Developing an integrated MDT service model for the management of patients with lung cancer

The motivation for this research was the publication in 1995 of the Calman-Hine report. This provided a strategic framework for the delivery of cancer care by creating a network of cancer care centres in England and Wales to enable patients to receive a uniformly high standard of care. The report acknowledged the fact that although the evidence on optimal cancer care used to prepare the report was based on two key sources (i) medical literature and (ii) audit data provided by UK cancer registries, they did not lend themselves to controlled experiments as most information came from retrospective analyses; hence they were subject to a number of possible flaws and biases. Yet the report recommended some key structural changes to be implemented. The focus of the research described in this thesis was centred on the recommendation of a multidisciplinary team (MDT) review of patients prior to a treatment decision, both in general cancer units as well as in specialised cancer centres. Given the mandate to implement these recommendations, the research questions addressed were “can the current configuration support this recommendation?”, “what evidence was there to support the effectiveness of the MDT?” and “was there a model of care to support the service delivery of cancer care?” A literature review established that there was no existing template upon which MDT services could be set up. This research therefore set out to develop an MDT model to support operational delivery of care in the setting of a cancer centre. The clinical specialty in which this research was undertaken was that of lung cancer. The research successfully developed a conceptual model. However, in the process, a number of operational and practical constraints were identified within the revised service configuration designed to deliver high quality cancer care through the incorporation of the MDT service, and this ultimately limited the extent to which the model could be deployed in the particular clinical setting. Nevertheless, the modelling process did enable a range of core issues to be identified, enabling design solutions to be formulated and tested, thereby confirming the effectiveness of the MDT model. In particular, the adoption of a soft modelling approach was shown to be beneficial in addressing operational problems. By engaging clinical and other end-users right from the start in the modelling process, the models did become operationally accepted, allowing resistance to change to be overcome and the solution to be integrated into the business process. MDT services are now well established, both in cancer units and cancer centres and published data on their effectiveness in the treatment of lung cancer, although not conclusive; demonstrate an increase in resection rates. However, assessing the long-term impact of MDTs on lung cancer outcomes remains a topic for future research

Multidisciplinary oncology care pathways, evaluation of organisational interventions

In het proefschrift van Van Huizen worden de reorganisatie van multidisciplinaire medische overleggen (MDO’s) en video-confereren (VC) geëvalueerd. Het bleek dat door de invoering van een multidisciplinair eerste-dag spreekuur voor hoofd-hals-kanker en de reorganisatie van het gastro-intestinale oncologische MDO, de efficiëntie van de zorgtrajecten, vooral de wachttijd tot behandeling, verbeterde. Daarnaast bleek dat bij multidisciplinaire behandelingen het informeren van de patiënt extra aandacht verdient en wensen steeds moeten worden meegewogen.Zes verschillende vormen van VC in oncologische netwerken werden geïdentificeerd. De toepassingen van VC varieerde van ad hoc overleg met experts over behandeling van complexe casussen of zeer zeldzame tumoren, tot regulier overleg tussen zorgprofessionals, bijvoorbeeld in de palliatieve zorg. Voordelen van VC voor patiënten waren minder reizen voor diagnostisch onderzoek, betere coördinatie van zorg, betere toegang tot schaarse voorzieningen en behandeling in de eigen regio. Voordelen voor zorgmedewerkers waren optimalisatie van behandelplannen door multidisciplinaire discussies van complexe cases, tegelijkertijd informeren van zorgmedewerkers over wijzigingen in het zorgplan voor individuele patiënten en medische ontwikkelingen, verbeterde zorgcoördinatie en minder reizen.Het reguliere VC-MDO Hoofd-Hals Oncologie tussen een Universitair Medisch Centrum Groningen en haar partner Medisch Centrum Leeuwarden bleek vooral van waarde voor het bespreken van complexe casussen, omdat het andere team er met een ‘frisse blik’ naar keek, en voor het afstemmen van medisch beleid. Voor de aansturing van een zorgtraject bleek er behoefte te zijn aan een ‘real-time dashboard’ betreffende diagnostische procedures en behandelplannen. De meerwaarde van zo’n dashboard zou in toekomstig onderzoek geëvalueerd moeten worden.Van Huizen's dissertation evaluates the reorganisation of multidisciplinary meetings (MDTMs) and video-conferencing (VC). It turned out that introduction of a multidisciplinary first-day consultation for head-and-neck cancer and reorganisation of the gastrointestinal oncological MDTM improved the efficiency of the care pathway, particularly waiting times to start treatment. It was shown that in case of multidisciplinary treatment, extra attention should be paid to informing the patient and that wishes should always be taken into consideration.Six different types of VC in oncology networks were identified. Applications ranged from ad hoc consultation with experts about complex cases or very rare tumours to regular meetings about e.g. palliative care. Benefits for patients were, less travel, better coordination of care, better access to scarce facilities and treatment in their own community. Benefits for healthcare professionals involved optimised treatment plans through multidisciplinary discussion of complex cases, the ability to inform all healthcare professionals simultaneously on developments in the care of individual patients, enhanced care coordination, less travel and continued medical education.The regular VC-MDTM Head-and-Neck Oncology between Groningen University Medical Centre and its partner Leeuwarden Medical Centre added value in discussing complex cases, because the other team offered a fresh perspective by hearing it ‘as new’ and in in keeping their medical viewpoints aligned.For management of a care pathway, there was a need for real-time information regarding diagnostic procedures and treatment plans in the form of a ‘real time dashboard’. The added value of such a dashboard should evaluated in future research

The application of process mining to care pathway analysis in the NHS

Background: Prostate cancer is the most common cancer in men in the UK and the sixth-fastest increasing cancer in males. Within England survival rates are improving, however, these are comparatively poorer than other countries. Currently, information available on outcomes of care is scant and there is an urgent need for techniques to improve healthcare systems and processes. Aims: To provide prostate cancer pathway analysis, by applying concepts of process mining and visualisation and comparing the performance metrics against the standard pathway laid out by national guidelines. Methods: A systematic review was conducted to see how process mining has been used in healthcare. Appropriate datasets for prostate cancer were identified within Imperial College Healthcare NHS Trust London. A process model was constructed by linking and transforming cohort data from six distinct database sources. The cohort dataset was filtered to include patients who had a PSA from 2010-2015, and validated by comparing the medical patient records against a Case-note audit. Process mining techniques were applied to the data to analyse performance and conformance of the prostate cancer pathway metrics to national guideline metrics. These techniques were evaluated with stakeholders to ascertain its impact on user experience. Results: Case note audit revealed 90% match against patients found in medical records. Application of process mining techniques showed massive heterogeneity as compared to the homogenous path laid out by national guidelines. This also gave insight into bottlenecks and deviations in the pathway. Evaluation with stakeholders showed that the visualisation and technology was well accepted, high quality and recommended to be used in healthcare decision making. Conclusion: Process mining is a promising technique used to give insight into complex and flexible healthcare processes. It can map the patient journey at a local level and audit it against explicit standards of good clinical practice, which will enable us to intervene at the individual and system level to improve care.Open Acces

The role of organisational and resource factors in determining lung cancer outcomes

Lung cancer outcomes in the UK show significant variation which are not entirely explained by case mix. Differences in access to lung cancer services contribute. However, the specific factors that underlie the relationship between service organisation and disease outcomes are not known. The systematic review highlights that co-ordinated access to specialist care is likely to be an important determinant of patient outcomes. In addition, a bundle of service factors, rather than an individual factor is a more robust proxy for hospital infrastructure quality. This hypothesis is explored through the creation of a novel organisational score. When adjusted for patient factors a higher score is associated with higher curative intent treatment rates, increased likelihood of patients receiving treatment within 62 days and improved one-year survival. To achieve these improved outcomes national variation in the provision of services and workforce as well as gaps in the optimal care of stage III patients in England need to be addressed. As well as aligning units with national commissioning guidance, qualitative work into decision making suggests that clinician preconceptions and nihilistic attitudes also require consideration. This work shows that inequity in access to essential services exists in the UK and this has a direct impact on patients

Clinician-Led Improvement in Cancer Care (CLICC): Complementing Evidence-Based Medicine with Evidence-Based Implementation

This thesis explores whether a multifaceted intervention implemented through the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network can improve the rates of referral of men with high-risk prostate cancer post-radical prostatectomy for consideration for adjuvant radiotherapy in line with clinical practice guideline recommended care. It comprises seven iterative studies that address urologists’ knowledge, attitudes and equipoise for the use of adjuvant radiotherapy for high-risk prostate cancer, the development of a clinical network embedded intervention and the evaluation of this intervention within a step-wedge cluster randomised trial ‘Clinician-Led Improvement in Cancer Care (CLICC)’ (NHMRC Partnership Grant 1011474; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910). The thesis found some evidence that the CLICC intervention resulted in desired practice change. Results are presented within the context of the CLICC conceptual program logic framework and are interpreted in relation to knowledge, attitudes and beliefs in the wider urological community. The thesis concludes with consideration of how findings could be translated to the implementation of other clinical practice guideline recommendations

Mobilising Clinical Practice Data to Improve Multidisciplinary Oncology Care

As cancer incidence grows, healthcare services are increasingly pressured to provide timely, efficient, evidence-based care. The use of quality indicators are essential to identify and address variations in care delivery and patient outcomes. This thesis aims to inform best-practice quality measurement, feedback, and improvement utilising routinely collected data in cancer care. A systematic review of electronic medical record enabled measurement feedback systems found 12 of 14 studies reported mostly positive outcomes, but were of low-quality and lacking implementation context to replicate findings. A qualitative study identified significant consensus among key informant interviews on factors influencing success of data use and measurement feedback systems. A common theme between the review and interviews was the importance of clinical relevance and engagement. The findings were applied to a case study in colorectal cancer (CRC), including a systematic review and modified Delphi to identify clinically relevant quality indicators and a quantitative study to test the feasibility of the identified indicators against a population-based linked dataset of clinical practice data. The review identified 93 indicators in the literature and 56 CRC professionals prioritised 26 of those indicators. The feasibility study found that only six of the clinically prioritised indicators were feasible using available data in NSW. Feasible indicators were predominantly surgical, whereas indicators related to imaging, (neo)adjuvant therapy, and supportive care were lacking required data. As the use of data and value-based care continues to grow, this thesis provides direction for future data driven quality measurement for clinically meaningful quality improvement. System-wide coordination and standardised data capture, management, and operable exchange is required to transform data and quality indicators into actionable information to improve care

The evolution of national skin cancer registration:Improving our understanding of skin cancers through use of national registry data

This thesis uses national registry data from UK and the Netherlands to report the incidence, demographics, survival and trends of skin cancers. We develop and validate a technique to improve basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) reporting. We then report the incidence of BCC and cSCC for the first time in the UK. We developed and validated a method to identify metastatic cSCC using national registry data and report the first national incidence of metastatic cSCC. A similar technique is then used to report the incidence of metastatic cSCC in the Netherlands. Finally we use these datasets to analyse current staging methods for cSCC and their predictive ability