Does every patient need to be discussed at a multidisciplinary team meeting?

AIM: To evaluate the clinical impact and cost-effectiveness of a multidisciplinary team (MDT) meeting in a large hospital in the UK. MATERIALS AND METHODS: A management plan for colorectal cancer patients was recorded by the supervising surgical consultant prior to the MDT meeting using the available clinical information and the available reports for imaging and histopathology. The recorded outcomes were then compared with the outcomes documented at the subsequent MDT meeting. The cost of the MDT meeting was calculated based on the salaries of individuals involved plus relevant overheads. A range of opportunity costs were considered, the most significant of which was the expenditure required to re-provide direct clinical care displaced by the MDT. RESULTS: Over a 3 month period a sample of 47 random cases were reviewed from the colorectal MDT. In three patients, there were significant differences between the preliminary consultant decision and the MDT recommendation: in one case management was changed based on further information about patient co-morbidity and performance status. In only one case was there a material alteration to a CT report, which altered management. The annual costs of running this colorectal local MDT alone were estimated at £162,734+ per annum with opportunity costs of at least twice that. CONCLUSION: The costs of MDT meetings are very high producing a small clinical impact. At a time of increasing financial and capacity pressure in healthcare systems, the use of scarce resources may be better deployed elsewhere.

Analysis of a paediatric orthopaedic network: a six-year experience in the South West of the United Kingdom.

PURPOSE: We report our experience of a paediatric orthopaedic network, based on a 'hub and spoke' model, covering the South West of the United Kingdom. We identify the areas of most clinical concern, the effect of the network on stream-lining patient management and the benefits of the network to the clinician. METHODS: Prospective data were collected from the minutes of the bi-annual meetings of the South West Paediatric Network (UK) between November 2006 and May 2012. Data collected included details of the condition, previous treatment, problems, complications and advice given. Cases continue to be followed up in subsequent meetings. RESULTS: In total 131 cases were included and hip conditions were discussed most frequently (35.1%). The most common indication for discussion was to support and confirm the local management plan. In total, a mean average of 8.75 cases in total were presented per consultant during the study period, with those within ten to 12 years of starting independent practice presenting the majority. The clinical outcome for patients discussed in this forum was local provision of care in 74%, with transfer to the regional centre in 15.7%. Following advice, 14% of direct referrals were given appropriate advice and avoided a journey to the tertiary centre. CONCLUSION: The network has enabled local provision of care, reduced the burden of travel on patients and prevented unnecessary referrals to the tertiary centre. Additionally, it provides a mechanism to reassure and educate clinicians.

Natural history of acalculous biliary symptoms.

INTRODUCTION: The radiological criteria for the diagnosis of gallbladder disease rely largely on the detection of calculi using ultrasonography. Patients may, however, suffer symptoms typical of biliary pain without detectable gallstones. The aim of this study was to identify a cohort of patients presenting with recurrent episodes of biliary symptoms in the absence of identifiable pathology on ultrasonography and to record the outcome of subsequent imaging investigations. METHODS: Records of patients having abdominal ultrasonography during a four-month period in 2006 were accessed retrospectively and those with symptoms suggesting biliary disease were identified. Radiology records were reviewed over a five-year follow-up period to identify patients undergoing further imaging for recurrent biliary symptoms and outcomes were recorded. RESULTS: A total of 512 patients had ultrasonography for investigation of symptoms consistent with biliary disease. Almost half (41.2%) of these were found to have gallbladder pathology on ultrasonography and 4.7% of patients went on to have further investigations for similar symptoms without achieving a diagnosis. The median age of this group was 47 years and 75% of these patients were female. During the follow-up period, 2.6% of patients with biliary symptoms and initially normal ultrasonography developed gallstones and in 1.3% pancreatitis was demonstrated on imaging. CONCLUSIONS: A small minority of patients who present with biliary symptoms and have no abnormality on ultrasonography present with recurrent symptoms or develop significant biliary pathology. These patients should be identified by interview at routine follow-up visits and further investigations should be considered.

Management of congenital femoral deficiency.

Abnormalities that affect the developing human limb range from subtle differences that are of no functional or cosmetic consequence, to complete absence of all limbs. Advances in non-invasive imaging have improved antenatal detection of these conditions and has broadened the options available to prospective parents. This paper considers congenital femoral deficiency and includes an overview of limb bud development and the mechanisms involved in normal growth. The use of ultrasound in antenatal screening and the clinical and radiological features in childhood will be discussed in addition to management including surgical reconstruction and prosthetic use. This should be one component of a multidisciplinary approach to provide the parents of an affected child with balanced information on functional prognosis, management choices and implications for future pregnancies.