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PubMed1999

The Palliative Care Education Group for Gloucestershire (PEGG): an integrated model of multidisciplinary education in palliative care.

Multidisciplinary teamwork is an essential part of palliative care. Traditionally, in the UK, education of health care professionals has been carried out within single professional disciplines. The Palliative Care Education Group (PEGG) for Gloucestershire, a county in the south-west region of England, UK, is a multidisciplinary group, which promotes and integrates palliative care education across the county. This report describes the evolution of the group, its aims and objectives and the methods used to evaluate its impact on clinical practice. PEGG is a practical model of multidisciplinary education, which could be adopted in other areas.

Attitude of Health Personnel↗

PubMed2002

Nursing-led in-patient units for intermediate care: a survey of multidisciplinary discharge planning practice.

The effectiveness of post-acute intermediate care in nursing-led intermediate care in-patient units (NLIU) has been studied over the past 20 years. Accounts, both positive and negative, have tended to view it as a uni-disciplinary intervention. The previous studies are in effect a series of single case studies and as such need to be accompanied by richer descriptions of care processes in order to be useful. A survey was conducted, in parallel with a randomized-controlled trial (n=177), to compare multidisciplinary care and discharge planning practice on the NLIU with 16 wards that referred patients to it. The findings identify that a wide range of professions participate in care on the NLIU with physiotherapists and occupational therapists most widely involved. In general the team composition and care processes differed little between the NLIU and control wards. There was some evidence that there was lower participation in care on the NLIU from occupational therapy and social work. It is concluded that the NLIU is a complex multidisciplinary intervention. Positive results from some NLIUs may only be generalizable to settings with similar skill mix across the multidisciplinary team as that found in the acute hospital. Reduced skill mix may be a causal factor leading to extended stays and increased total care costs. This caution should be extended to other models of intermediate care, whether or not they are nursing-led.

Humans↗

PubMed2001

Medical dominance in multidisciplinary teamwork: a case study of discharge decision-making in a geriatric assessment unit.

AIM: To investigate the degree of medical dominance in multidisciplinary teams in a geriatric assessment unit by focusing on decision-making with regard to patient discharge. BACKGROUND: The persistence of medical dominance in multidisciplinary teamwork has been widely assumed but insufficiently researched, particularly through close observation of team practice. The present study seeks to rectify this by examining the extent of medical dominance in two multidisciplinary teams working in a hospital-based geriatric assessment unit. METHODS: Team practice was analysed by observing and audiotaping five case review meetings in each team and by semi-structured interviews with team members. RESULTS: In terms of level of contribution, the issues raised at meetings, and the team responses to discharge initiation, a lower than expected level of medical dominance was identified. This lower than expected level is related to consultants' views on the nature of rehabilitation, leading to a consensus amongst team members as to the purpose of geriatric assessment, and to a high level of team stability. CONCLUSION: Reducing the level of medical dominance encourages the contributions of all team members and thus enhances patient care. More training in team skills would also be beneficial, including interprofessional training.

Aged↗

PubMed2001

Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback.

BACKGROUND: Benzodiazepines are commonly prescribed for older people. Inappropriate benzodiazepine prescribing may result in serious adverse effects, including confusion and falls. AIMS: To determine the prevalence and appropriateness of benzodiazepine prescribing for elderly inpatients at nine public hospitals in Victoria, Australia, and to assess the impact of multidisciplinary feedback on quality of benzodiazepine prescribing. METHODS: Clearance for the study was obtained from ethics committees of participating hospitals. Medication charts for 1301 patients aged 65 years and over were reviewed to identify patients prescribed a benzodiazepine. Using an evidence-based indicator of prescribing appropriateness, cross-sectional notes-based audits were conducted at three time points (baseline, 4-8 weeks and 6 months). Feedback of baseline audit results was provided to medical, pharmacy and nursing staff at multidisciplinary meetings. Changes in benzodiazepine prescribing over the following 6 months were assessed. RESULTS: At baseline, benzodiazepines were prescribed for 36% of patients, and 20% of prescriptions were appropriate. Four to six weeks after feedback, the proportion of patients prescribed a benzodiazepine had not changed significantly (31%, P = 0.125); however, more prescriptions were appropriate (44%, P < 0.0001). For patients who were using a benzodiazepine prior to admission and had a contraindication, there were more attempts to withdraw or reduce the dose (47% vs 21%, P = 0.002) and more prescriptions were for acceptable indications (7.4% vs 2.6%, P = 0.024). Six months after feedback, appropriateness of prescribing remained improved compared with baseline (50%, P = 0.002). CONCLUSIONS: Benzodiazepines were prescribed for approximately one in three elderly hospital inpatients and a large proportion was inappropriate. A multidisciplinary intervention based on audit and feedback improved prescribing and the impact of the intervention was still evident after 6 months.

Aged↗

PubMed1998

A multidisciplinary approach to hemodialysis access: prospective evaluation.

Dialysis access procedures and complications represent a major cause of morbidity, hospitalization and cost for chronic dialysis patients. To improve outcomes and reduce the cost of hemodialysis access procedures we developed a multidisciplinary approach, involving nephrologists, access surgeons, and radiologists. A full-time dialysis access coordinator scheduled all access procedures with the surgeons and radiologists, and tracked outcomes. A computerized database was developed for prospective documentation of procedures and complications. Confidential, detailed analyses and recommendations for improvements were provided periodically to the surgeons and radiologists. The major changes arising from the multidisciplinary approach were as follows: (1) The approach to clotted grafts evolved from an inpatient surgical procedure to an outpatient radiologic procedure. The immediate technical success rate of graft declots increased from 48% to 69%. (2) Elective placement of arteriovenous (A-V) grafts evolved from a three-day inpatient hospitalization to a largely outpatient procedure. The proportion of A-V grafts placed as same day surgery or outpatient surgery increased from 16% to 81%. (3) Surgical complications of new A-V graft surgery decreased from 25% to 11%. (4) Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year. (5) The proportion of native A-V fistula construction in new dialysis patients increased from 33% to 69%. In conclusion, an integrated multidisciplinary approach markedly reduced surgical complications of access surgery and decreased access failures. These improvements occurred despite a marked decrease in hospitalization for access procedures, with a substantial cost saving.

Aged↗

PubMedDate not supplied

Multidisciplinary care for breast cancer: barriers and solutions.

Breast cancer treatment and research is becoming more multidisciplinary in nature. Several modalities and areas of expertise are critical for optimal patient management. The basis for medical decisions and recommendations must reflect outcomes and clinical trial data that are designed and interpreted with broad input across different fields. Hence there has been a trend for specialization in breast disease in many large community and academic practices. Furthermore, a system of communication and standardization of data values, procedures, and protocols has begun, but needs much further development. There are many natural barriers to the process of multidisciplinary care and research in terms of logistics, finances, and education. The example of preoperative neoadjuvant therapy for early stage locally advanced breast cancer is one that involves multiple disciplines in the formulation of a treatment and in future research that will define the optimal individualized approach. This process can also shed further light on biologic principles and potential for improved treatment. Solutions for overcoming barriers to multidisciplinary care should include incentives for collaborative and coordinated clinical care across disciplines. A model of increased efficiency because of pooled resources and specialization in several fields should also be accompanied by a demonstration of increased quality of care and patient satisfaction. Any process that adds to cost or inconvenience needs to be justified in an evidence-based manner. Finally, these initiatives need to be effectively communicated to the professional and policy-making communities and to the public at large through well-conceived and unbiased educational venues.

Breast Neoplasms↗

PubMed1999

Comprehensive multidisciplinary programs for the management of patients with congestive heart failure.

OBJECTIVE: To evaluate the impact of comprehensive, multidisciplinary management programs on the process of care, resource utilization, health care costs, and clinical outcomes in patients with congestive heart failure. MEASUREMENTS AND MAIN RESULTS: A MEDLINE search identified seven english-language reports that compared the process of care, clinical outcomes, or economic variables related to implementation of a multidisciplinary congestive heart failure management program of at least 3 month's duration to a control or reference group. The primary intent of the programs was to emphasize compliance with recommended therapeutic principles, enhance patient education, and provide careful patient surveillance. Five of the studies reported improved functional status, aerobic capacity, or patient satisfaction. Six of the studies reported a 50% to 85% reduction in the risk of hospital admission. Three studies reported economic analyses with suggestive but not compelling evidence of financial benefit. CONCLUSIONS: Comprehensive, multidisciplinary management programs for congestive heart failure can improve functional status and reduce the risk of hospital admission, and they may lower medical costs.

Aged↗

PubMed2000

Setting up a multidisciplinary clinic.

Chronic pelvic pain can be a perplexing and complex problem, frustrating to both clinicians and patients. The traditional medical and surgical model does not always relieve symptoms, and many patients suffer years of pain and undergo multiple surgical procedures without long-term benefit. The biopsychosocial model for chronic pelvic pain gives clinicians the opportunity to broaden the scope for management. A multidisciplinary team can offer simultaneous assessment and management of somatic, behavioural and psychosocial components of the pain. Key members of the team are identified and their roles explored. Practical aspects of operating a multidisciplinary clinic are discussed. A multidisciplinary approach comprises many elements. Further research is needed to identify which are the essential elements to secure optimum outcome for the individual patient.

Chronic Disease↗

PubMed2006

Attitudes of Canadian nephrologists toward multidisciplinary team-based CKD clinic care.

BACKGROUND: Although evidence supporting the advantages of multidisciplinary team-based chronic kidney disease (CKD) care is not well developed, many groups are advocating increased availability of this model. METHODS: The research design is a mailed survey sent to 523 members of the Canadian and Quebec Societies of Nephrology. RESULTS: After excluding 113 respondents who declared themselves to be ineligible, the response rate was 54%. Ninety-one percent of nephrologists reported that they usually or always use a CKD clinic. Decisions about when to perform CKD-related tasks were based mainly on an estimate of glomerular filtration rate, rather than time remaining before end-stage renal disease (ESRD). The ideal creatinine clearance for referral to a CKD clinic was 30 to 59 mL/min (0.50 to 0.98 mL/s), but the usual level was 20 to 29 mL/min (0.33 to 0.44 mL/s). The ideal time for referral was more than 12 months before ESRD. Renal replacement therapy discussions were initiated at a creatinine clearance of 20 to 29 mL/min (57%). Nephrologists supported promotion of home dialysis for suitable patients, but not mandating this. Nephrologists did not provide a blunt prognosis to patients who did not specifically ask. Late referral based on adequate time for ESRD preparation was reported to be 4 to 6 months (27%), 7 to 9 months (26%), or 10 to 12 months (30%). Thirty-eight percent said that optimal preparation takes 13 months or longer. CONCLUSION: The literature's common definition of less than 3 months as a cutoff value between late and early referral is not endorsed. Given that multidisciplinary team-based care is widely available in Canada, this study might inform other jurisdictions about the merits and problems associated with multidisciplinary team-based care and might shape the agenda for future empirical research.

Attitude of Health Personnel↗

PubMed2001

Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate.

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol. We give the results observations of operations of a single surgeon's functional primary surgery over a 6-year period in terms of dental arch relationships, cephalometric analyses, aesthetic assessments, and speech analysis. The results show good early facial growth, with dental arch relationships appropriate for the age and group; we found only minor speech discrepancies, with no patients requiring pharyngoplasty. The results show the importance of multidisciplinary management, the value of keeping to sound surgical protocols, and functional techniques in cleft lip and palate surgery. Our study includes the neglected group of children who have bilateral cleft lip and palate, and it conforms to the style of pan-European projects.

Cephalometry↗

PubMed2000

Which patients with heart failure respond best to multidisciplinary disease management?

BACKGROUND: Multidisciplinary disease management approaches have been shown to decrease resource use in selected samples of patients with heart failure. We remain uncertain regarding the effectiveness of this approach in a general heart failure population and who can be expected to benefit most. The purpose of this study was to test the effectiveness of a multidisciplinary disease management intervention in an unselected population of patients with heart failure and to determine if subgroups could be identified in which the intervention is most effective. METHODS AND RESULTS: Two hundred forty patients with heart failure who were matched on preadmission functional status, comorbidity, and age participated in a quasi-experimental clinical trial. Half (n = 120) were given a multidisciplinary disease management intervention, whereas the other half (n = 120) received usual care. Data on acute care resource use were collected 3 and 6 months after enrollment. No intervention effect was seen in the primary analysis. When the data were analyzed by preadmission functional status (I to IV), acute care resource use was lower in the class II intervention patients. Class I intervention patients had a 288% increase in total costs and a 14-fold increase in heart failure costs. A model of predictor variables explained 17.2% of the variance in heart failure readmission at 3 months. CONCLUSIONS: An intervention of this type and intensity is recommended primarily for functional class II heart failure patients. Increases in cost in class I patients may have resulted from improved access to care.

Activities of Daily Living↗

PubMed2002

Multidisciplinary management of fetal surgical anomalies: the impact on maternal anxiety.

AIM: To assess the impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies. DESIGN: A case-control study was undertaken: Group A (cases) consisted of 16 couples receiving a prenatal multidisciplinary counselling, Group B (controls) was represented by 16 couples, who received diagnosis of the fetal anomaly and the relevant counselling by an obstetrician only. The fetuses were affected by the following gastrointestinal anomalies: gastroschisis, omphalocele, intestinal atresia. METHODS: The Italian version of the Spielberger State-Trait Anxiety Inventory was utilized to assess maternal anxiety. In Group A maternal anxiety level was assessed after the first antenatal counselling and at birth, whereas in Group B only at birth. RESULTS: At birth, Group A presented STAI-S scores significantly lower than after the first antenatal consultation with the team (Mean +/- SD = 39.87 +/- 6.46 versus 68.93 +/- 5.81; p < 0.01). At the end of the first day spent with the baby in the Neonatal Surgery Unit, Group A presented STAI-S scores significantly lower than Group B (Mean +/- SD = 39.87 +/- 6.46 versus 70.62 +/- 4.12; p < 0.01). CONCLUSIONS: This study provides evidence of the positive impact on maternal anxiety of a multidisciplinary approach in prenatal management of fetal surgical anomalies.

Adult↗

PubMed2000

Beyond multidisciplinary care: a new conceptual model for spina bifida services.

Medical care for people who are born with spina bifida (myelodysplasia) is complex and challenging, but the goal of such care is to optimize health and function for people with this condition. Despite years of expert agreement that multidisciplinary care is the medical standard for individuals with spina bifida, this model does not seem to go far enough towards accomplishing the goal of improved function as well as health for all people with spina bifida. Advances in the medical and surgical management of people with spina bifida and society's increased desire to include those with disabilities in family and community life has heightened our expectations for functional/participatory improvement for people with this condition. Some large spina bifida programs have added a separate rehabilitation component to the comprehensive package of services offered to people with spina bifida. The problem with adding further services to the traditional multidisciplinary spina bifida program is the increased complexity and potential for fragmentation that it presents, particularly for the patient and family. We performed a MEDLINE literature search to find information on integrating these services. Although several articles address the importance of either the multidisciplinary spina bifida clinic or a rehabilitation approach, there is little information about integration of medical and rehabilitation services. We propose a new model for spina bifida services throughout the lifespan that integrates the medical and functional/rehabilitative perspectives. Our model for conceptualizing spina bifida services builds on the WHO framework for coding disability (ICIDH-2). This framework includes not only health and functional perspectives, but a participation dimension as well. Furthermore, our new model emphasizes the importance of anticipatory guidance and transitional planning as an integrating dimension applicable across the lifespan. The model is based on three main conceptual dimensions--comprehensiveness, coordination and longitudinality. We are using the model to create standards of care, integrate services and improve their efficiency, and to develop policies regarding spina bifida services. Through this effort we hope to provide better medical and rehabilitation services to those with spina bifida and meet the complex challenge the condition presents throughout the lifespan.

Comprehensive Health Care↗

PubMed1993

The effects of multidisciplinary team care for acute spinal cord injury patients.

The care of 169 survivors of spinal injury receiving acute treatment at the Hamilton General Hospital in Ontario, Canada, was studied. This paper compares treatment of groups of patients before and after formation of a multidisciplinary Acute Spinal Cord Injury Team. The establishment of multidisciplinary team care for acute spinal cord injury patients in our tertiary referral center correlates with clinically and statistically significant reductions in length of stay in the acute care hospital, alterations in the rate of surgical treatment for them, changes in the use of radiological resources, and reduction in the average number of days febrile. The team also brought stronger representation of allied health professionals to the hospital records of acute spinal cord injury patients. These important changes result from implementation of an effective multidisciplinary medical team without the addition of new funds, personnel, or hospital facilities and without alteration in referral patterns. Our team did not reduce mortality, duration of intensive care unit stay, or work for physicians.

Acute Disease↗

PubMedDate not supplied

Therapy outcome after multidisciplinary treatment for chronic neck and chronic low back pain: a prospective clinical study in 365 patients.

OBJECTIVES: This prospective longitudinal clinical study analyses the therapy outcome of 365 patients with either chronic neck (n = 134) or low back (n = 231) pain treated with a multidisciplinary biopsychosocial therapy approach. METHODS: Patients with chronic neck pain (NP) or low back pain (LBP) for 3 months or longer, corresponding sick leave for longer than 6 weeks, and clearly defined inclusion and exclusion criteria underwent a 3-week standardized inpatient multidisciplinary biopsychosocial therapy. Baseline sociodemographic, occupational, functional, and psychological data at entry into the study (T0) were comparable in both groups. At the 6-month follow-up (T1), five different therapy outcomes were analysed in both groups: back-to-work status, generic health status (the 36-item Short Form Health Survey, SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. RESULTS: Both treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up there were no significant differences between the group with chronic NP and the group with chronic LBP in the outcome criteria back-to-work status, improvement of health status and functional capacity, satisfaction with therapy, and reduction of pain. CONCLUSION: Evaluation of the main results of this study suggests that patients with chronic NP also derive significant benefit from a multidisciplinary treatment strategy, demonstrated in the literature so far mainly for patients with chronic LBP.

Activities of Daily Living↗

PubMed1996

The impact of distribution of a patient-education pamphlet in a multidisciplinary breast clinic.

STUDY GOAL: To determine the impact of the distribution of patient-education pamphlets to women with benign breast conditions in a large urban multidisciplinary breast clinic. METHODS: It is clinic policy to administer such materials at the first patient visit for these conditions. A standardized telephone interview was conducted with a random sample of 50 such patients at a mean of five months after that visit (range 1-12 months). RESULTS: While only 29 of the 50 women interviewed reported receiving such materials, 27 of these 29 women reported reading them. The patient's level of education and whether the patient had friends/relatives with breast cancer were not different between the women who had read the pamphlets and the women who had not (p = NS). The women who had received and read the material scored significantly better than did women who had not on a brief breast cancer screening questionnaire (p = 0.027). Of the former, all but three found the information of use; three-fourths of such women rated the materials 8 or higher on an increasing-usefulness scale of 1-10. The most frequently reported benefit gained from the materials was the proper conduct of breast self-examination. Overall patient satisfaction with the pamphlets was 91%. Half of the women receiving such materials shared them with other women. CONCLUSIONS: Patient-education pamphlets distributed at a multidisciplinary breast clinic result in high patient satisfaction and better patient knowledge of breast health. However, these materials were received and read by patients less often than was expected by staff. Because 82% of all women interviewed reported that the clinic staff, the distributed pamphlets, and other reading materials were their best sources of information, it is further concluded that the distribution of such materials is an important function of a multidisciplinary breast clinic.

Adult↗

PubMed2004

Effects on sick-leave of a multidisciplinary rehabilitation programme for chronic low back, neck or shoulder pain: comparison with usual treatment.

OBJECTIVE: To test the outcome of active multidisciplinary treatment in an outpatient setting upon sick-leave status among patients with neck, shoulder and low back pain. DESIGN: Multidisciplinary treatment was administered to 121 patients (intervention group) over 4 weeks of structured intervention, followed by 8 weeks of less structured consultations. Effects of treatment were compared with usual treatment (control group: n = 97). PATIENTS: All patients were in the chronic stage of pain (average sick-leave: 6 months) with different diagnoses: neck-shoulder pain, low back pain or low back pain with radiating extremity pain. METHOD: The intervention group programme included posture corrections, pain perception, skills to cope with pain, aerobic and fitness-promoting activities and relaxation techniques administered to groups of 8-10 patients. The Local National Insurance Office referred the patients who were diagnosed by general practitioners. A 12-month follow-up by the Local National Insurance Office provided feedback about sick-leave status of all 218 patients. RESULTS: There was a significant treatment difference in proportion taken off the sick list after 12 months (intervention group: 78.5%; control group: 50.5%; p < 0.001). The difference was greater among low back pain (p < 0.001) than among neck-shoulder (p < 0.053) and low back pain with radiating extremity pain (p < 0.031) patients. CONCLUSION: Long-term effects of active multidisciplinary treatment were superior to treatment as usual in all diagnostic groups.

Adult↗

PubMed2003

Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years.

OBJECTIVE: To evaluate the impact of an interventional multidisciplinary antibiotic management program on expenditures for antibiotics and on the incidence of nosocomial infections caused by Clostridium difficile and antibiotic-resistant pathogens during 7 years. DESIGN: Prospective study with comparison with preintervention trends. SETTING: University-affiliated teaching hospital. PATIENTS: All adult inpatients. INTERVENTION: A multidisciplinary antibiotic management program to minimize the inappropriate use of third-generation cephalosporins was implemented in 1991. Its impact was evaluated prospectively. The incidence of nosocomial C. difficile and resistant Enterobacteriaceae infections as well as the rate of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) were compared with those of National Nosocomial Infections Surveillance System hospitals of similar size. RESULTS: Following implementation of the program, there was a 22% decrease in the use of parenteral broad-spectrum antibiotics (P < .0001) despite a 15% increase in acuity of patient care during the following 7 years. Concomitantly, there was a significant (P = .002) decrease in nosocomial infections caused by C. difficile and a significant (P = .02) decrease in nosocomial infections caused by resistant Enterobacteriaceae. The program also appeared to have a favorable impact on VRE rates without a sustained impact on MRSA rates. CONCLUSION: These results suggest that an ongoing multidisciplinary antibiotic management program may have a sustained beneficial impact on both expenditures for antibiotics and the incidence of nosocomial infection by C. difficile and resistant bacterial pathogens.

Anti-Bacterial Agents↗