Practice Variation in Preoperative Multidisciplinary Team Discussions

Practice Variation in Preoperative Multidisciplinary Team Discussions for High-risk Noncardiac Surgical Patients in the Netherlands: A Multicenter Prospective Observational Study.

Preoperative multidisciplinary team (MDT)discussions are recommended by national and international guidelines. However, no guidance is given on how to organise and execute an MDT discussion. The objective of this study is to describe the methods used for preoperative MDT discussion executed in the Netherlands.

Study Overview

• Status: Completed
• Conditions: Frailty; Pre-operative; High-risk Patient
• Intervention / Treatment: Other: preoperative MDT discussion

Detailed Description

Due to the increase in life expectancy and improved care for patients suffering from a chronic disease, the number of complex patients requiring surgery increases. Surgical treatment is often the optimal treatment to improve survival, but it is important for high-risk patients, to balance the potential benefits of treatment against the risk of potential permanent loss of functional capacity and quality of life. Multidisciplinary Team (MDT) meetings may be a sophisticated solution to discuss the harm-benefit ratio between different caregivers. There are currently no randomized studies comparing preoperative MDT meetings for high-risk non-cardiac surgery patients with no preoperative MDTs. In observational studies, the preoperative MDT altered medical treatment and management in more than 80% of patients, including 13-36% of patients who, after MDT, did not undergo the planned surgical procedure.(1, 2) The implementation of a preoperative MDT for frail patients scheduled for colorectal surgery was associated with a statistically nonsignificant reduction in severe postoperative complications from 33% to 22% of patients or up to 25% changes in care management.(1, 3) In a retrospective study Sroka found that for 36% of the discussed, high-risk cancer patients the case was risk prohibitive. The retrospective study by Vernooij et al. showed that only 27% of discussed patients received care as planned.(4) In cancer care, extensive experience exists with MDT meetings also known as tumor boards. The introduction of MDTs has impacted patient treatment in oncology. However, these tumor boards may be hindered by an excessive caseload and time pressure(5) which may limit a positive effect of MDT meetings on patient outcome.(6) A preoperative MDT may therefore complement these tumor boards since only the high-risk cases are selected for discussion and medical consultants are invited based specifically on the patients' comorbidities.

Several international guidelines have recommended MDT discussions for high-risk patients but they are not widely implemented yet. (7-9) Not executing preoperative MDT meetings may be a consequence of the fact that objective evidence for the value of the preoperative MDT meetings for high-risk, noncardiac patients is practically nonexistent. Also, no guidance exists on how best to organize an MDT meeting. Sroka proposes a protocol for the identification and multidisciplinary discussion of predefined high-risk patients.(2) In the current multicenter observational study in the Netherlands, the aim is to document how preoperative MDT meetings for high-risk non-cardiac surgery patients are executed. For the hospitals where MDT meetings are executed, considerable practice variation between hospitals may exist concerning performing and organizing MDT meetings. The practice variation may exist regarding patient selection, MDT meeting organization and attendance, MDT discussions, decisions made and, lastly, regarding nonsurgical management.

The first objective of this study is to describe the practice variation in executing preoperative MDT meetings in the presence of an anesthesiologist. The research question is: How much and what kind of variation exists in execution of preoperative MDT meetings for high-risk non-cardiac surgical patients. Secondary objectives are: what is the frequency of care management changes ordered by an MDT discussion; how do these changes affect outcome of the patients measured by the frequency of Serious adverse events; 30 day, 3 months and 12 months mortality postoperatively or post MDT discussion; calculated risks; differences in high-risk patient identification and the relation between calculated risks and outcome.

• Study Type: Observational
• Enrollment (Actual): 225

Contacts and Locations

Study Locations

• Netherlands
  • Utrecht, Netherlands
    • UMCU
  • Friesland
    • Leeuwarden, Friesland, Netherlands
      • MC Leeuwarden
  • Gelderland
    • Arnhem, Gelderland, Netherlands, 6800 TA
      • Rijnstate Hospital
    • Ede, Gelderland, Netherlands, 6716RP
      • Gelderse Vallei
  • Noord Brabant
    • Eindhoven, Noord Brabant, Netherlands
      • Catharina Ziekenhuis
  • Zuid Holland
    • Amsterdam, Zuid Holland, Netherlands, 1081HV
      • Amsterdam University Medical Centre location VU
    • Leiden, Zuid Holland, Netherlands
      • LUMC
    • Rotterdam, Zuid Holland, Netherlands, 3079DZ
      • Maasstad Ziekenhuis
    • Rotterdam, Zuid Holland, Netherlands
      • Franciscus Gasthuis

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 100 years (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: N/A

• Sampling Method: Non-Probability Sample

Study Population

All high risk noncardiac surgical patients selected for a preoperative MDT discussion.

Description

Inclusion Criteria:

* All patients selected for a Multidisciplinary Team discussion

Exclusion Criteria:

* No implicit consent given for scientific research

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Only
• Time Perspectives: Prospective

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
high-risk noncardiac surgery patients for preoperative Multidisciplinary Team (MDT) discussion; observation of MDT in 11 hospitals	Other: preoperative MDT discussion; high-risk patients are subjected to an MDT discussion among care providers

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Attendance of the MDT	number of carers present at meeting	1-4-2022 untill 1-10-2022
Decisions made in MDT	number of decisions made	01-04-2022 untill 01-010-2022
12 months postoperative mortality or post MDT	number of patients that died within 12 months postoperative or 12 months post MDT	01-04-2022 untill 01-10-2024

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
30 day postoperative mortality or post MDT	number of patients that died within 30 days	01-04-2022 untill 01-10-2022
Serious adverse events at 12 months postoperative or post MDT	number of serious adverse events per patient at 12 months postoperative or 12 months post MDT classified by the Clavien Dindo Classification	01-04-2022 untill 01-10-2024
Hospital admissions at 12 months postoperative or post MDT	number of hospital admissions per patient at 12 months postoperative or 12 months post MDT	01-04-2022 untill 01-10-2024

Collaborators and Investigators

• Sponsor: Rijnstate Hospital
• Investigators: Principal Investigator: Jacqueline M Vernooij, MD, Rijnstate

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2022
• Primary Completion (Actual): June 1, 2024
• Study Completion (Actual): June 1, 2024

Study Registration Dates

• First Submitted: January 18, 2022
• First Submitted That Met QC Criteria: March 22, 2022
• First Posted (Actual): March 31, 2022

Study Record Updates

• Last Update Posted (Actual): June 12, 2024
• Last Update Submitted That Met QC Criteria: June 10, 2024
• Last Verified: June 1, 2024

More Information

Terms related to this study

• Keywords: high-risk;; preoperative risk prediction; perioperative mortality; Multidisciplinary Team meeting
• Additional Relevant MeSH Terms: Pathologic Processes; Frailty
• Other Study ID Numbers: 2021-1952

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No