Int Urogynecol J DOI 10.1007/s00192-015-2662-4

ORIGINAL ARTICLE

Multidisciplinary team meetings in urogynaecology Deepa Gopinath & Swati Jha

Received: 17 September 2014 / Accepted: 12 February 2015 # The International Urogynecological Association 2015

Abstract Introduction and hypothesis The concept of multidisciplinary team (MDT) is well accepted in the current National Health Service (NHS) and is considered good practice for the management of chronic conditions. There has been a recent drive to have MDTs in managing women with incontinence and complex prolapse as a result of recommendations by National Institute for Health and Care Excellence (NICE) guidance, Medicines and Healthcare Products Regulatory Agency (MHRA) etc. Currently, there are no data on the outcome of case discussion at urogynaecology MDTs. The aim of this study was to review the clinical impact of discussion of a select group of cases at an urogynaecology MDT and review the clinical literature to justify the MDT approach. Methods MDT proformas of cases discussed from October 2012 to December 2013 were reviewed. Outcomes of the MDT were compared with recommendations at the initial consultation. This included change in management plan, type of surgery and surgeon as well as time delay due to MDT discussion. Results One hundred six proformas were available for analysis. Age range was 23–89 (58) years. Average time from clinic visit to MDT discussion was 8.32+5.9 days. The MDT recommended a change in management plan in 31 cases (29.3 %), with 11 cases (10.4 %) resulting in alternative surgery and 1 case (0.9 %) with an alternative surgeon. In 18.5 %

of cases, MDT discussion formulated the initial management plan. Conclusions Case discussions at our MDT provide an effective clinical forum to formulate management plans for complex cases. The decision-making process is made robust, without significant impact on waiting time. Investment in setting up MDTs has financial implications but provides patient benefit. Keywords Multidisciplinary team . MDM . MDT . Cancer . Prolapse . Incontinence Abbreviations MDT Multidisciplinary team NICE National Institute for Health and Care Excellence MHRA Medicines and Healthcare Products Regulatory Agency BSUG British Society of Urogynaeocology ePAQElectronic personal assessment questionnairePF pelvic floor PGI-I Patient Global Impression of Improvement STH Sheffield Teaching Hospitals

Introduction Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2662-4) contains supplementary material, which is available to authorized users. D. Gopinath (*) Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, UK e-mail: [email protected] S. Jha Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2SF, UK

The close anatomical and functional relationship of the lower urinary tract, lower genital tract and anorectum means that the disorders of the pelvic floor are likely to have symptoms affecting multiple compartments. Double incontinence (faecal and urinary incontinence) can coexist in 8–24 % of women and functional bowel disorders are also known to coexist with pelvic organ prolapse as well as urinary incontinence [1–4]. With an increasing elderly population, there is greater demand

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on the healthcare services with more complex patients due to the aetiology of disease, other modulating factors as well as need for longer lasting treatments. Hence, a multidisciplinary approach across the related specialties would be ideal in assessing and managing patients with multiple pelvic floor symptoms in urogynaecology. The UK Department of Health defines a multidisciplinary team (MDT) as a Bgroup of people of different healthcare disciplines, which meets together at a given time (whether physically in one place, or by video- or teleconferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient^. The value of the MDT meeting is in ensuring that all patients with a particular condition will benefit from the knowledge and expertise of a wide variety of professionals in order to improve their chances for the best possible outcomes. In 1995, publication of the Calman-Hine report caused major organisational changes within the UK cancer services, including more team working to reduce inequalities in cancer care and improve outcomes [5]. Currently there is a drive to have similar MDT meetings in managing patients with urinary incontinence as per recent recommendations by the National Institute for Health and Care Excellence (NICE) [6]. The other drives for MDT include the Medicines and Healthcare Products Regulatory Agency (MHRA), British Society of Urogynaecology (BSUG), specialist commissioning services [National Health Service (NHS) England] and the Department of Health’s vision for high quality care for all [7–10]. The aim of this article is to evaluate the outcomes of such MDT meetings and also review the evidence to support such an approach in managing patients with pelvic floor disorders in urogynaecology.

Method This was a retrospective cohort study done at Sheffield Teaching Hospitals (STH) which is a tertiary teaching hospital within the UK. The study was registered as a service evaluation project with approval from the trust clinical effectiveness unit and formal ethical approval was not required. Proformas for the time period October 2012 to December 2013 were reviewed. All patients completed a validated symptomspecific and quality of life questionnaire-electronic personal assessment questionnaire-pelvic floor (ePAQ-PF) on four dimensions including urinary, bowel, vaginal and sexual symptoms [11]. Data collected included attendance of individual members at various MDTs, the initial consultation advice prior to MDT and MDT recommendation. This included change in management plan, type of surgery and surgeon. The time delay due to MDT discussion was also noted. Within STH there other parallel pelvic floor MDTs run by the urologists and colorectal surgeons, which the

urogynaecologists attend; however, the emphasis of this study was on the urogynaecology MDT where the predominant patient complaint was of prolapse or incontinence either primary or secondary. The MDT included core members that consisted of three consultant urogynaecologists, two continence nurse specialists, pelvic floor physiotherapists, subspeciality trainee, administrative person and other extended members including urologists with an interest in female urology, colorectal surgeons with an interest in functional bowel disorders, community continence lead, managers and senior sisters. The MDT met on a weekly basis for 45–60 min. To be quorate the MDT required two consultant urogynaecologists. The MDT had a reference document as well as a referral criterion (Table 1) and notes were prepared using a structured proforma (Appendix 1). This proforma was internally validated by the MDT members to ensure that it captured the necessary information. The MDT had an administrative secretary who would collect the notes and all necessary clinical correspondence, urodynamic traces, questionnaires etc. The initial preparatory work was done by the subspecialist trainee prior to and the meeting was chaired by the lead consultant for urogynaecology. The cases were presented by the trainee or the named consultant responsible for the patient’s care and comments were minuted as well as documented on the proforma. A copy of the Table 1

MDT referral criteria

Referral criteria Cases listed for surgery • Recurrent prolapse (same compartment) • Recurrent incontinence • Cases considering SNS or PTNS • BMI >35 considering POP or incontinence surgery • POP/incontinence surgery at the extremes of age (<30 and >80) • Previous complication/anticipated difficulty with surgery • All mesh procedures, including vaginal, abdominal and laparoscopically placed meshes • Laparoscopic colposuspension Complications • Returns to theatre • Cases with intra-/postoperative complications, I.e. pelvic organ injury, mesh complications • Cases requiring blood transfusion • Urogynaecology complications referred from other units Other cases • Cases requiring management decisions or multidisciplinary input, e.g. joint operating, second opinion • Referrals between teams • Clinician discretion, including interesting cases, points of technique or learning points SNS sacral nerve stimulation, PTNS percutaneous tibial nerve stimulation, BMI body mass index, POP pelvic organ prolapse

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proforma was filed in a central file and another copy in the notes. Outcomes suggested by the MDT were then communicated to the general practitioner (GP) and the patient by a formal letter.

Results One hundred six MDT proformas were available for analysis. There were 40 MDT meetings during this time period of 14 months which equates to an average of 2.9 sessions per month. The attendance at the MDTs is summarised in Table 2. All meetings were attended by at least two urogynaecologists (100 %). However, the urologists and colorectal surgeons were present only at one meeting each (2.5 %); 16/40 (40 %) sessions were attended by continence nurse specialists and 9/40 (22.5 %) sessions were attended by the community continence lead. Pelvic floor physiotherapists attended 17/40 (42.5 %) sessions. Managers attended 3/40 (7.5 %) sessions and senior nursing staff attended 13/40 (32.5 %) sessions. Administrative staff were present in 39/40 (97.5 %) sessions. The age range of patients discussed was 23–89 (58) years. The distribution of the case range and the results of their outcome are summarised in Table 3. Of the 45 cases with urinary incontinence, 26/45 had mixed urinary incontinence, 7/45 had primary stress urinary incontinence, 10/45 had recurrent stress incontinence and 2/45 had urge urinary incontinence. The cases who had primary incontinence were discussed due to extremes of age or because objective testing was negative with subjective symptoms. The practice of discussion of primary Table 2

Attendance at MDT meetings

Total number of meetings

40 (%)

Urogynaecologist 1 Urogynaecologist 2 (lead)

35 (87.5 %) 38 (95 %)

Urogynaecologist 3 Subspeciality trainee urogynaecology Urologist Urology research fellow Colorectal surgeon Continence nurse 1 Continence nurse 2 Community continence lead Physiotherapist 1 Physiotherapist 2 Administrative staff1 Administrative staff 2 Manager Senior sister gynaecology outpatients Matron

35 (87.5 %) 27 (67.5 %) 1 (2.5 %) 1 (2.5 %) 1 (2.5 %) 10 (25 %) 14 (35 %) 9 (22.5 %) 16 (40 %) 3 (7.5 %) 34 (85 %) 5 (12.5 %) 3 (7.5 %) 11 (27.5 %) 1 (2.5 %)

Table 3

Cases discussed at MDT with outcome

Predominant symptom

Number of cases (%)

Change in management (%)

Change in surgery (%)

Change in surgeon (%)

UI MUI Primary SUI Recurrent SUI UUI POP Primary POP Recurrent POP POP+UI Primary POP Recurrent POP+UI Recurrent

45 (42.5) 26 7 10 2 34 (32.1) 22 12

16 (15.1) 7 2 6 1 11 (10.4) 5 6

4 (3.8) 1 1 2 0 5 (4.7) 1 4

1 (0.9) 1 0 0 0 0 0 0

7 (6.6) 1 5

1 (0.9) 0 0

0 0 0

0 0 0

POP+Recurrent SUI1100Voiding dysfunction2 (1.9)000Pelvic pain7 (6.6)1 (0.9)1 (0.9)0Post-op complications7 (6.6)2 (1.9)1 (0.9)0Mesh complications3 (2.8)000Fistula1 (0.9)000UI urinary incontinence, MUI mixed urinary incontinence, SUI stress urinary incontinence, UUI urge urinary incontinence, POP pelvic organ prolapse

urinary incontinence as per NICE guidance was included in the referral criteria in December 2014, but MDT discussion of these cases only started in January 2014, excluding these cases from the current study. Of 34 cases with prolapse symptoms 22 were primary and 12/34 had recurrent prolapse. The primary cases mostly discussed were women who wished to have uterinepreserving surgery using mesh, complicated prolapse following anterior exenteration, medical comorbidities increasing anaesthetic risk, class III obesity and also by continence nurse specialist to expedite the pathway. The average time from the first patient contact, i.e. their clinic visit to the MDT discussion, was 8.32 + 5.9 days. The MDT recommended a change in management plan in 31 cases (29.3 %), with 11 cases (10.4 %) resulting in alternative surgery and 1 case (0.9 %) with an alternative surgeon. An example of alternative surgery offered was for a 66-year-old woman with mixed incontinence who was initially listed for an autologous fascial sling and following MDT discussion laparoscopic colposuspension was suggested also resulting in change in the surgeon. All changes in management plan were suggested by urogynaecologists rather than other members of the MDT. In cases where the plan was changed, 8 (26 %) were initially seen by the subspecialty trainee and 23 (74 %) by the consultants. In 18.5 % cases, MDT discussion formulated the initial management plan. The categories of changes as a result of MDT discussion are listed in Table 4.

Int Urogynecol J Table 4 Categories of changes recommended as a result of MDT discussion Predominant symptom Changes suggested as a result of MDT discussion Urinary incontinence

Pelvic organ prolapse

Prolapse and urinary incontinence Pelvic pain

Postoperative complications

Changes in medication (stop doxazosin, further anticholinergics) Change of surgery (e.g. fascial sling to laparoscopic colposuspension) Consider neuromodulation Second opinion by urogynaecology colleague Incontinence surgery as staged procedure (e.g. TAH for fibroids-then TVT if SUI not improved) Further physiotherapy Referred to urology due to significant bladder neck scarring after two failed SUI surgeries Urodynamics prior to tape division in recurrent incontinence with voiding dysfunction Not for surgery due to disparity of UDS findings and clinical picture Cardiology opinion on fitness for surgery Additional repair at laparoscopic surgery (e.g. hysteropexy and anterior repair) Mode of delivery in pregnant patient with prolapse Change of surgery (e.g. laparoscopic surgery instead of vaginal repair) Consider vaginal mesh Suprapubic catheter management for urinary incontinence Change of planned surgery (e.g. initially planned removal of cervical stump after subtotal vaginal hysterectomy for cervical discomfort) Staged approach to investigate mesh-related pain after laparoscopic sacrocolpopexy Local anaesthetic injection for mesh-related pain after TVT

TAH total abdominal hysterectomy, TVT tension-free vaginal tape, SUI stress urinary incontinence, UDS urodynamic study

Discussion This study shows the decision-making process is made more robust when discussed at an MDT without a significant impact on waiting times. The MDT also provides an excellent clinical forum to discuss complex cases. This is the first study that has reviewed the outcomes from an urogynaecology MDT in the UK. There are currently no data on the MDT models in the urogynaecology set-up and we attempt to critically review the current structure and outcomes and compare this to the evidence from cancer MDTs in the UK. MDTs improve coordination, communication and decision-making between healthcare team members as well as patients and produce more positive outcomes [12]. As per NICE guidance in the management of female urinary incontinence, an MDT should include a urogynaecologist, a urologist with an interest in female

urology, a specialist nurse, a pelvic floor physiotherapist, a colorectal surgeon with subspecialist interest in functional bowel problems for women with coexisting bowel problems and a member of the care of the elderly team or an occupational therapist for women with functional impairment [6]. The care pathway for managing recurrent prolapse and incontinence by the specialist commissioning group NHS England also recommends MDTs have members from related specialties [3]. However, currently very few units in the UK have MDTs with all the recommended team members. Within the hospital where this study was conducted parallel urology and colorectal MDTs were also run where the urogynaecologists presented cases relevant to these specialties. This was after prior discussion at the urogynaecology MDT. It was not felt feasible that every case discussed at the urogynaecology MDT be presented at these MDTs. The main impediment to the discussion of all cases at MDTs involving the different pelvic floor specialists including urogynaecologists, female urologists and colorectal surgeons is the additional costs to the NHS in order to provide this service. MDT-driven care is expensive. From cancer models, the expenditure was found to be £87.41 (US$141.95) per case discussion with an overall cost to the NHS of around £50 million (€57 million, US$79 million) per year [12, 13]. For the urogynaecology MDT there was no time or funding allocated for the preparatory work or the post task work generated as a result of the MDT discussion. It would have been ideal to have all members present for the meeting that would have resulted in better contribution to case discussions. Also, apart from the urogynaecologists and administrative staff, the rest of the members were unable to attend more than 50 % of the meetings. An effective MDT as envisaged by the NICE is hence difficult to provide without involving the additional expenditure to an already strained financial budget. This is unlike the cancer MDT meetings which are funded as a part of the cancer care pathway. This study has shown that the decision-making process in an MDT setting is made more robust by reflection and clinical discussion. The skill mix of the MDT also meant that patients could consider other treatment options which may not be offered by the individual surgeon. MDT decisions are more robust because it is a collective opinion rather than an individual clinical decision [14]. This aspect of MDT is especially relevant in the context of mesh complications we have seen in recent years with vaginal meshes for prolapse and also taperelated complications in stress incontinence [15, 16]. Currently, there is paucity of malpractice litigation involving MDTs, suggesting that the decisions made in MDT settings are medicolegally safer, which makes this a useful forum to discuss cases that require vaginal meshes or tape operations. However, the MDT does have a medicolegal responsibility and all doctors should feel personally responsible for all team decisions. MDTs should avoid the situation in which there is

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poorly defined group responsibility resulting in no individual feeling completely accountable [17]. A greater awareness of these responsibilities and improved team dynamics should optimise outcomes for patients while limiting exposure of the participants to legal liability [17]. One of the other concerns with the MDT is the impact on waiting times. In the current study, the waiting time ranged from 2 to 14 days showing this had minimal impact on the NHS targets [18]. This was because the MDT meetings were held on a weekly basis. It is probable that if this is less frequent it can have an impact on the waiting times. Also, if there are several cases to be discussed, the quality of discussion may be poor due to time restraints and it may have an effect on the next MDT which may already be overbooked [19]. The NICE guidance recommends that we discuss all cases of incontinence who are considered for surgical management for stress incontinence or invasive treatment for overactive bladder [6]. This is to ensure that the care is up to date and follows evidence-based guidelines as a part of the governance process. For a clinician who practises NICE recommendations, the additional benefit in MDT discussion is debatable and it can have significant impact on the valuable MDT time which can be used to discuss other complex cases. Clinical audit would give similar information about adherence to NICE standards and the results can be discussed at the MDT for recommendations from the collected MDT expertise. However, this is a retrospective exercise compared to prospective MDT discussion. Since January 2014, we have been discussing cases with primary incontinence considered for surgery and have so far seen no additional advantage or change in management plan subsequent to this discussion, but this has had some impact on time taken for the administrative tasks as a result of discussion. This may be more relevant in set-ups where there is a single urologist or urogynaecologist practising in isolation to provide more support to the individual surgeon/s. MDTs should have referral criteria so that cases can be prioritised for discussion. The time commitment required for an individual meeting will depend on the frequency and duration of the meeting, the number of patients to be discussed and the complexity of the cases. Based on the current study, we recommend a weekly meeting in a tertiary centre which is likely to have a higher case volume and complex cases, to minimise the impact on waiting times. Videoconferencing may help in reducing travel times if the sites are distant from each other. However, there should be good technical support and an audiovisual facility to undertake teleconferencing. One of the negative impacts of videoconferencing is that it is thought to be less personal compared to a face-to-face conversation, and if the link gets cut off it can affect the quality of decision and hence have direct clinical impact [20]. The outcomes measured in the current study were the impact on waiting times and change in management plan. The other measurable outcomes from an MDT include the change

in patient’s quality of life, patient satisfaction rates, cost-effectiveness, team satisfaction and stress levels of the team members. In cancer, survival rates are usually taken as a quantifiable outcome measure and this has improved in some cancers like breast cancer due to MDT discussion [14]. However, in urogynaecology, an overall score like Patient Global Impression of Improvement (PGI-I) may be a better outcome measure than individual symptom-specific and quality of life questionnaires as the cases are not comparable due to other confounding factors. Though team satisfaction and stress have been used as outcome measures, they are directly dependent on the structure of the MDT and also the team dynamics. A productive MDT that would deliver high quality care would require a non-hierarchical system with motivated team members who act outside the boundaries of ego, share a common goal, have complimentary expertise, have an honest and open relationship and have a clear leader. The MDT leader should have good communication skills, encourage participation of members to get their input and then utilise this to reach a group consensus and guide decisions. When there are controversial decisions to be made, the team leader must be able to get the best out of individual players and also be able to make independent decisions when the need arises [21]. One of the disadvantages of MDT discussion is the lack of personal contact of the individual MDT members with the patient who is being discussed. However, this can be overcome by using validated questionnaires as well as patient goals and expectations which will then guide the MDT members in suggesting the management options that would best suit the patient. There are two ways cases can be discussed at the MDT. The first option is to discuss the case at the MDT prior to giving the patient the options and then rediscuss if the MDT recommendation is not the patient’s choice. The disadvantage of this method is that the clinician is not educationally challenged by the clinical situation and leaves the management decision to be made by the MDT. Also, if the patient decided not to choose the MDT recommendation, further time and resources are wasted to rediscuss the case. The second option would be to offer the possible options to the patient and then rediscuss at the MDT depending on the patient’s choice. The initial option is more likely if a trainee is doing the initial consultation. In our study there was no difference between proportion of cases discussed by the consultants or the trainees suggesting a training issue. Thus, the educational value of MDT is further improved by opting for the second option with less impact on resources and time [22]. Evidence from cancer MDTs has shown other benefits like better chance of inclusion of patients into clinical trials, improve audits, coordinate services, improve pathways and also prevent unnecessary or repeated investigations being performed [21, 23]. Though the evidence is mostly from cancer and other sectors of health service, there is no reason to consider that MDT in urogynaecology would not be similarly productive.

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From this study the main barriers identified were funding issues and lack of time. Unless this is included in job plans, this is unlikely to change and will continue to affect the feasibility of running an effective MDT. As a solution, NHS managers should be made aware of the positive aspects to support this service as we will reap the benefits in the long run of a high quality service with good patient satisfaction. However, this still remains to be proven. We also review the feasibility of such a set-up in the international pelvic floor centres. The UK has a single unified healthcare provider—the NHS. Internationally, very few countries have a similar set-up and it is often a combination of private and public healthcare providers. In the NHS, consultants are expected to provide direct clinical care in 80–90 % of the weekly sessions and the time for the MDT would be included under this programmed activity. The average time for a pelvic floor MDT is considered to take an hour compared to a cancer MDT that takes an average of 2.14 h [12]. This would account for 0.25 of programmed activities of the consultant job plan. For easier facilitation of the MDT meetings, scheduling some of these meetings before a joint pelvic floor clinic may make it easier to attend for most clinicians including trainees and also incorporate into consultant job plans. Internationally, a pelvic floor MDT is easier to set up than a cancer MDT as the majority of team members are likely to be present even in the smallest of the institutions. Having criteria of cases as described in the current study would limit the number of cases discussed and if distance is an obstacle, videoconferences and good electronic communication may be more suitable. The single most effective resource the hospital administrators can provide to facilitate MDT care is to provide the essential administrative support [24] Also, national guidelines promoting MDT set-up and accreditation of centres that provide MDT care would encourage MDTs internationally which will provide a continuous peer review process of the clinical practices to ensure that they are based on the best evidence, thereby reducing the clinical risk.

Conclusion Given the recommendations of the various national and international professional bodies, there is a clear role for MDT meetings in managing patients with urinary incontinence and prolapse. Investment in MDTs should be considered as a longterm venture in the development of the urogynaecological service, as this is not only a gatekeeper for clinical governance, but also fulfils several other roles. Enthusiastic team members who have respect for colleagues and a desire to make the team philosophy work will clearly achieve more within a MDT setting than an independent setting. A successful team not only provides outstanding service to patients, but also allows the members to learn and support each other,

thereby providing a positive working environment and richer work experience. Conflicts of interest None. Authors' contributions DG was responsible for the conception, design of the study, acquisition, analysis and interpretation of the data. She was substantially involved in the drafting, revision and final approval of the manuscript. SJ was responsible for the conception and design of the study interpretation and analysis of the data as well as drafting, revision and final approval of the manuscript.

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