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PubMed1986

Medical aspects of the multidisciplinary assessment and management of osteoarthritis.

Osteoarthritis, the most common form of arthritis, influences a person's mental well-being, ability to work or perform activities of daily living, and personal and family relationships. Ideally, the management of this disease is multidisciplinary, involving not only the use of medication but also exercise instruction, dietary counseling, and psychosocial interventions. The effects of such a comprehensive treatment program have not been well studied. A 12-week trial of multidisciplinary assessment and management of osteoarthritis was conducted. In addition to receiving the anti-inflammatory agent sulindac, patients were evaluated and followed up by health professionals in the disciplines of medicine, physical therapy, occupational therapy, nutrition, social work, and psychology. An initial assessment of the degree of pain, swelling, tenderness, stiffness, and ability to conduct activities of daily living was made, which represented patients' entry status. Subsequent assessments were made by the multidisciplinary team every two weeks for 12 weeks. Seventy-seven patients completed at least ten of the 12 weeks. On entering the study, two thirds of the patients had pain, tenderness, or swelling affecting the hip, knee, or hand. At the end of 12 weeks, 80% of the patients had improvement in their osteoarthritis, and 71% improved in their ability to conduct activities of daily living. The results support the view that a comprehensive approach to osteoarthritis can significantly reduce disability and pain.

Activities of Daily Living↗

PubMedDate not supplied

Multidisciplinary bedside notes: an experiment in care.

An experimental system of multidisciplinary medical records was introduced in an elderly ward at St George's Hospital, London. The new-style notes improved multidisciplinary communication in goal-setting and care-planning and, by placing the record at the foot of the patient's bed, brought the focus of patient care to the patient's bedside. Major difficulties included duplication of paperwork, refiling after discharge and the matter of confidentiality. All the members of the multidisciplinary team were in favour of continuing the system, however, and recommended its use in other wards.

Documentation↗

PubMedDate not supplied

Collaboration: the solution to multidisciplinary care planning.

Case management is a patient care delivery system that is transforming health care in the 1990s. The key to its success is its primary tenet of collaboration among all disciplines. Case management enhances communication among all disciplines and coordinates patient care services. Multidisciplinary action plans have been developed as a tool for the multidisciplinary team, to guide health care practitioners toward the highest quality, cost-effective care possible. At Beth Israel Medical Center in New York City, the Multidisciplinary Care Model has proven successful on both the Orthopaedic and Rehabilitation services.

Humans↗

PubMed1993

Multidisciplinary task force for controlling drug expenses.

The establishment of a multidisciplinary task force to control increasing drug costs is described. From 1986 to 1992, dollars spent on drugs at a 964-bed teaching hospital increased from $9.8 million to $26.8 million, despite a tightly controlled formulary, prudent purchasing practices, prescribing restrictions, an antimicrobial order form program, a target-drug program, and an active pharmacy-run cost intervention program. These increases occurred as a result of changes in the mix of drugs prescribed, increases in outpatient volume, inflation, and price increases resulting from the Omnibus Budget Reconciliation Act of 1990. A multidisciplinary task force composed of seven teams--AIDS and related issues, ambulatory care, medicine, obstetrics and gynecology, pediatrics, surgery, and systems and procedures--was formed to identify ways to reduce drug expenses and enhance revenue. Each team made recommendations designed to reduce the rate of growth of pharmaceutical expenses. To implement these recommendations, the task force used a variety of verbal and written strategies to educate and communicate with physicians, pharmacists, nurses, pharmaceutical company representatives, and patients. A system was developed so that goal achievement could be monitored. The program, which was implemented on September 16, 1991, and continued through September 30, 1992, reduced the growth in drug expense by $2.33 million. As a result of the program, control of the drug expenses became an institutional priority, not merely a pharmacy department priority. By establishing a multidisciplinary team approach involving physicians, administrators, nurses, and pharmacists, a substantial reduction in the growth of drug expenses can be achieved.

Budgets↗

PubMedDate not supplied

Multidisciplinary day hospital treatment of rheumatoid arthritis patients. Evaluation after two years.

The availability of multidisciplinary care for rheumatoid arthritis is still limited. The Raoul Dufy Program offered by the Saint-Antoine Teaching Hospital in Paris provides one-on-one personalized care in a day hospital setting as an adjunct to conventional medical follow-up. Listening and providing information and education are major objectives of the nurse, rheumatologist and physical therapist participating in the program. The team also includes a social worker, a surgeon, a dietician, a podiatrist and a psychologist, who intervene as needed. Seventy patients attended the program between December 1993 and September 1995 and were asked to complete a baseline and a three-month questionnaire designed to evaluate the effects of the program in terms of new therapeutic interventions, patient knowledge and quality of life. The patient knowledge score increased significantly (P < 0.0001). Many therapeutic interventions were initiated after program attendance, especially in the fields of podiatry, psychology and physical therapy. However, the quality of life score failed to improve. These results and the substantial patient demand for appointments are encouraging. Further work is needed on the methodology of multidisciplinary care evaluation. Coping strategy evaluation tools may allow to identify some of the specific benefits provided by the multidisciplinary approach.

Adult↗

PubMed1998

[Surgery and multidisciplinary treatment for colorectal cancer].

Evaluation of surgery and multidisciplinary treatment for colorectal cancer was performed based on the review of the results of clinical trials. Although most improvement in prognosis for colorectal cancer patients was obtained by the development of surgical techniques until the mid-70's, further extended surgery could not have demonstrated the obvious improvement in survival after the 80's. In this regard, various multidisciplinary treatments were evaluated by a meta-analysis of clinical trials. Among those modalities, preoperative irradiation for rectal cancer, postoperative adjuvant chemotherapy for resected colorectal cancer and biochemical modulation of 5-fluorouracil by methotrexate or leucovorin for advanced colorectal cancers proved to be significantly effective for improvement of prognosis. Clinical trials of immunochemotherapy using either levamisole or PSK for resected colorectal cancers, a trial of hepatic artery infusion for liver metastasis, and a trial of an adjuvant monoclonal antibody treatment, were also reported to demonstrate significant effects. For further progress in multidisciplinary treatment for colorectal cancers, standardization of the appropriate surgical technique for each stage of the disease is much anticipated.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1998

Multidisciplinary treatment of persistent symptoms after Gulf War service.

Research suggests that individuals commonly describe persistent symptoms or syndromes after a war. After the Persian Gulf War, the Department of Veterans Affairs and the Department of Defense initiated registries and expedited health care for those with Gulf War-related health concerns. At Walter Reed Army Medical Center, the Gulf War Health Center was created in mid-1994 to contribute a continuum of care for those with Gulf War-related health problems. The purpose of this report is to describe the Gulf War Health Center's Specialized Care Program, a 3-week intensive outpatient multidisciplinary treatment program for people with persistent, disabling Gulf War-related symptoms. The program uses an evidence-based model of multidisciplinary care employed at chronic pain centers internationally and shown to yield stable improvements in pain, mood, health care use, and return to work rates. A patient is described to illustrate how the program works. Finally, a Deployment Medicine Treatment Center is proposed, a multidisciplinary treatment center like the Specialized Care Program that would offer care to those with persistent, disabling symptoms after all future deployments.

Adult↗

PubMed1998

[Value of multidisciplinary consultation in diagnosis and survival of Marfan syndrome].

OBJECTIVES: To facilitate diagnosis, define a strategy for prevention and treatment and obtain further insight concerning Marfan's disease, we conducted a series of multidisciplinary consultations in French clinics. PATIENTS AND METHODS: Five specialists (a genetics specialist, a pediatrician or a rheumatologist, an ophthalmologist, and a psychologist) saw all the patients successively in the same clinic. A synthesis of the clinical files was prepared for analysis. Since the first consultation on 1 January 1995 and the study end on 30 June 1997, 494 patients (67% adults) participated in primary consultations, 143 were seen at follow-up consultations. RESULTS: The diagnosis of Marfan's disease was affirmed in 41% of the patients, disaffirmed in 48% and uncertain in 11%. Among the Marfan's patients, 75% were seen again within the framework of a multidisciplinary follow-up consultations. Annual work-up included cardiology (echocardiography with measurement of the proximal aorta diameter in search for indication for beta-blocker therapy or preventive valve replacement), ophthalmology (lens, retina) and rheumatology examinations (skeletal involvement). CONCLUSION: Early diagnosis and rigorous follow-up can help prevent ocular and cardiac complications in Marfan's disease. The multidisciplinary approach provides more precise data for diagnosis and possible phenotype-genotype correlations.

Adult↗

PubMedDate not supplied

Rationale, development, and clinical outcomes of a multidisciplinary amiodarone clinic.

OBJECTIVES: To review the rationale and development of a multidisciplinary amiodarone clinic, and document the clinical outcomes resulting from its implementation. METHODS: A clinic was established to provide an ambulatory setting in which patients receiving amiodarone could be followed according to published guidelines by a multidisciplinary team of cardiovascular health care specialists. Patients receiving amiodarone were referred to the clinic by their primary physicians. A data base containing each patient's medical history, current drug therapy, and baseline laboratory values was developed during the initial visit. Liver function tests, thyroid function tests, and chest radiographs were performed every 6 months, and pulmonary function tests were scheduled on an annual basis. Dosage adjustments were performed in select patients. RESULTS: Since November 1996, 60 patients have been referred to the amiodarone clinic. Mean length of follow-up before and after referral was 16.3+/-25.5 and 9.2+/-5.5 months, respectively. Laboratory tests were performed according to accepted guidelines in 14 (23%) patients before referral compared with 54 (90%) patients after enrollment (p<0.001). Previously unrecognized adverse events were detected in 21 (35%) patients, including pulmonary fibrosis, QT prolongation, liver enzyme elevation, hypothyroidism, hyperthyroidism, and asthma exacerbation. Amiodarone was discontinued in six patients, four of whom had suspected pulmonary toxicity. The dose of amiodarone was adjusted in 29 (48.4%) patients. CONCLUSION: Many patients receiving amiodarone are not being followed according to published recommendations. Implementation of a specialized, multidisciplinary amiodarone clinic improves outcomes by monitoring for early detection of drug-related toxicities and by facilitating proper dosage modifications.

Adult↗

PubMed2002

European Society of Intensive Care Medicine statement: intensive care medicine in Europe--structure, organisation and training guidelines of the Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) of the European Union of Medical Specialists (UEMS).

This article describes the structures and institutions in the European Union by which professional training and qualification in medical specialities will be harmonised. All main medical specialities are represented in the European Union of Medical Specialists (UEMS) by speciality sections. For intensive care medicine, as a multidisciplinary speciality, a new structure of a Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) within the UEMS was established in 1999. In this MJCICM the European Society of Intensive Care Medicine and the European Society of Paediatric and Neonatal Intensive Care are represented by delegates without voting capacity in a Standing Advisory Board. Statements and recommendations which the MJCICM has worked out until now are presented: Definitions of intensive care medicine, structural conditions for education and training, continuing medical education, criteria for accreditation of intensive care medicine training centres, common core curriculum for optional specialist training in intensive care medicine, as well as an intensive care units accreditation visiting programme and standards for medical treatment and nursing care.

Accreditation↗

PubMed2024

Genomics-informed neuropsychiatric care for neurodevelopmental disorders: Results from a multidisciplinary clinic.

PURPOSE: Patients with neurodevelopmental disorders (NDDs) have high rates of neuropsychiatric comorbidities. Genomic medicine may help guide care because pathogenic variants are identified in up to 50% of patients with NDDs. We evaluate the impact of a genomics-informed, multidisciplinary, neuropsychiatric specialty clinic on the diagnosis and management of patients with NDDs. METHODS: We performed a retrospective study of 316 patients from the University of California, Los Angeles Care and Research in Neurogenetics Clinic, a genomics-informed multidisciplinary clinic. RESULTS: Among the 246 patients who underwent genetic testing, 41.8% had a pathogenic or likely pathogenic variant. Patients had 62 different genetic diagnoses, with 12 diagnoses shared by 2 or more patients, whereas 50 diagnoses were found in only single patients. Genetic diagnosis resulted in direct changes to clinical management in all patients with a pathogenic or likely pathogenic variant, including cascade testing (30.6%), family counseling (22.2%), medication changes (13.9%), clinical trial referral (2.8%), medical surveillance (30.6%), and specialty referrals (69.4%). CONCLUSIONS: A genomics-informed model can provide significant clinical benefits to patients with NDDs, directly affecting management across multiple domains for most diagnosed patients. As precision treatments advance, establishing a genetic diagnosis will be critical for proper management. With the growing number of rare neurogenetic disorders, clinician training should emphasize core principles of genomic medicine over individual syndromes.

Humans↗

PubMed2002

Pathology review of cases presenting to a multidisciplinary pigmented lesion clinic.

OBJECTIVES: To determine if pathology review, within the context of a multidisciplinary pigmented lesion clinic, results in changes in diagnosis of melanocytic lesions and to ascertain if the change in diagnosis altered clinical management and outcome. METHODS: Retrospective review of pathology reports, progress notes, and diagnoses entered in the University of Pennsylvania (Philadelphia) Pigmented Lesion Clinic database. RESULTS: A total of 5136 primary melanocytic lesions from patients referred to the pigmented lesion clinic between 1991 and 1999 were reviewed by a single pathologist. Of these, 559 (11%) had diagnoses that were changed significantly from the submitting diagnosis, with 120 (2.3%) undergoing a "critical" revision, 63 (1.2%) defined as a change from malignant to benign, and 57 (1.1%) from benign to malignant; 171 (3.3%) remained within the same category (benign or malignant) but had a downgrade in diagnosis (less severe) that would have a significant impact on treatment, prognosis, and research. Likewise, 268 (5.2%) remained within the same category but had an upgrade in diagnosis (more severe) that would have a significant impact on the same parameters. In addition, 257 reexcisions of melanocytic lesions were reviewed, of which 15 (5.8%) were changed from clear to involved margins, while another 16 (6.2%) were changed from involved to clear margins, for a total of 12%. Of the lesions with a critical revision, follow-up was obtained in 98 (83%). The patients in the malignant-to-benign category were followed up for an average of 2.6 years while those in the benign-to-malignant category were followed up for an average of 4.2 years. The change of diagnosis from malignant to benign resulted in 9 patients (17%) being spared a reexcision while 12 patients (23%) were downgraded from a radical to moderate reexcision. The change in diagnosis from benign to malignant resulted in 45 patients (98%) requiring a reexcision after review. Twenty-five of these patients were found to have residual disease in their reexcision specimens or had already had recurrence at the excision site. Furthermore, 7 patients (15%) underwent lymph node dissection or sentinel lymph node biopsy after review. However, none of the nodes were positive for metastatic disease. During this time, 8 patients (17%) in the benign-to-malignant category, and 1 patient (1.9%) in the malignant-to-benign category (who had previously had 4 primary melanomas) developed metastatic disease. CONCLUSIONS: Pathology review of primary melanocytic lesions, within the context of a multidisciplinary pigmented lesion clinic, results in changes in diagnosis in a significant proportion of cases. These changes have important implications for clinical decision making, patient outcome, and research data collection.

Diagnosis, Differential↗

PubMed2004

Clinical characteristics and management of vascular anomalies: findings of a multidisciplinary vascular anomalies clinic.

OBJECTIVE: To describe the scope of the University of California, San Francisco (UCSF), Vascular Anomalies Clinic (VAC), including the types of diagnoses, characteristics, and management of patients seen in the clinic. DESIGN: Case series. SETTING: Referral, outpatient, multidisciplinary clinic in a university system. PATIENTS: Consecutive sample of 175 patients seen in the VAC at UCSF from January 2001 to July 2003. MAIN OUTCOME MEASURES: Diagnosis before and after clinic visit, symptoms, treatment recommendations, age of onset, age at clinic visit, location of lesion, sex, and type of referring physician. RESULTS: A total of 96% of patients had cutaneous involvement, 71% of patients had vascular malformations, and 14% had infantile hemangiomas. Fifty-eight percent of patients were referred from outside the UCSF system. Of the patients who had not been previously seen by members of the VAC team or UCSF dermatologists, only 22% had been assigned correct specific diagnoses before coming to the VAC, and 13% had incorrect specific diagnoses before coming to the VAC. Fifty-six percent of vascular malformations were first noted at birth and 17% were noted at later than 10 years of age. Eighty-seven percent of patients were symptomatic from their vascular lesion. Sixty-six percent of patients underwent prior magnetic resonance imaging of their lesion. Further diagnostic workup was recommended in 43% of cases, and treatment recommendations were made in 83% of cases. CONCLUSIONS: Significant confusion still exists regarding the appropriate terminology, diagnosis, and management of vascular anomalies. Multidisciplinary clinics effectively address these complicated and troubling disorders by providing accurate diagnoses, clear treatment recommendations, and counseling from a team of specialists.

Child↗

PubMed1985

Diagnosis and management of obstructive sleep apnea. A multidisciplinary approach.

Snoring has been shown to be the primary sign of a potentially serious medical condition, ie, obstructive sleep apnea (OSA). Traditionally, the otolaryngologist has been the primary medical resource for patients with snoring problems. However, until recently, little was known about the now-acknowledged serious complications of this phenomenon. Of the primary treatments for this condition, those most commonly utilized to date involve surgical procedures routinely performed by the otolaryngologist, ie, tracheostomy and uvulopalatopharyngoplasty. Thus, the practicing otolaryngologist has been thrust into the forefront in the diagnosis and management of OSA. Hence, it behooves the modern practitioner to be cognizant of the multidisciplinary approach to this problem. Herein, we review snoring as a medical problem, sleep laboratory studies of patients with OSA, and the interaction of multidisciplinary team members in the optimal management of this ubiquitous problem.

Airway Obstruction↗

PubMed1994

The management of high grade dysplasia and early cancer in Barrett's esophagus. A multidisciplinary problem.

BACKGROUND: The incidence of Barrett's-associated esophageal adenocarcinoma is rising, but experience in the treatment of high-grade dysplasia (HGD) or early cancer is limited. Based on an endoscopic surveillance program, the authors developed a systematic multidisciplinary approach to this problem. METHODS: Surgical resection was considered if biopsies of the Barrett's segment, performed according to a published protocol, showed invasive cancer, intramucosal carcinoma, or repeated evidence of HGD. The type of resection was based on the length of the Barrett's segment and included an en bloc lymph node dissection for staging purposes. Careful intraoperative pathologic evaluation ensured that all of the Barrett's mucosa was resected. RESULTS: From 1984 to 1993, 27 consecutive patients (23 men, 4 women), with median age of 61 years (range, 45-75 years) underwent surgical exploration. Indications for operation were invasive cancer in 17 patients, intramucosal carcinoma in 5 patients, and HGD in 5 patients. Median length of the Barrett's segment was 9 cm (range, 1-17 cm). Only 15 patients (55%) had abnormalities visible with endoscopic examination that were potentially suspicious for malignancy. Twenty-six patients underwent resection with complete removal of the Barrett's mucosa, 20 by Ivor Lewis esophagogastrectomy, and 6 by transhiatal esophagectomy. Pathologic tumor stages were: TisN0M0 in 10 patients; T1N0M0 in 11 patients; T2N0M0 in 2 patients; T3N0M0 in 3 patients; and T1NXM1 in 1 patient. There were no postoperative deaths or anastomotic leaks. Major complications occurred in 4 patients. With a median follow-up of 3.7 years, 22 patients were alive, and only 2 patients had recurrences. CONCLUSIONS: This increasingly important group of patients with HGD or early carcinoma in the Barrett's esophagus has a high chance of cure but requires careful multidisciplinary treatment by the surgeon, gastroenterologist, and pathologist.

Adenocarcinoma↗

PubMed2004

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment.

BACKGROUND: Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance. OBJECTIVES: The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care. SEARCH STRATEGY: The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus*. The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases. SELECTION CRITERIA: Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. DATA COLLECTION AND ANALYSIS: Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply. MAIN RESULTS: No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population. REVIEWERS' CONCLUSIONS: The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Aged↗

PubMed2001

Provisional stenting for symptomatic intracranial stenosis using a multidisciplinary approach: acute results, unexpected benefit, and one-year outcome.

Percutaneous techniques have dramatically changed our approach to coronary and peripheral revascularization. Intracranial atherosclerosis is a highly morbid disease; however, techniques for revascularization are still in evolution. The authors comprise a multidisciplinary team of neurologists, neuroradiologists, and interventional cardiologists who have collaborated in treating fifteen patients with symptomatic intracranial stenosis who have failed medical therapy. The acute success rate (100%) and one-year freedom from death and stroke (93.4%) using balloon angioplasty and provisional stenting are encouraging. A surprising observation in this patient cohort was that 53% of patients had improvement or resolution of a deficit that was chronic and presumed to be permanent and irreversible. This type of chronic but reversible deficit is termed "brain angina". The background, rationale for a multidisciplinary team, techniques, and preliminary results of intracranial angioplasty with provisional stenting are presented.

Aged↗

PubMed2003

Neoadjuvant chemotherapy for breast carcinoma: multidisciplinary considerations of benefits and risks.

BACKGROUND: The majority of patients with breast carcinoma receive chemotherapy as a component of multimodality treatment. Over the past decade, it has become increasingly more common to deliver chemotherapy first, but this has raised new questions within all disciplines of cancer management. METHODS: The authors reviewed published studies on the effect of neoadjuvant chemotherapy for breast carcinoma on the practice of medical oncology, surgical oncology, radiation oncology, pathology, and radiology. RESULTS: Treating breast carcinoma with neoadjuvant chemotherapy has several advantages, such as providing the earliest possible treatment against preexisting micrometastases, offering selected patients breast conservation therapy, and allowing for measurement of disease response, which can then be used to customize subsequent chemotherapy. However, neoadjuvant chemotherapy affects the practice not only of medical oncology, but also has important implications for the specialties of surgery, radiology, pathology, and radiation oncology. The current review addressed the new opportunities and challenges within the multidisciplinary care of breast carcinoma provided by neoadjuvant chemotherapy. CONCLUSIONS: The complexity of the issues led the authors to conclude that patients who receive neoadjuvant chemotherapy are likely to benefit from a coordinated multidisciplinary approach to their care.

Breast Neoplasms↗