Multidisciplinary cancer care has gained some traction in academic cancer centers worldwide. Such models not only enhance the quality of cancer care through deliberative collaboration but also can be cost-effective for health systems and society. They can also be more patient-centered and allow patients to see all specialists in one visit, ultimately receiving a final consensus treatment plan. However, there are important impediments to widespread implementation, the most pressing of which include administrative and financial concerns at the facility level. Processes that emphasize the efficiency of clinic operations—considering patient-specific needs for each clinic day—allow for deployment of necessary resources (and only necessary resources) to meet the needs of patients and their caregivers. We provide a framework to achieve more robust delivery of multidisciplinary care to patients with cancer.
Too often, cancer care is organized around physicians. Patients and families are often required to make multiple visits to physicians before a final diagnosis is reached. Once patients are diagnosed with cancer, they are hurriedly added into the busy schedules of specialists, and can wait weeks or even months before initiating proper treatment.1 Specialists often fall short of communicating pertinent information to each other, delaying consensus on diagnoses and treatment plans. This lack of cohesion can increase stress, confusion, and anxiety for patients and result in incorrect diagnoses—and downstream—inappropriate treatments.
Multidisciplinary care can offer a welcome departure from this scenario. In multidisciplinary care, specialists come together into a single forum to discuss patient cases. The model has become increasingly common in academic cancer centers in the form of tumor boards, disease-specific conferences, and multidisciplinary clinics. In principle, multidisciplinary care mirrors the scientific community's gold standard for academic veracity: peer review. Determining a patient's pathologic diagnosis, stage of disease, and likely prognostic course is by no means trivial. Oncologic specialists such as radiologists and pathologists are required to interpret multiple diagnostic tests. Multidisciplinary care models require these experts to consult with each other directly, producing a cohesive diagnosis and multiple reasonable treatment options. The entire treatment team presents these options to patients, who can then choose their course in accordance with their values.
Hence, by its nature, multidisciplinary cancer care offers a more patient-centered approach. With individual visits, the consultant who encounters a patient initially often determines the ultimate course of treatment. This is primarily because evidence-based treatment pathways are not yet available for every cancer (especially rare malignancies); as a result, patient and clinician preference becomes paramount. But patients' preferences may be met more consistently if they can see all or most of their caregivers in a coordinated setting.
In addition, multidisciplinary clinics are more convenient for patients. One report showed reductions in time from biopsy to treatment by 21 days and significantly fewer in-person consult visits for patients with pancreatic cancer. This convenience is especially important for those with more limited resources and time.2 In this context, patient satisfaction surveys evaluating multidisciplinary cancer clinics have been favorable.3
As much as peer review enhances our pursuit of scientific truth, evidence does suggest that diagnostic truth is also reached more often with multidisciplinary cancer care.4-6 Fifty-two percent of patients with breast cancer4 and 23% of patients with pancreatic cancer5 have had changes in diagnosis or disease stage after referral to a multidisciplinary clinic. The association is understandable: a cohesive group of providers is now directing care, reducing the likelihood of missing information that is germane to the patient's diagnosis. In addition, misdiagnosis is not a trivial concern. Experts estimate that wrong diagnoses account for at least 40,000 patient deaths per year for patients with all medical conditions.6 This number may significantly underrepresent the death rate in patients with cancer.
Although changes in diagnoses do not guarantee that the new diagnosis is more accurate, reports suggest that patients who receive multidisciplinary care have better clinical outcomes. Observational assessments of patients treated in multidisciplinary clinics for breast,7 ovarian,8 and pancreatic9 cancers report improved survival. As a result, several clinical practice guidelines in both Europe10 and the United States11 recommend the use of multidisciplinary clinics as a strategy to improve cancer care quality.
Multidisciplinary clinics can also allow providers to treat patients sooner in the disease course. Patients with pancreatic cancer who received care in a multidisciplinary clinic received treatment 20 days earlier than those seen by individual physicians.2
Experience suggests that multidisciplinary care can also be more cost-effective. For example, by achieving correct diagnoses at the outset, multidisciplinary settings may limit unnecessary or ineffective therapies. In our clinic, about 13% of patients with pancreatic cancer were upstaged to metastatic disease, which allowed us to avoid futile attempts at resection.4 Referral to a multidisciplinary clinic soon after a suspicion of pancreatic cancer may spare patients from undergoing unnecessary and dangerous staging procedures. For example, before being evaluated in our pancreatic multidisciplinary clinic, patients with resectable disease underwent a mean of 3 procedures (biopsies/imaging) with a mean added cost of $3,371 per patient. In addition, these unnecessary preoperative tests and interventions were associated with a longer time to definitive surgical intervention, which could ultimately effect survival.12
Furthermore, including clinicians such as social workers and pain specialists in treatment planning allows for more thorough evaluations of patients' functional status and quality of life. This not only is better for patients but also can spur further cost savings: adequate earlier treatment of pain and other symptoms may prevent expensive downstream clinical encounters, such as emergency room visits and hospital admissions. We also see the opportunity for cost savings to society, because reducing the number of clinic day visits can allow patients and their caregivers fewer losses of productivity.
Despite these benefits, why haven't multidisciplinary clinics become the predominant form of cancer care delivery? Resistance is mainly at the facility level. First, multidisciplinary clinics require coordinating the schedules of multiple clinicians, support staff, and clinic space, leading to administrative challenges.13 Second, cancer center administrators worry about achieving adequate patient throughput with multidisciplinary care.4 Patients are often in rooms for several hours while each consultant sees them separately. This raises financial concerns over inefficient use of clinic space and physician time. Third, and most concerning, are some objective reports suggesting that providers' well-being may be compromised in multidisciplinary settings. Medical and surgical oncologists participating in multidisciplinary teams have experienced measurable increases in job stress without a commensurate rise in job satisfaction, according to one European study.14 Team leaders and nurses have also reported higher rates of emotional exhaustion from mounting workloads.15
These issues reflect the substantial operational challenges of managing the time of many important personnel in the same setting. These issues are not insurmountable, however. Preparing patient insurance forms, obtaining medical records and imaging, and performing other administrative tasks proactively before the day of clinic allows clinic time to be spent focusing on patients' symptomatic and psychosocial problems, which are especially prevalent in patients with cancer. Timely completion of these tasks on clinic day requires standardization of workflow for each team member, which also allows for higher patient volumes while maintaining high-quality care.
Standardization provides other benefits as well. For example, using operational data from our multidisciplinary clinic and publicly available Medicare reimbursement rates, we estimated the cost impact of missing important symptoms and not addressing patient concerns adequately during clinic (Table 1). Standardization allows for more reliable completion of these essential tasks and could liberate resources needed to provide care for additional patients. In addition, our clinic garners more outpatient revenue per patient than for patients with the same diagnosis who come with individual referrals. Data suggest that this is because patients are more likely to return for further care if they came through our multidisciplinary program, regardless of their region of origin.16
Downstream Medicare Costs Associated With Missed Tasks in a Pancreatic Multidisciplinary Clinic
We are also exploring other strategies for increasing efficiency. For example, given that workload has been shown to affect physician performance,17 we are implementing a health care “cognitive load balancing” methodology that can mine clinical data to predict the need for each type of provider for each patient in advance, allowing them to be present only if needed. Conversely, when providers are overburdened because of high patient volume and complexity, the methodology allows for a clinic coordinator to mobilize staff such as mid-level providers and pain specialists to shoulder tasks that are performable by other providers.
Published accounts suggest that this strategy works to reduce inpatient readmissions using the method of Process Arbitrage.18 Through standardizing workflow and prioritizing completion of relevant tasks for our patients with pancreatic cancer, we project substantial annualized savings, arriving at a possible margin gain of more than 5% (Table 2). These savings come from a greater time allotted to first-line providers to assess acute symptoms (preventing downstream emergency department visits), address patient questions and concerns (preventing phone calls for unanswered questions), and, most importantly, achieve more accurate disease staging as early as possible (preventing needlessly invasive or risky procedures). We also offer an organizational framework that has enhanced our clinic's overall operational performance, and have outlined generalizable lessons for any cancer clinic to achieve similar outcomes (Figure 1).
Potential Impact of Process Arbitrage for Selected Tasks on Quality and Costs in a Pancreatic Multidisciplinary Clinic
Multidisciplinary care confers many benefits to patients and their caregivers. Our experience reveals that patients take comfort in knowing that multiple physicians are discussing their case thoroughly. At the facility level, myriad challenges exist, but these are surmountable with thoughtful operational strategies. With robust clinical practice guidelines such as those offered by NCCN, implementing multidisciplinary care is made even easier for some cancers through standardization. More objective research is needed to assess the true effect of multidisciplinary cancer care on clinical outcomes, costs, and patient and provider satisfaction. After standards are developed for measuring outcomes associated with operational care models, the quality, efficiency, and safety of multidisciplinary cancer care should only improve.
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NewmanEAGuestABHelvieMA. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer2006;107:2346-2351.
PawlikTMLaheruDHrubanRH. Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Ann Surg Oncol2008;15:2081-2088.
SainsburyRHawardBRiderL. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet1995;345:1265-1270.
KatzMHGWangHFlemingJB. Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol2009;16:836-847.
PerryNBroedersMde WolfC. European guidelines for quality assurance in breast cancer screening and diagnosis: fourth edition—summary document. Ann Oncol200819:614-622.
CooperMNewmanNAIbrahimAM. Unnecessary tests and procedures in patients presenting with solid tumors of the pancreas. J Gastrointest Surg2013; in press.
CattSFallowfieldLJenkinsV. The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. Br J Cancer2005;93:1092-1097.
ElnahalSMWildATPawlikTM. Patient retention and costs associated with a pancreatic multidisciplinary clinic [abstract]. J Clin Oncol2012;30(Suppl 34):Abstract 96.
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