentative mean of scale band 3 administrators, 37.5 h per week, 46 weeks p.a. without backfill for annual leave. MDT meeting room costs taken from Reference costs return 2011/12.

N.Chinai

etal./

ClinicalRadiology

68(2013)

780e784

782

N. Chinai et al. / Clinical Radiology 68 (2013) 780e784 783

73-year-old woman referred with rectal bleeding and foundto have four colonic polyps. Three of the four polyps werehyperplastic; however, one polyp in the ascending colonhad a focus of poorly differentiated adenocarcinoma. Thepolyp had been completely excised endoscopically, and itwas the consultant’s opinion that the patient be fully stagedusing computed tomography (CT), and undergo regularendoscopic and CT surveillance. The recommendation of theMDT meeting was that the patient be staged and thenoffered a right hemi-colectomy.

The second case was a 71-year-old man who had un-dergone an anterior resection. Postoperative histologydemonstrated a Dukes’ B moderately differentiated adeno-carcinoma, and the preoperative CT examination demon-strated indeterminate lung nodules. Based on theinformation available, it was the consultant’s recommen-dation that the patient have clinical follow-up and a repeatCT examination of the chest in 3 months. At the MDTmeeting, an addendum was added to the CT examinationregarding the lung lesions, and it was recommended thatthe patient undergo a repeat CT examination of the chestimmediately and be referred for adjuvant chemotherapy.

In the third case of non-concurrence, a 78-year-old manon hormone therapy for primary prostate cancer had pre-sented with a change of bowel habit. Endoscopy and his-tology demonstrated a rectal adenoma. It was the treatingconsultant’s recommendation that the patient be referredfor consideration of palliative chemo-radiotherapy for therectal lesion. However, after extensive discussion at theMDT meeting, it was felt that the lesion was more likely tobe rectal invasion of a primary prostate carcinoma and thebest course of treatment was to leave the adenoma andcontinue with hormone therapy for the primary prostatecancer. In light of patient co-morbidities, it was felt that thepatient would not be suitable for chemoradiotherapy.

Table 2Accepted benefits of the introduction of multidisciplinary team meetings.

� Improved co-ordination and consistency of care� Improved clinical outcomes� Increased patient satisfaction and psychological wellbeing� Improved communication between health professionals� Educational opportunities for health professionals� Support from a collegial environment� Opportunities to improve audit� Increased recruitment into clinical trials

Discussion

In this small series of treatment recommendations madewithin a colorectal cancer MDT meeting, 94% concurredwith the treatment strategy outlined by the supervisingcolorectal surgeon. The management decisions thatchanged were in light of new clinical information madeavailable at the MDT meeting in two cases. It can be arguedthat in both cases the management would have been ulti-mately decided by the oncologist.

In the case of the cancer in the polyp, there remains somecontention about the most appropriate management and,perhaps most importantly, the decision should be madewith the patients themselves. Because the patient is notpresent, an MDT meeting may make treatment recom-mendations without a full picture of co-morbidity, mobility,comprehension, personal preference, and the wider psy-chosocial implications of any decision. Recent publicationssuggest that as many as 10e15% of MDT meeting recom-mendations made in the UK are not implemented.8,9

It is appreciated that the ability to extrapolate from theresults of this observational case series is limited by the

small sample size and restriction to a single cancer spe-cialty. Although limiting its external validity, the resultsdemonstrate that the accepted belief that improvements inpatient diagnosis and management processes are due spe-cifically due to the introduction of MDT meetings is difficultto substantiate. Over the same time period, knowledgeabout cancer and available diagnostic and treatment op-tions has evolved alongside organizational restructuring(e.g., centralization of processes, streamlining of the clinicalpathway, introduction of evidence-based guidelines, andprotocols of care). Together thesemake the interpretation ofa causal link between the introduction of MDT meetingsand improved clinical outcomes tenuous.

The emphasis of MDT meetings is on collaborativedecision-making where the core team members of relevantspecialties participate, share their knowledge, and makecollective evidence-based recommendations for patientmanagement. The published empirical evidence to supportthe benefits of cancer MDT meetings is weak and limited,and therefore, it is paradoxical that individual clinical de-cisions must be based on evidence but overall organiza-tional decisions, such as themandating of MDTmeetings forall patients are not based on similarly sound empiricalevidence.

The value of the MDT meeting in changing clinicalpractice in the UK has certainly been important and anumber of accepted benefits are set out in Table 2. However,these benefits are difficult to quantify. Previous publicationssuggest that MDTmeeting decisions concur with consultantopinion in 90% of cases, and when changed, tend to adopt amore conservative approach due to patient-relatedfactors.9,10

In calculating the financial costs, the authors havedeliberately underestimated the time involved and notincluded all the oncosts that would be incurred. Despitethis, the costs are very significant and are of questionablejustification when measured against clinical impact.

Furthermore, the utility costs to patients of delayedmanagement decisions due to MDT meetings often beingunable to copewith the volume of patients allocated to eachmeeting have not been discussed. For a comprehensivemultidisciplinary discussion for each patient, all clinicalinformation (including endoscopy results), all imaging, andall histology must be reported and available to review. Dueto the MDTmeeting workload expanding more rapidly thanthe rate at which resources can be allocated away fromroutine work, this is not always possible, and often casesneed to be brought back to a subsequent MDT meeting todiscuss management.

N. Chinai et al. / Clinical Radiology 68 (2013) 780e784784

The clinical results of this study cannot be generalizedbeyond this specific colorectal MDT, but can be validated byundertaking further audits of other teams with differentworking methods and at various stages of development andexperience. However, given the time and resources thatMDTworking requires, a stronger evidence base is essential.In light of the now established guidelines for managementof colorectal cancer, the MDT meeting guidelines should bereconsidered to allow more selected discussions of appro-priate cases and, therefore, better use of scarce resources.

Further research needs to be undertaken to assess theoutcomes of MDT effectiveness. This should include clinicalaudits to examine whether team decisions influence betterpatient management and ultimately survival and patientaudits to check whether the introduction of MDT meetingshave enabled patients to be involved in decision-making bysharing adequate information on options discussed by theMDT.

If the time spent in MDT meetings across all specialtieswas rationalized in a cost-effective way, the efficiency sav-ings for the National Health Service (NHS) would be sig-nificant, and the time spent discussing difficult orcontroversial cases would be more appropriate, thus,hopefully, improving clinical outcomes.

References

1. Berrino F, Esteve J, Coleman MP. Basic issues in estimating andcomparing the survival of cancer patients. IARC Sci Publ 1995:1e14.

2. Sant M, Capocaccia R, Verdecchia A, et al. Comparisons of colon-cancersurvival among European countries: the Eurocare Study. Int J Cancer1995;63:43e8.

3. Calman K, Hine D. A policy framework for commissioning cancer services:a report by the Expert Advisory Group on Cancer to the Chief MedicalOfficers of England and Wales. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4071083; 1995 [last accessed January 2012].

4. Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams incancer care: are they effective in the UK? Lancet Oncol 2006;7:935e43.

5. Finan P, Smith J, Trivella M, Meulen J, Greenaway K, Yelland A. TheNational Bowel Cancer Audit Annual Report 2010. 2010. Available at:http://data.gov.uk/dataset/national-bowel-cancer-audit-annual-reports[last accessed January 2012].

6. Tattersall MH. Multidisciplinary team meetings: where is the value?Lancet Oncol 2006;7:886e8.

7. Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team work-ing in cancer: what is the evidence? BMJ 2010;340:c951.

8. Blazeby JM, Wilson L, Metcalfe C, et al. Analysis of clinical decision-making in multi-disciplinary cancer teams. Ann Oncol 2006;17:457e60.

9. Wood JJ, Metcalfe C, Paes A, et al. An evaluation of treatment decisions ata colorectal cancer multi-disciplinary team. Colorectal Dis2008;10:769e72.

10. Sharma A, Sharp DM, Walker LG, Monson JR. Colorectal MDTs: theteam’s perspective. Colorectal Dis 2008;10:63e8.