Understanding, measuring and improving clinical decision-making in urological cancer multidisciplinary team meetings

Cancer care in many countries is delivered by healthcare professionals working together as multidisciplinary teams (MDTs). In the UK the delivery of care by MDTs is mandatory. The aims of the research reported here were to investigate the factors that affect the quality of clinical decision-making in MDT meetings, to develop and evaluate tools to measure this process, and to use these tools to evaluate interventions designed to improve the quality of such decisions. The introduction presents an overview of the evidence for clinical decision-making in MDT meetings, before Chapter 2 provides a critical appraisal of existing evidence, focussing on specific factors that affect decision-making by MDTs. My first empirical Chapters have explored the attitudes and experiences of MDT members and patients. Chapters 3 and 4 present analyses of national survey data that explore the views of MDT members from different professional groups across a range of tumour types. Chapters 5 and 6 present data from in-depth exploration of the views of urology MDT members and cancer patients respectively. Chapters 8 and 9 present data from studies that develop and cross-validate an observational tool for the assessment of decision-making in MDT meetings (MDT-MODe). I have used this tool in Chapter 10 to assess the relationship between organisational factors, information use, teamworking and decision-making in urology MDT meetings. Having built up a picture of the factors that are important for good decision-making, Chapter 11 reports a study that uses MDT-MODe to evaluate a multistage intervention to improve the quality of decision-making in urological MDT meetings. Finally, my general discussion reflects on the findings and the wider evidence base, explores the limitations and presents implications of my work for clinical practice, patient care, future research and policy

Benefits of robotic cystectomy with intracorporeal diversion for patients with low cardiorespiratory fitness: a prospective cohort study

Background: Patients undergoing radical cystectomy have associated comorbidities resulting in reduced cardiorespiratory fitness. Preoperative cardiopulmonary exercise testing (CPET) measures including anaerobic threshold (AT) can predict major adverse events (MAE) and hospital length of stay (LOS) for patients undergoing open and robotic cystectomy with extracorporeal diversion. Our objective was to determine the relationship between CPET measures and outcome in patients undergoing robotic radical cystectomy and intracorporeal diversion (intracorporeal robotic assisted radical cystectomy [iRARC]). Methods: A single institution prospective cohort study in patients undergoing iRARC for muscle invasive and high-grade bladder cancer. Inclusion: patients undergoing standardised CPET before iRARC. Exclusions: patients not consenting to data collection. Data on CPET measures (AT, ventilatory equivalent for carbon dioxide [VE/VCO2] at AT, peak oxygen uptake [VO2]), and patient demographics prospectively collected. Outcome measurements included hospital LOS; 30-day MAE and 90-day mortality data, which were prospectively recorded. Descriptive and regression analyses were used to assess whether CPET measures were associated with or predicted outcomes. Results: From June 2011 to March 2015, 128 patients underwent radical cystectomy (open cystectomy, n = 17; iRARC, n = 111). A total of 82 patients who underwent iRARC and CPET and consented to participation were included. Median (interquartile range): age = 65 (58–73); body mass index = 27 (23–30); AT = 10.0 (9–11), Peak VO2 = 15.0 (13–18.5), VE/VCO2 (AT) = 33.0 (30–38). 30-day MAE = 14/111 (12.6%): death = 2, multiorgan failure = 2, abscess = 2, gastrointestinal = 2, renal = 6; 90-day mortality = 3/111 (2.7%). AT, peak VO2, and VE/VCO2 (at AT) were not significant predictors of 30-day MAE or LOS. The results are limited by the absence of control group undergoing open surgery. Conclusions: Poor cardiorespiratory fitness does not predict increased hospital LOS or MAEs in patients undergoing iRARC. Overall, MAE and LOS comparable with other series