An Integrated Literature Review of Time-on-Task Effects With a Pragmatic Framework for Understanding and Improving Decision-Making in Multidisciplinary Oncology Team Meetings

Multidisciplinary oncology team meetings (MDMs) or tumor boards, like other MDMs in healthcare, facilitate the incorporation of diverse clinical expertise into treatment planning for patients. Decision-making (DM) in relation to treatment planning in MDMs is carried out repeatedly until all patients put forward for discussion have been reviewed. Despite continuing financial pressure and staff shortages, the workload of cancer MDMs, and therefore meeting duration continue to increase (up to 5 h) with patients often receiving less than 2 min of team input. This begs the question as to whether the current set-up is conducive to achieve optimal DM, which these multi-specialty teams were set out to achieve in the first place. Much of what it is known, however, about the effects of prolonged cognitive activity comes from various subfields of science, leaving a gap in applied knowledge relating to complex healthcare environments. The objective of this review was thus to synthesize theory, evidence and clinical practice in order to bring the current understanding of prolonged, repeated DM into the context of cancer MDMs. We explore how and why time spent on a task affects performance in such settings, and what strategies can be employed by cancer teams to counteract negative effects and improve quality and safety. In the process, we propose a pragmatic framework of repeated DM that encompasses the strength, the process and the cost-benefit models of self-control as applied to real-world contexts of cancer MDMs. We also highlight promising research avenues for closing the research-to-practice gap. Theoretical and empirical evidence reviewed in this paper suggests that over prolonged time spent on a task, repeated DM is cognitively taxing, leading to performance detriments. This deterioration is associated with various cognitive-behavioral pitfalls, including decreased attentional capacity and reduced ability to effectively evaluate choices, as well as less analytical DM and increased reliance on heuristics. As a short to medium term improvement for ensuring safety, consistently high quality of care for all patients, and the clinician wellbeing, future research and interventions in cancer MDMs should address time-on-task effects with a combination of evidence-based cognitive strategies. We propose in this review multiple measures that range from food intake, short breaks, rewards, and mental exercises. As a long term imperative, however, capacity within cancer services needs to be reviewed as well as how best to plan workforce development and service delivery models to achieve population coverage whilst maintaining safety and quality of care. Hence the performance detriments that arise in healthcare workers as a result of the intensity (time spent on a task) and complexity of the workload require not only more research, but also wider regulatory focus and recognition

In-depth critical analysis of complications following robot-assisted radical cystectomy with intracorporeal urinary diversion

Background: Robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) is an attractive option to open cystectomy, but the benefit in terms of improved outcomes is not established. Objective: To evaluate the early postoperative morbidity and mortality of patients undergoing iRARC and conduct a critical analysis of complications using standardised reporting criteria as stratified according to urinary diversion. Design, setting, and participants: A total of 134 patients underwent iRARC for bladder cancer at a single centre between June 2011 and July 2015. Intervention: Radical cystectomy with iRARC. Outcome measurements and statistical analysis: Patient demographics, pathologic data, and 90-d perioperative mortality and complications were recorded. Complications were reported according to the Clavien-Dindo (CD) classification and stratified according to urinary diversion type and either surgical or medical complications. The chi-square test and t test were used for categorical and continuous variables respectively. Multivariable logistic regression was performed on variables with significance in univariate analysis. Results and limitations: The 90-d all complication rate following ileal conduit and continent diversion was 68% and 82.4%, and major complications were 21.0% and 20.6% respectively. The 90-d mortality was 3% and 2.9% for ileal conduit and continent diversion patients, respectively. On multivariate analysis, the blood transfusion requirement was independently associated with major complications (p = 0.002) and all 30-d (p = 0.002) and 90-d (p = 0.012) major complications. Male patients were associated with 90-d major complications (p = 0.015). Critical analysis identified that surgical complications were responsible for 39.4% of all 90-d major complications. The incidence of surgical complications did not decline with increasing number of iRARC cases performed (p = 0.742, r = 0.31). Limitations of this study include its retrospective nature, limited sample size, and limited multivariate analysis due to the low number of major complications events. Conclusions: Although complications following iRARC are common, most are low grade. A critical analysis identified surgical complications as a cause of major complications. Addressing this issue could have a significant impact on lowering the morbidity associated with iRARC. Patient summary: We looked at the surgical outcomes in bladder cancer patients treated with minimally invasive robotic surgery. We found that surgical complications account for most major complications and previous surgical experience may be a confounding factor when interpreting results from a different centre even in a randomised trial setting

ASO Author Reflections: The Pursuit of Digitalised Quality Improvement Assessment Tools for Cancer Multidisciplinary Teams

Funder: King's Health Partners; doi: http://dx.doi.org/10.13039/501100002102Funder: Guy's and St Thomas’ CharityFunder: Maudsley Charity; doi: http://dx.doi.org/10.13039/10001217

Modeling spatiotemporal abundance of mobile wildlife in highly variable environments using boosted GAMLSS hurdle models

Modeling organism distributions from survey data involves numerous statistical challenges, including accounting for zero‐inflation, overdispersion, and selection and incorporation of environmental covariates. In environments with high spatial and temporal variability, addressing these challenges often requires numerous assumptions regarding organism distributions and their relationships to biophysical features. These assumptions may limit the resolution or accuracy of predictions resulting from survey‐based distribution models. We propose an iterative modeling approach that incorporates a negative binomial hurdle, followed by modeling of the relationship of organism distribution and abundance to environmental covariates using generalized additive models (GAM) and generalized additive models for location, scale, and shape (GAMLSS). Our approach accounts for key features of survey data by separating binary (presence‐absence) from count (abundance) data, separately modeling the mean and dispersion of count data, and incorporating selection of appropriate covariates and response functions from a suite of potential covariates while avoiding overfitting. We apply our modeling approach to surveys of sea duck abundance and distribution in Nantucket Sound (Massachusetts, USA), which has been proposed as a location for offshore wind energy development. Our model results highlight the importance of spatiotemporal variation in this system, as well as identifying key habitat features including distance to shore, sediment grain size, and seafloor topographic variation. Our work provides a powerful, flexible, and highly repeatable modeling framework with minimal assumptions that can be broadly applied to the modeling of survey data with high spatiotemporal variability. Applying GAMLSS models to the count portion of survey data allows us to incorporate potential overdispersion, which can dramatically affect model results in highly dynamic systems. Our approach is particularly relevant to systems in which little a priori knowledge is available regarding relationships between organism distributions and biophysical features, since it incorporates simultaneous selection of covariates and their functional relationships with organism responses

Quality improvement for cancer multidisciplinary teams: lessons learned from the Anglian Germ Cell Cancer Collaborative Group

Summary: Shamash and colleagues describe how their supra-regional germ cell tumour multidisciplinary team achieved standardisation of treatment and improved survival. We discuss some of the insights the study provides into prioritising complex patients, streamlining processes, the use of telemedicine, and the centrality of good data collection to continuous quality improvement

The anatomy of clinical decision-making in multidisciplinary cancer meetings:A cross-sectional observational study of teams in a natural context

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled "Holistic and Clinical inputs" (patient views, psychosocial aspects, patient history, comorbidities, oncologists', nurses', and surgeons' inputs), "Radiology" (radiology results, radiologists' inputs), "Pathology" (pathology results, pathologists' inputs), and "Meeting Management" (meeting chairs' and coordinators' inputs). A negative cross-loading was observed from surgeons' input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P &lt; 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P &lt; 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs' input and their corresponding surgical input into case reviews.</p

Amplitude equations and pattern selection in Faraday waves

We present a systematic nonlinear theory of pattern selection for parametric surface waves (Faraday waves), not restricted to fluids of low viscosity. A standing wave amplitude equation is derived from the Navier-Stokes equations that is of gradient form. The associated Lyapunov function is calculated for different regular patterns to determine the selected pattern near threshold. For fluids of large viscosity, the selected wave pattern consists of parallel stripes. At lower viscosity, patterns of square symmetry are obtained in the capillary regime (large frequencies). At lower frequencies (the mixed gravity-capillary regime), a sequence of six-fold (hexagonal), eight-fold, ... patterns are predicted. The regions of stability of the various patterns are in quantitative agreement with recent experiments conducted in large aspect ratio systems.Comment: 12 pages, 1 figure, Revte

Gaps and Overlaps in Cancer Multidisciplinary Team Communication: Analysis of Speech

Funder: Health Services and Delivery Research Programme; FundRef: https://doi.org/10.13039/501100002001 Guided by the principles of conversation analysis, we examined the communication practices used to negotiate levels of participation in cancer multidisciplinary team meetings and their implications for patient safety. Three cancer teams participated. Thirty-six weekly meetings were video recorded, encompassing 822 case reviews. A cross-section was transcribed using Jefferson notation. We found a low frequency of gaps between speakers (3%), high frequency of overlaps (24%), and no-gaps-no-overlaps (73%), suggesting fast turn transitions. Securing a turn to speak is challenging due to a systematic reduction in turn-taking opportunities. We contribute to group research with the development of a microlevel methodology for studying multidisciplinary teams. </jats:p

Team functioning across different tumour types: Insights from a Swiss cancer center using qualitative and quantitative methods.

BACKGROUND: Multidisciplinary care is pivotal in cancer centres and the interaction of all cancer disease specialists in decision making processes is state-of-the-art. AIM: To describe differences of MDTMs by tumour type. METHODS: Twelve multidisciplinary team meetings (MDTMs) with participation of different cancer disease specialists at a tertiary hospital were assessed by an exploratory sequential mixed method approach with interviews, observations and a survey to address the following five topics: organisational structure and supporting technology; leadership; teamwork; decision-making, perceived value and motivation. Thirteen persons with different tumour specialities and levels of seniority were interviewed. The 12 MDTMs were observed twice by uninvolved persons and evaluated by the participating physicians with a survey. RESULTS: There were no systematic differences between MDTMs for different tumour types with the exception of the non-disease specific type MDTM, which was the only one for which the organisational structure was not driven by an electronic tool. However, several factors could be identified that generally influenced the functioning of the MDTMs. In particular, the quality of decision-making was highly dependent on the availability of case-based information and the presence of relevant cancer disease specialists. Leadership and teamwork were rated as important and were comparable across the MDTM. Team participants' motivation and perceived value of MDTMs was high across all meetings. CONCLUSION: MDTM at a single institution did not demonstrate disease specific characteristics. An effective MDTM, irrespective of the tumour type, can be successfully structured by technical means and a chairperson coordinating the interaction of cancer disease specialists to improve the decision-making process