ABSTRACT
ABSTRACT
Over the last 10 years, community and hospital-based multidisciplinary teams (MDTs) have been set up for the management of patients with chronic obstructive pulmonary disease (COPD) in the UK. Meetings of the MDTs have become a regular occurrence, mostly on healthcare professionals’ own initiatives. There are no standardized methods to conduct an MDT meeting, and although cancer MDT meetings are widely implemented, the value and purpose of COPD MDT meetings are less clear. Therefore, the aim of this study was to conduct a cross-sectional descriptive online survey to explore COPD MDT members’ perceptions of the purpose and usefulness of MDT meetings, and to identify suggestions or requirements to improve the meetings.
In total, we received 68 responses from 10 MDTs; six teams (n = 36 members) were located in London and four (n = 32 members) outside. Analysis of the replies by two independent researchers found that MDT meetings aim to optimise management and improve pathways for respiratory patients by improving communication between providers across settings and disciplines. Education of the MDT members also occurs with the aim of safer practice. Discussed patients are characterised by (multiple) co-morbidities, frequent exacerbations and admissions, social and mental health problems, unclear diagnosis and suboptimal responses to interventions. Members reported participating in a COPD MDT as very useful (74%) or useful (20%). Meetings could be improved by ensuring attendance through requirement in job plans, by clear documentation and sharing of derived plans with a wider audience including general practitioners and patients.
Introduction
There is increasing interest in implementing integrated multidisciplinary teams (MDTs) in the care of patients with chronic diseases including chronic obstructive pulmonary disease (COPD) (1). In chronic disease care, MDTs have the potential to improve coordination, communication, and decision making between healthcare professionals and patients (2), and lead to fewer hospital admissions whilst improving quality of life (3). Over the last 10 years, community and hospital-based COPD MDT meetings have evolved within the United Kingdom, mostly on the initiative of healthcare professionals. Doctors, nurses, physiotherapists, occupational therapists, pharmacists, dieticians, social workers and mental health specialists can be involved and contribute within their field of expertise (1).
Although the quality of cancer MDT meetings is well studied (4), little is known about COPD MDT members’ attitudes, perceptions and satisfaction. The aim of this study was to explore COPD MDT members’ perceptions of the purpose and usefulness of MDT meetings, and to identify suggestions or requirements to improve the meetings. Through this process we wished to explore which patients should be discussed, how value and outcomes can be measured, and if other healthcare providers or patients themselves should be included in the meetings.
Methods
We conducted a cross-sectional descriptive online survey to assess the attitudes, perceptions and experiences of UK healthcare professionals participating in a COPD MDT meeting. The survey was developed by the first and last author and comprised 15 questions: 6 closed and 9 open-ended. Questions were intended to determine members’ perceptions on the purpose of the meeting, its usefulness, examples of discussed patients, suggestions for improvement, the need to involve patients and other healthcare providers in the meeting and ideas on how to measure the success of the meeting. The survey was developed and distributed using Qualtrics survey tool (www.qualtrics.com).
The first author visited six COPD MDTs in London and collected 48 team members’ email addresses. Four chairpersons of known MDTs outside London were requested to disseminate the survey to all their team members on our behalf. All MDT members participated voluntarily and remained anonymous, so that they are not individually identifiable in the results. To optimise response rates, non-respondents were followed up with three additional mailings over a 4-week period. Surveys and reminders were sent out between 23rd of January and the 21st of February 2014. The first and last author individually performed thematic analysis of the survey through an inductive process (5). Chi-squared tests were used to compare findings between different healthcare providers and between MDT members in and outside London.
Results
In total, 68 MDT members participated in the survey, of which 36 (53%) were nurses, 14 (21%) physiotherapists, 10 (15%) respiratory physicians, three general practitioners (GPs) and five other healthcare providers. Fifty-three percent (n = 36) were working in London and 47% (n = 32) outside London.
Purpose of the MDT
The first question was about the purpose of the MDT.
The main themes that emerged were:
Communication: around 49% reported the MDT meetings improved communication and team working, and established more consistent and efficient care across settings.
Education and improvement of knowledge: 40% of the respondents considered the MDT as a platform for information exchange and believed participation in an MDT improved their knowledge about the disease.
Devising management plans: 81% percent of respondents reported the aim of the meeting was to obtain a proper diagnosis and assessment, to create a management plan or to obtain quick and efficient referral to other disciplines. Other aims mentioned were to reduce hospital admissions or to discuss end of life issues.
Coordination of care: 44% felt the meetings helped align pathways and processes between professions and organisations so that care became more coordinated for patients.
The perceived purpose appeared to be “to optimise management and improve pathways for respiratory patients by improving communication between providers across settings and disciplines.” There were no differences in answers between disciplines and between professionals working in or outside London.
Examples of patients that should be discussed
When asked about which patients were usually discussed in the MDT, the themes that emerged were:
Complex needs: the majority of the respondents stated that those with complex needs, including anxiety and depression, social care, and co-morbidities should be discussed.
Palliative care: There appears to be a need for support in the management of patients nearing the end of life. Both researchers rated this as the second-most cited group of patients requiring discussion.
Admission to, and discharge from hospital: as part of coordinated care pathways.
Managing severe disease; including those on oxygen and non-invasive ventilation.
Exacerbation management and disease optimisation.
Patients that the MDT members felt should be discussed were sub-optimally managed patients with complex needs and co-morbidities, an unclear diagnosis, psychological/social problems, frequent exacerbations or hospital admissions, or those requiring oxygen or palliative care. There were no differences in answers between disciplines or between members working in or outside London.
Usefulness of the MDT meetings and suggestions for improvement
Ninety-four percent of the members rated their MDT meetings as either very useful (74%) or useful (20%). The professionals outside London rated the MDT meetings more often as very useful compared to the professionals working in London (p = 0.03). Six percent gave no answer; nobody rated the MDT meetings as not useful. Nurses and physiotherapists reported the meetings were an opportunity to discuss management plans and to receive support and advice on their decisions from the consultants and senior colleagues.
Furthermore, they mentioned the meetings were an opportunity to learn more about the disease and share knowledge. Finally, the meetings improved communication between healthcare providers and were a unique way to further improve integrated working. Thirty-one percent of the members suggested meetings could be improved by formalising the structure to include clear objectives, adequate preparation of cases and accountability of outcomes. Other suggestions included a (rotating) chairperson (7%) and to end every meeting with a proper documentation of the derived agreements (17%) in the form of a care plan to be shared with the patient. They also suggested reporting outcomes to primary care (5%).
Involving the GP
In our sample, there were only three GPs included from two MDTs, one in London and one outside London. Almost all (99%) members reported they wanted the GP to somehow be included in the meeting. They mentioned GPs to be an essential part of the team as they have knowledge of their patients including co-morbidities and social background and are responsible for the care in the community. Others felt involving the GP could assure better care delivery and could make the treatment more successful. Finally, they mentioned GPs could increase their own disease-specific knowledge when participating in the MDT. Concerns for feasibility included GPs’ time and cost.
Involving other healthcare professionals
Eighty-three percent of the members reported it would be useful to extend the membership of the MDT. There was a need for social service expertise (33%), community matrons or district nurses (28%), palliative care (15%), mental health workers (15%), nutritionists (13%) and oxygen specialist therapists (13%). Sixteen percent indicated that they had no need to include other healthcare professionals.
Involving patients
Although 43% of the respondents reported they would like to invite the discussed patients to the meeting, most of them expressed practical reasons not to do so. There were, however, differences between healthcare providers: 75% of the respiratory physicians wished to include the patient, while in nurses it was 50% and in physiotherapists 21%. Lack of time during the meetings and logistical problems were the main reasons given (84%) for not inviting patients. Others expressed problems with confidentially or healthcare providers including too much medical details in professional discussions, which might not necessarily benefit the patient. However, members appeared to agree that sharing the care plan with the patient was important, especially to gain more insight into the patients or family's perspective of the plan, and to assure patients would comply with the plans (‘no decision about me, without me’). However, they suggested this could be discussed and fed back in a separate consultation with the patient and carers.
Outcomes for success
When asked how the success of a meeting could be measured the following outcomes were suggested:
Number of management plans devised per meeting;
Number of interventions/care plans implemented;
Team satisfaction or team surveys;
Patient satisfaction or related outcomes, such as health-related quality of life;
Decrease in emergency hospital admissions or attendances.
Discussion
This cross-sectional survey of members of COPD multidisciplinary teams (MDT) in the United Kingdom shows that the majority rate participation in MDT meeting as (very) useful. The meetings aim to optimise management and improve pathways for COPD patients by improving communication between providers across settings and disciplines. Education of the MDT members is an important aim to ensure safer practice and maintain up to date knowledge. Discussed patients are often characterized by (multiple) co-morbidities, frequent exacerbations or admission to hospital, social or mental health problems, an unclear diagnosis or suboptimal responses to interventions. Meetings could be improved by ensuring attendance through requirement in job plans, by clear documentation, sharing of derived plans and by inclusion of the GP and patient in the meeting outcomes.
Our findings are subject to certain limitations. The sample size was relatively small, and with the sampling method outside London we were not able to estimate the representativeness of respondents. However, the sample adequately represented types of respondents across core hospital and community based MDTs in and outside London, in which a variety of patients are discussed. Furthermore, our survey was not developed using an iterative process of consultations with experts, but was developed by clinicians with expertise in MDTs, in order to provide illustrative findings rather than to be conclusive. As a result of the high response rate and extensive responses, this is the first study to date which gained insight into members’ perceptions on the value of COPD MDT meetings.
Despite recommendations in the recent NICE guidelines (1), there is currently no standardized method of conducting a COPD MDT meeting. Our survey indicated a need for a more structured approach, with an agenda and chairperson, more pre-planned discussions linked to specific questions and evidence based learning and outcomes. There should be clear documentation of the derived plan and actions that are shared with the extended MDT including GPs and possibly patients. In addition, the measurement of the effectiveness of COPD MDT meetings remains debatable.
It may not be possible to attribute changes in usage of healthcare to the success of MDTs only, as there are more recent developments influencing these outcomes (6). In our survey, patient and team satisfaction were also suggested as a way to measure success of team working. In cancer MDTs, there is evidence that the ability of an MDT to reach a decision on first-case presentation and ability of decisions to be implemented appear to be a useful marker of the performance of the MDT meetings (4). This study demonstrates a need for further evaluation of MDT meetings to define how the effectiveness can be measured, and if standardisation of team meetings can lead to better outcomes for the patient and higher satisfaction within the whole team.
Acknowledgements
The authors would like to thank all COPD MDT members who contributed to the survey, and to Vincent Mak, Irem Patel, Myra Stern, Sian Williams, Lianne Jongepier, Samantha Prigmore, Jo Congleton, Stephen Gaduzo, Nawar Bakerly, Jocelyn Fraser and Timothy Howes for their help by disseminating the survey.
Declaration of Interest Statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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