Abstract
Objectives:
To report on the performance and cost of a surgeon-led renal cancer specialist multidisciplinary team meeting at a high-volume centre.
Materials and methods:
Retrospective analysis of 1500 consecutive cases discussed from 2 September 2015 onwards. Performance was assessed as the number of cases where a clinical recommendation was made. The cost per meeting, discussion and patient were calculated using the mid-point of pay band attributable to the attendees (National Health Service pay scales 2015).
Results:
Over 34 meetings, 1500 discussions occurred (933 patients: 61.7% male; mean age 63.8). Above a one-quarter of discussions (n = 399, 26.6%) were new referrals. Each patient’s case was discussed a mean of 1.6 times, the majority being discussed once (n = 563, 60.3%). In 93.3% of discussions, a clinical recommendation was made. Only 100 discussions (6.7%) were deferred due to incomplete clinical information. A total of 11.1% (n = 166) cases were discharged. The average costs were: £141,901 per year, £2729 per meeting, £62 per case discussed and £99 per patient.
Conclusion:
One discussion was usually sufficient to decide management; deferral was uncommon; and, given the low discharge rate, referrals seemed appropriate. The cost per patient was modest, and represented good value in providing a focused and shared clinical decision-making pathway for renal cancer patients.
Level of evidence:
2C
Introduction
Multidisciplinary team (MDT) meetings are structured assemblies of individuals from different disciplines that occur at scheduled times with the aim of discussing the clinical management of a given patient. 1 These meetings (also known as tumour boards in other countries such as the USA) were established as a means to improve patient outcomes and develop a critical mass of knowledge, by transferring the diagnostic and management decision from one individual to a group of experts from complementary disciplines. Based on this concept, they were adopted as standard of care and, since the early 2000s, it has been mandated in the UK that all patients diagnosed with cancer are reviewed at MDT meetings. 2 MDT meetings must be regularly audited in the UK and have been shown to change patient management, 3 increase patient satisfaction 4 and may contribute towards better clinical outcomes. 5 Furthermore, a recent discrete choice experiment involving patients, health professionals and the public found that access to a specialist MDT was a particular preference when selecting a specialist cancer surgery service provider. 6
There is evidence that centralisation of cancer surgical services is occurring on a global scale, including in Europe and the USA. In the UK, particularly in London and Manchester, prostate, bladder, kidney and oesophageal cancer care have been rearranged into centralised high-volume centres, where excellent levels of clinical and organisational expertise are expected to further improve treatment outcomes whilst also reducing costs.6,7
At a time when the health services, including the National Health Service (NHS), are under unprecedented budget pressure, the ability to combine rationalisation of costs with high-quality care and clinical benefit appears attractive. The aim of our work is to use standardised metrics and report on the performance and cost efficiency of the surgeon-led specialist MDT (sMDT) meeting for the North Central and North East London renal cancer centre.
Materials and methods
The renal cancer sMDT meeting
The renal cancer sMDT meeting is organised according to NHS recommendations. It is a weekly 3h meeting hosted at the Royal Free Hospital (Royal Free London NHS Foundation Trust). All patients with confirmed or a high-suspicion index of upper tract urological cancer from 13 referring hospital trusts across North Central and North East London are reviewed at this meeting. After the meeting, an outcome report is issued per case discussed and disseminated to referring clinicians. Discussion at the meeting precedes the clinic appointment with the patient, and thus any informed discussion with the patient regarding the ensuing management options available usually occurs after MDT discussion.
Participants of the meeting include both core and extended members from various medical fields (urology, oncology, radiology, interventional radiology, histopathology and nephrology). Core members are attendees that sit throughout the duration of the meeting and whose presence is necessary to establish quorum. These include the meeting chair (a urology consultant), consultant urologists, consultant radiologists, consultant oncologists, clinical nurse specialists and an sMDT meeting coordinator. Extended members are attendees that sit on the meeting, either for a limited period of time to participate in the discussion of their referred cases or throughout the duration of the meeting but whose presence does not count towards establishing a minimum quorum necessary for decision-making. Some extended members attend the meeting solely via videoconference. Additionally, each referring centre provides administrative support via a local MDT coordinator to organise the list of cases to be discussed and ensure all relevant clinical information (history, examination, scan images, pathology reports and/or slides) is available at the time of the meeting.
The NHS pay scale
In the NHS, base annual salaries for all staff are predefined nationwide according to a scale. 8 This scale is further subdivided into bands and each band into spines. A range of bands is attributed to each type of job. Previous salary and level of expertise define the exact band each employee is allocated to; for example, a junior doctor is paid according to band 7, while consultants are paid according to bands 8–9. The number of years working on the job defines the spine payment within each band (first year on the job corresponds to spine 1, second to spine 2 and so forth).
Data collection and analysis
We retrospectively reviewed 1500 consecutive case discussions at the renal cancer sMDT meeting starting from 2 September 2015, and conducted descriptive analysis of patient demographics, referring hospital, referring specialty, reason for discussion, average number of discussions per meeting, number of discussions per patient in the time period considered, number of cases deferred to subsequent meetings and number of cases discharged back to the community care. Cases were categorised according to previous referral to the meeting into new referrals (no previous discussion prior to 2 September 2015) and previously discussed cases (previous discussion prior to 2 September 2015).
As described previously, 9 performance of the meeting was assessed by calculating the rate of cases where a clinical recommendation was made (for example, requirement of further imaging scans, treatment/management recommendation, discharge or post-treatment follow-up scheme). Meeting decision implementation was not assessed. As MDT discussion usually precedes the clinic appointment with the patient, information on suitable management options made by the referring physician was in the main not available. Thus, it was not possible to assess if the sMDT ratified the referring physician’s management decision.
To calculate the cost of running the meeting, three factors were considered: the member attendance records of relevant meetings, the time spent at the meeting by core and extended members (3 h for core members and the average time spent by each extended member at the last three meetings included in the analysis), and the time spent preparing or actioning on outcomes from the meeting. These are the costing metrics advised by the NHS to calculate MDT meeting cost. 10 MDT coordinators and lead core members (urology, oncology, radiology, pathology and nursing) provided information regarding the average amount of time per week devoted to preparing case discussions and actioning on meeting outcomes. All lead core members, and 4 out of 13 MDT coordinators, responded to the request for information. When an estimate of preparation time was not provided, this was estimated as a function of the number of cases per referring hospital discussed per meeting. Each member and MDT coordinator were classified according to banding using the NHS pay scales from 1 April 2015. 8 The mid-spine value of each band was taken into consideration to calculate cost. When there were two mid-spine values, the lowest one was considered. London allowance was added to this value.
The cost of each meeting was calculated as a function of the NHS salary pay of each coordinator and member based on the three factors named above. The cost per hour discussed and per patient was calculated. The annual cost of the sMDT meeting was extrapolated.
The specialist renal cancer service at Royal Free Hospital was established in 2014, after the UK mandate that all patients diagnosed with cancer must be discussed at an MDT, thus no control group of cases not discussed at the sMDT was available for outcome comparison.
Reporting was done in accordance with the Revised Standards for Quality Improvement Reporting Excellence (2.0). 11
Results
One thousand and five hundred case discussions took place over 34 meetings (2 September 2015 to 20 April 2016). All meetings had quorum. Overall, 1375 (91.7%) discussions were done in the context of disease localised to the kidney and 125 (8.3%) were held in the context of metastatic disease. These discussions represented a cohort of 933 patients with a mean age of 63.8 (interquartile range 24; minimum 14; maximum 96) and where 61.7% were male (n = 576). The Royal Free London NHS Foundation Trust referred most patients to the sMDT meeting (n = 538, 57.7%), followed by the University College London Hospitals Trust (n = 108, 11.6%; Figure 1). Urology was the specialty that referred the majority of patients (n = 720, 77.2%), followed by renal medicine (n = 52, 5.6%) and oncology (n = 45, 4.8%; Figure 2).
Referring trusts.
Referring specialties.
On average, 44 case discussions took place per meeting, with an average of 4 minutes spent per case discussion. Just above a quarter of discussions (n = 399, 26.6%) were new referrals. While most discussions were based on reviewing imaging scans, more than one in four (n = 416, 27.7%) represented discussions to decide management based on biopsy or surgical pathology results.
Each patient’s case was discussed a mean of 1.6 times: the majority of patients required one (n = 563, 60.3%) or two case discussions (n = 234, 25.1%) during the period studied. Eighty-nine (9.5%) patients required three discussions, 34 (3.6%) required four discussions, 9 (1%) required five, one (0.1%) required six and three (0.3%) required seven.
Regarding meeting outcomes, in nearly two-thirds of discussions (n = 980, 65.3%) an intervention recommendation was made (such as renal tumour biopsy, active surveillance, surgery, cryotherapy and/or systemic therapy). The post-operative follow-up scheme was decided in 155 discussions (10.3%). Overall, 11.1% (n = 166) of cases were discharged from care in the period considered. Ninety-nine (6.6%) cases required further imaging prior to management recommendation. Only 100 discussions (6.7%) were deferred due to incomplete clinical data, such as unavailability of imaging scans, pathology reports or slides for review. Thus, 93.3% of sMDT discussions resulted in clinical recommendations, which was the chosen performance outcome measure for this study.
The renal cancer sMDT meeting has 15 core members and 17 extended members (Table 1), with annual salaries varying from NHS clinical salary bands 4–9 plus London allowance. Four out of 13 MDT coordinators reported the time taken to prepare and action on outcomes from the meeting (ranging from 0.5–20 h a week). For the remaining coordinators, time was estimated as a function of the number of cases per referring hospital discussed per meeting. Preparing and actioning on meeting outcomes involved 8.5 h of consultant time (urology 2.5 h, oncology 0.5 h, histopathology 1.5 h and radiology 4 h) and 5 h of clinical nurse specialist time. Based on the number of hours spent preparing for the meeting, the attendance record of meetings and the amount of time each member spent at the meeting, the estimated average cost of the meeting was: £141,901 per year, £2729 per meeting, £62 per case discussed and £99 per patient.
Renal cancer specialist multidisciplinary team meeting members.
MDT: multidisciplinary team.
Discussion
Our analysis shows that our surgeon-lead renal cancer sMDT meeting is efficient and provides good value. In 1500 discussions over 34 meetings, and spanning over 8 months, a clinical recommendation was made in 93.3% of discussions. In general, one or two discussions were usually sufficient to make management recommendations, deferral of cases was uncommon and, given the low discharge rate, referrals to the meeting seemed appropriate. In addition, the meeting expenditure seemed reasonable: while the headline annual cost for the sMDT meeting seems high (£141,901), the cost per patient is modest (£99) and is less than the cost of an outpatient clinic appointment within the NHS. 12
Cases that required only one sMDT discussion likely represent situations where patients who had been discussed at the meeting before 2 September 2015 needed review regarding follow-up requirements (such as deciding a surveillance plan after surgery or to review new images for patients on surveillance) or where recommendations were made that did not require repeat sMDT discussion (initiation of systemic treatment, watchful waiting, best supportive care or discharge). Several reasons could explain the need for three or more discussions in 14.6% of patients. The wide time span of the study (over 8 months) likely includes rereview of patients with clinical progression on postoperative surveillance schemes and allows coverage of the small renal mass clinical pathway adopted by the specialist centre; whereby patients very frequently start their management by having a renal tumour biopsy, the results of which are reviewed at the MDT (second discussion), that can be followed by active treatment, such as surgery, which generates a third sMDT discussion to ascertain the best post-operative follow-up scheme based on surgical histology. The minority of patients discussed four or more times likely represent highly complex situations, where multiple additional investigations were required and/or complications from treatment arose.
The average time of 4 minutes per case discussion is likely to reflect a wide time range that correlates positively with case complexity. Notwithstanding, this illustrates the fast pace of the meeting and the importance of pre-meeting case preparation. It may also illustrate that the clinical decision-making process for some of the cases was very straightforward, questioning the utility of discussing all cancer cases at the MDT. However, even for what seems the most straightforward scenario for a patient diagnosed with a renal mass, the management decision process can become more difficult than initially apparent. Consideration of lesion location and size may limit the technical feasibility of certain types of intervention, such as renal tumour biopsy, partial nephrectomy or ablative treatment. Likewise, present and previous medical history can dictate the choice of active surveillance over intervention, preclude the start of systemic treatment, or expose the need for further clinical investigations or treatments prior to decision of management of the renal lesion. One could advocate that given that 91.7% discussions were done in the context of disease localised to the kidney, the clinical decision-making relies mostly on the surgeons and radiologists present at the meeting, and that a separate meeting including pathologists and oncologists would suffice to discuss histology results (27.7% of discussions) and metastatic disease settings (8.3% of discussions). While the idea of streamlining MDTs is under discussion at present 13 and is something we are considering at our centre, it is still unclear how this should be implemented. Often, a case is reclassified from ‘straightforward’ to ‘complex’ precisely because there was an MDT discussion where all key members were involved and contributed towards this decision. If a pathway outside MDT discussion were to be implemented for straightforward situations, it is unclear who and how these would be triaged, and what criteria should warrant MDT discussion. Likewise, given that MDT discussion is now considered the gold standard in the UK, it is not known if patients would accept having their care diverge from that pathway. Further studies involving all stakeholders, including patients, are required to fully critically appraise the MDT discussion pathway and develop streamlining tools.
There are two main limitations to our cost calculations: one is that an estimate of the gross salary per member was used to calculate cost (as opposed to using the actual salary of each member), and the second is that only costs in salaries were taken into account and other costs, such as videoconferencing and other overheads, were not considered. These factors may have contributed to a lower meeting-associated expenditure when compared to previous UK reports. 14 Nonetheless, considering the similar member composition of sMDT meetings in the UK across different cancer types and the use of standardised NHS metrics for MDT cost calculation, 10 the overall salary associated cost calculated for this meeting may be used for reference indication for the cost of other specialist clinical service meetings.
Given the current UK practice of discussing all patients at cancer MDT meetings, within the NHS it is not possible to formally compare the clinical efficacy and cost-effectiveness of these meetings to the previous single clinician decision pathway using a contemporaneous comparative cohort. Historical cohort studies have many limitations. In addition, as our specialist centre and its MDT were established after the UK mandate, the use of a historical cohort was not possible. On one hand, studies suggest that MDT meetings contribute to faster and more appropriate patient management,3–5 particularly in unusual or rare situations, 15 are cost beneficial 16 and lead to increased patient satisfaction. 4 On the other hand, poor study design, publication bias and heterogeneity between study outcomes may prevent a factual assessment of the benefits (or lack thereof) of MDT discussions. 17 In addition, some have pointed out that the need to discuss all diagnostic and treatment options for straightforward cases limits the resources available to discuss difficult situations, 18 and that the absence of the patient at MDT decision-making threatens autonomy. 19 In fact, the UK MDT mandate was established before strong evidence of effectiveness was available, limiting accurate evaluation of its clinical benefit. 20 Our study is unable to address these controversies. However, we do show that, at a modest cost, the renal cancer sMDT meeting addresses the clinical management of a large volume of patients, has a lower deferral rate than previous reports, 14 and in more than 90% of cases defines focused and clinically valid management options that can be presented and discussed with patients. These data are encouraging and support the continued use of a multidisciplinary decision-making platform for all renal cancer patients at a high-volume expert centre. Streamlining MDT discussions is under consideration, 13 but further discussions are needed between all stakeholders to understand how this can be implemented without compromising patient care.
Footnotes
Acknowledgements
JBN received funding from St Peters’ Trust for Kidney, Bladder and Prostate Research (Royal Free Charity), and MGBT from the Nick Maude Memorial Fund/Kidney Cancer UK and Facing Up 2 Kidney Cancer charities. This study was previously presented at the Public Health England National Cancer Registration and Analysis Service Cancer Data and Outcomes Conference 2017, UK (poster), the Société Internationale d‘Urologie meeting 2017 (moderated Eposter presentation), and the American Urological Association meeting 2018 (moderated poster presentation).
Conflicting interests
TP has received funding from AstraZeneca, Merck Sharp and Dohme, Pfizer, Roche, Novartis and Bristol-Myers Squibb, and honoraria from AstraZeneca, Merck Sharp and Dohme, Pfizer, Exelixis, Lilly and Janssen. The remaining authors declare no conflicts of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Ethical approval
Research Ethics Committee approval is not required for reporting clinical audits.
Informed consent
Not sought as only anonymised data was used for this analysis.
Guarantor
MT.
Contributorship
MT is responsible for the study design. JBN and SS acquired the data. JBN and SS analysed the data. DC, TP, MA and MT provided expertise on renal cancer and on the renal cancer MDT process. All authors contributed to the critical discussion of results and writing of the manuscript.
