Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature

  • K Melissa Ke1Email author,

    Affiliated with

    • Jane M Blazeby2, 3,

      Affiliated with

      • Sean Strong2,

        Affiliated with

        • Fran E Carroll2,

          Affiliated with

          • Andy R Ness1 and

            Affiliated with

            • William Hollingworth2

              Affiliated with

              Cost Effectiveness and Resource Allocation201311:7

              DOI: 10.1186/1478-7547-11-7

              Received: 19 September 2012

              Accepted: 12 March 2013

              Published: 4 April 2013

              Abstract

              Objective

              To investigate the cost effectiveness of management of patients within the context of a multidisciplinary team (MDT) meeting in cancer and non-cancer teams in secondary care.

              Design

              Systematic review.

              Data sources

              EMBASE, MEDLINE, NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC.

              Eligibility criteria for selecting studies

              Randomised controlled trials (RCTs), cohort, case–control, before and after and cross-sectional study designs including an economic evaluation of management decisions made in any disease in secondary care within the context of an MDT meeting.

              Data extraction

              Two independent reviewers extracted data and assessed methodological quality using the Consensus on Health Economic Criteria (CHEC-list). MDTs were defined by evidence of two characteristics: decision making requiring a minimum of two disciplines; and regular meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing. Studies that reported on the costs of administering, preparing for, and attending MDT meetings and/or the subsequent direct medical costs of care, non-medical costs, or indirect costs, and any health outcomes that were relevant to the disease being investigated were included and classified as cancer or non-cancer MDTs.

              Results

              Fifteen studies (11 RCTs in non-cancer care, 2 cohort studies in cancer and non-cancer care, and 2 before and after studies in cancer and non cancer care) were identified, all with a high risk of bias. Twelve papers reported the frequency of meetings which varied from daily to three monthly and all reported the number of disciplines included (mean 5, range 2 to 9). The results from all studies showed mixed effects; a high degree of heterogeneity prevented a meta-analysis of findings; and none of the studies reported how the potential savings of MDT working may offset the costs of administering, preparing for, and attending MDT meetings.

              Conclusions

              Current evidence is insufficient to determine whether MDT working is cost-effective or not in secondary care. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective cancer and non-cancer care are required.

              Keywords

              Multidisciplinary teams Cost-effective Secondary care

              Introduction

              Multi-disciplinary teams (MDTs) are an integrated approach to healthcare in which medical and allied health professionals consider relevant treatment options and collaboratively develop an individual treatment plan for patients [1, 2]. Despite some scepticism about the effectiveness of MDT working in health care [24], the concept of MDT working is now widely accepted [5] and considered to be good practice in many parts of the world for the successful management of chronic disease [68]. Teamwork is recommended because of increasing complexity in patient management and subspecialisation of health professionals, and because of changes in working patterns in the health care sector with reduced hours of work [9].

              Areas where MDT working is now commonly adopted in secondary care include care of the elderly, heart failure, stroke, mental health, and critical care. The area that has seen the most increase in MDT working, however, is in oncology where MDT working has been widely recommended including in North America [10], Australia [11, 12], and continental Europe [13, 14]. Indeed it is now mandated as part of the NHS Cancer Plan in the UK [6]. Studies have shown that MDT working in cancer care is associated with decreased time from diagnosis to treatment [15], more accurate pathological staging of disease [16], increased number of patients treated with radical intent [17, 18], improved survival [19], and greater patient satisfaction [20]. However, these studies are largely retrospective, and there is a lack of well designed randomised controlled trials and prospective studies in this field [1, 2123]. There is also a need to consider the costs of administering, preparing for, and attending MDT meetings in any evaluation.

              MDTs demand considerable organisation, management infrastructure and funding to ensure that the correct personnel are present, that the relevant patient details are collated, and that the pathological and radiological materials are reviewed by the appropriate specialists before and during the meeting [1, 24, 25]. Indeed, it has been shown that if critical information is absent at the MDT meeting, decisions may need to change following the meeting and this can delay the start of treatment [26]. In the UK enormous investment has been made to ensure the functioning of cancer MDT meetings and it is estimated to cost the National Health Service (NHS) around £50 million a year for preparation and a similar amount for attendance time [23]. Whether this substantial investment is justified, however, is unknown and has not been previously considered. The aim, therefore, of this paper was to systematically summarise economic studies of MDT working in secondary cancer and non-cancer care.

              Methods

              Criteria for considering studies for this review

              Types of studies

              We reviewed economic evaluations of MDT working compared to no MDT in the provision of secondary care which includes hospital-based and community-based care (Table 1). The types of study designs eligible for inclusion were randomised controlled trials (RCTs), cohort, case–control, before and after, cross-sectional, and decision analysis modelling studies.
              Table 1

              Inclusion and exclusion criteria for systematic review on cost-effectiveness of MDT working

              Inclusion criteria

              Exclusion criteria

              Studies comparing MDT care with no MDT care

              Studies that are not comparative i.e. focus on MDT care only

              Secondary care services i.e. hospital-based or community-based

              Primary care

              Study design – RCT, cohort, case–control, before and after, cross-sectional studies, or modelling studies

              Ecological studies, case reports

              Applied study (i.e. studies generating primary data or modelling of secondary data)

              Methodological and general articles, expert opinion, letters and abstracts

              Population – persons diagnosed with any diseases

               

              Study setting – any country

               

              MDTs are defined as:

              Multidisciplinary ward rounds

              a) Team members from a minimum of two disciplines making decisions; and

              b) Regular team meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by tele-conferencing

              Outcomes - health outcomes which are relevant to the disease being investigated

               

              Costs – average costs of organising MDT meetings, average cost per patient treated, or incremental cost effectiveness ratios

               

              Journal articles, grey literature

              Books

              English language

              Foreign languages

              Types of participants

              We included studies which enrolled people with any disease type, receiving secondary care and we classified these as cancer and non-cancer.

              Types of interventions

              MDTs were defined by evidence of both of the following characteristics:
              1. 1.

                Team members from a minimum of two disciplines making decisions;

                 
              2. 2.

                Regular team meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing.

                 

              Where team members came from different grades within one discipline, this was considered to represent a single discipline (e.g. a consultant surgeon and a specialist surgical registrar were counted as one discipline).

              Studies that evaluated MDT decision making at the patient bedside during ward rounds were excluded because we felt that they were substantially different from the type of meeting room based MDT work advocated in recent policy initiatives (e.g. for cancer services) [6, 27]. The key differences between the two are that meeting room based MDTs require a coordinator, and include a systematic review of information about the patient without the patients’ input or interruptions. If a paper did not state whether the MDT meeting was ward-based or meeting room based, this was inferred from the description of the meeting.

              Types of outcome measures

              Full economic evaluations (i.e. cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis and cost-consequences analysis) [28] were considered for inclusion.

              Types of costs

              We included studies that reported on the costs of supporting an MDT meeting or the subsequent direct medical costs of care, non-medical costs (e.g. patient travel), or indirect costs (e.g. productivity losses). The costs of supporting an MDT typically include the costs of team members preparing and attending MDT meetings; the latter could include travel expenses, or costs of teleconferencing, as well as administrative support provided by a team coordinator.

              Search methods for identification of studies

              We searched the databases EMBASE and MEDLINE (both via the Ovid interface), NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC for relevant publications published from the date of inception of each database to December 2011. Grey literature was identified through the NHS HMIC database as well as based on specialised knowledge of one of the authors (JMB). The search strategy consisted of combinations of free text and MeSH terms related to the economic evaluation of an MDT (see Appendix 1). The search included journal articles and grey literature published in the English language. Reference lists from included studies and other relevant publications, including reviews, were manually checked for citations missed by the electronic search.

              Data collection and analysis

              Selection of studies

              Initially, one author (KMK) selected reports fulfilling the first inclusion criterion (see Table 1) of this review based on title and abstract. Full articles of possibly relevant studies were retrieved for more detailed evaluation. A final selection of included studies was decided by discussion with the whole team.

              Data extraction

              A data extraction template, developed using the guidelines provided by the Centre for Reviews and Dissemination [29], was used to extract the following data alongside the critical appraisal of original studies: country of investigation; objective of the study; study intervention and comparator; study design and setting; target population characteristics; sources and quality of clinical data, if applicable; sources and quality of cost data; methods for dealing with uncertainty; and study results. The following data detailing the characteristics of MDT meetings were also extracted: frequency of meetings, number of disciplines contributing, meeting venue, description of leadership style, method of dissemination of decision, and administrative support. Two authors (KMK, SS) independently extracted data. All discrepancies were reviewed and consensus achieved by discussion.

              Due to the varied nature of the studies, we provide a narrative summary of the study results for our review rather than a formal meta-analysis of results.

              Methodological quality assessment

              The methodological quality of the included studies was assessed using the Consensus on Health Economic Criteria (CHEC-list), a 19-item assessment tool [30]. The CHEC-list represents a minimum set of methodological criteria that address aspects of the internal and external validity of individual economic evaluation studies. For each criterion, a study received a ‘yes’ if it had sufficiently addressed that aspect of the study, and a ‘no’ if it had not. Two authors (KMK, FEC) independently evaluated the methodological quality of included studies. Both piloted the use of the CHEC-list. Disagreement was resolved by discussion.

              The six CHEC-list criteria that are regarded as most important in assessing risk of bias are appropriate choice of an time horizon, measurement of costs, valuation of costs, measurement of outcomes, valuation of outcomes, and discounting of future costs and outcomes [31]. Therefore, the risk of bias among the included studies would be high if the number of studies that fulfilled these six criteria is low.

              Results

              Overview

              Our electronic literature search identified 1,788 articles. After a detailed review of 63 articles, 15 were included in the final analysis (Figure 1) [3246]. Eleven were based on RCTs, [32, 34, 36, 3841, 4346] most commonly performed in diseases of older people [34, 39, 40, 44] (Table 2). Only two studies evaluated MDT working in cancer care [35, 37], and none were conducted in the UK. The majority of studies only included costs borne by the health care payer. No studies estimated the full cost of administering, preparing for and attending an MDT meeting.
              http://static-content.springer.com/image/art%3A10.1186%2F1478-7547-11-7/MediaObjects/12962_2012_Article_163_Fig1_HTML.jpg
              Figure 1

              Studies selection process.

              Table 2

              Summary of key characteristics of included studies (n = 15)

              Characteristics

              Number of studies

              Study country

               

               USA

              8

               The Netherlands

              2

               Japan

              2

               Ireland

              1

               Italy

              1

               Sweden

              1

              Study design

               

               RCT

              11

               Cohort

              2

               Before and After

              2

              Type of economic evaluation

               

               Cost-consequences analysis

              12

               Cost-utility analysis

              2

               Cost-benefit analysis

              1

              Disease type

               

               Geriatrics

              4

               Cancer

              2

               Heart failure

              2

               Terminal/critical illness

              2

               Various

              2

               Mental health

              1

               Rheumatoid arthritis

              1

               Stroke

              1

              Study perspective

               

               Health care payer

              12

               Societal

              3

              Care setting*

               

               Inpatient

              8

               Outpatient

              8

              Type of decisions

               

               Treatment/care plan

              11

               Diagnosis and treatment/care plan

              4

              * 1 study had both inpatient and outpatient care.

              Methodological quality assessment

              Only four of the nineteen criteria (i.e. research question posed in answerable form, appropriate economic study design, appropriate time horizon, and identification of important and relevant outcomes) were met by all the studies (Table 3). The choice of an appropriate time horizon is one of the six CHEC-list criteria that are regarded as important in assessing risk of bias [31]. None of the other five criteria were fulfilled by all the studies. In particular, the criteria of appropriate valuation of costs and appropriate discounting of future costs were met by very few studies – four and two respectively. The reasons for a high number of studies not meeting the criterion of appropriate valuation of costs were either a lack of information on the method of valuation, the reference year, or the use of a top-down approach in the apportionment of costs a. There were four studies in the review that should have discounted future costs and outcomes because their analytic horizon was more than a year. However, only two [42, 43] stated that discounting was undertaken in the analysis. Therefore, given that five of the six criteria that had an impact on the assessment of risk of bias were not met by all studies, there is a relatively high risk of bias in the results of the reviewed studies.
              Table 3

              Number of studies fulfilling each Consensus on Health Economic Criteria (CHEC-list) quality criterion

              CHEC-list quality criteria

              Number of studies fulfilling criterion

              1. Is the study population clearly described?

              12

              2. Are competing alternatives clearly described?

              14

              3. Is a well-defined research question posed in answerable form?

              15

              4. Is the economic study design appropriate to the stated objective?

              15

              5. Is the chosen time horizon appropriate in order to include relevant costs and consequences?

              15

              6. Is the actual perspective chosen appropriate?

              3

              7. Are all important and relevant costs for each alternative identified?

              0

              8. Are all costs measured appropriately in physical units?

              11

              9. Are costs valued appropriately?

              4

              10. Are all important and relevant outcomes for each alternative identified?

              15

              11. Are all outcomes measured appropriately?

              13

              12. Are outcomes valued appropriately?

              13

              13. Is an incremental analysis of costs and outcomes of alternatives performed?

              3

              14. Are all future costs and outcomes discounted appropriately?

              2

              15. Are all important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?

              3

              16. Do the conclusions follow from the data reported?

              9

              17. Does the study discuss the generalizability of the results to other settings and patient/client groups?

              2

              18. Does the article indicate there is no potential conflict of interest of study researcher(s) and funder(s)?

              4

              19. Are ethical and distributional issues discussed appropriately?

              0

              Characteristics of MDT meetings

              The amount of detail provided about MDT meetings varied. Twelve papers reported the frequency of meetings which varied from daily to once every three months (Table 4). The average number of disciplines in each MDT was 5 ranging from 2 to 9. Only one study stated the venue of the MDT meeting [44]. Five of the studies gave details of who led the meetings. No information was provided in any study about the amount of administrative support required for an MDT meeting. Finally, 11 reported how the MDT decisions were disseminated.
              Table 4

              Characteristics of MDT meeting

              Study

              Frequency of meeting

              Number of disciplines

              Meeting venue

              Leadership

              Administration support

              Dissemination of decision

              Collard et al., 1985

              Twice a week

              6

              Not stated

              Not stated

              Not stated

              Not stated

              Williams et al., 1987

              Daily

              6

              Outpatient clinic

              Not stated

              Not stated

              Care plan

              Timpka et al., 1997

              Weekly

              3

              Not stated

              Physicians

              Not stated

              Not stated

              Fader et al., 1999

              Biweekly

              9

              Not stated

              Not stated

              Not stated

              Treatment plan

              Kominski et al., 2001

              At least once every 3 months

              8

              Not stated

              Not stated

              Not stated

              Treatment plan

              Capomolla et al., 2002

              Not stated

              6

              Not stated

              Not stated

              Not stated

              A report

              Kasper et al., 2002

              Weekly

              3

              Not stated

              Not stated

              Not stated

              Treatment plan

              Carling et al., 2003

              Not stated

              2

              Not stated

              Infectious disease physician

              Not stated

              Pro forma placed in front of patient’s chart

              Van Den Hout et al., 2003

              Weekly

              5

              Not stated

              Not stated

              Not stated

              Not stated

              Rabow et al., 2004

              Regularly

              8

              Not stated

              Team Physician

              Not stated

              Care plan

              Yagura et al., 2005

              Weekly

              7

              Not stated

              Not stated

              Not stated

              Discharge plan

              Gade et al., 2008

              Daily

              4

              Not stated

              Not stated

              Not stated

              Palliative care plan

              Wolfs et al., 2009

              Weekly

              6

              Not stated

              Not stated

              Not stated

              Care plan

              Hagiwara et al., 2011

              Twice per week

              4

              Not stated

              Hemato-oncologist

              Not stated

              Care plan

              Pope et al., 2011

              Not stated

              3

              Not stated

              Modified Delphi method

              Not stated

              Not stated

              RCTs assessing cost-effectiveness of MDTs in non-cancer care

              There were 11 RCTs that reported full economic evaluations of MDT care (Table 5). Four evaluated geriatric care, and the results were mixed. One RCT found that MDT directed care resulted in lower costs as well as improvement in some outcome measures. This study included two sites, and it was found that for one of the sites, total costs were lower by approximately 15%, and there were fewer complications during hospitalisation (between 3 to 12 fewer for different types of complications) [34]. However, two other RCTs of geriatric care concluded that there was no evidence of differences in costs or outcomes between MDT and no MDT care [39, 44]. The fourth RCT in geriatric care showed that MDT care was associated with higher costs because the cost of implementing MDT care b for 6 months offset the reduction in medication costs, but there was no evidence of differences in functional status and survival between the two groups [40].
              Table 5

              Details of included studies (n = 15)

              Authors, date, and country

              MDT team composition

              Patient group or disease; sample size

              Study design; type of economic evaluation

              Comparison group

              Outcome measures

              Costs included

              Findings

              RCTs assessing cost-effectiveness of MDTs in non-cancer care

              Geriatric care

              Collard et al., 1985, [34] USA

              Primary nurse, social worker, physician, physical therapist, occupational therapist, medical director

              Geriatric patients; treatment = 218, control = 477

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              Health status, complications during hospitalisation, use of physical/chemical restraints at 5 months

              Hospitalisation

              Incremental costs of MDT – lower by US$564 (£350) per person

              Morbidity –better for MDT group

              Mortality – not measured

              Cost per QALY: not calculated

              Williams et al., 1987, [44] USA

              internists and family physicians with special expertise in geriatrics, psychiatrists, nurses, social workers, nutritionists

              Geriatric patients; treatment = 58, controls = 59

              RCT; cost-consequences analysis

              Care by 1 internist

              Functional status, institutional placement at 12 months

              Hospitalisation, nursing home, home aid, transportation, GP visit, day centre, visits by various health professionals, meals-on-wheels, nurse & homemaker hours

              Incremental costs of MDT – equivalent

              Morbidity – equivalent

              Mortality – not measured

              Cost per QALY: not calculated

              Kominski et al., 2001, [39] USA

              Nurses, psychiatrists, psychologists, social workers, geriatricians, nutritionists, pharmacists

              Geriatric patients; treatment = 814, usual care = 873

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              36-item Health Survey Short Form (SF-36), Mental Health Inventory (MHI) at 12 months

              Inpatient, ambulatory care clinic

              Incremental costs of MDT – equivalent

              Morbidity – equivalent

              Mortality – not measured

              Cost per QALY: not calculated

              Pope et al., 2011, [40] Ireland

              Consultant geriatrician, specialist registrar in geriatric medicine, pharmacists, nurse practitioners

              Geriatric patients; treatment = 110, control = 115

              RCT; cost-consequences analysis

              Regular assessment i.e. no MDT

              Mortality, Barthel Index, Abbreviated Mental Test Score (AMTS) at 6 months

              Medical review, medication, acute hospital transfer

              Incremental costs of MDT – higher by £510 per person

              Morbidity – equivalent

              Mortality – equivalent

              Cost per QALY: not calculated

              Heart failure care

              Capomolla et al., 2002, [32] Italy

              cardiologist, nurses, physiotherapists; part-time participation of dietician, psychologist, social assistant

              Heart failure; treatment =112; control = 122

              RCT; cost-utility analysis

              Usual care by cardiologist

              Death, QALY at 12 months

              Pharmacologic, care management

              Incremental costs of MDT – lower by US$10,768 (£6,688) per person

              Morbidity – better for the MDT group

              Mortality – lower for MDT group

              Cost per QALY: US$1,068 (£663)

              Kasper et al., 2002, [38] USA

              Telephone nurse co-ordinator, CHF nurse, CHF cardiologist, patient’s primary physician

              heart failure; treatment = 102, control = 98

              RCT; cost-consequences analysis

              Care provided by GP only

              Death, quality of life (QoL) at 6 months

              Personnel, inpatient, outpatient pharmacy, supplies

              Incremental costs of MDT – equivalent

              Morbidity – better for the MDT group

              Mortality – equivalent

              Cost per QALY: not calculated

              Terminal/critical care

              Rabow et al., 2004, [41] USA

              Social worker, nurse, chaplain, pharmacist, psychologist, art therapist, volunteer coordinator, physician

              Life limiting diseases such as cancer, advanced COPD, or advanced CHF; treatment = 50, control = 40

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              Physical functioning and symptoms, psychological, spiritual well-being at 6 months and 12 months

              Office visits, emergency department visits, hospital stays

              Incremental costs of MDT - equivalent

              Morbidity – better for MDT group

              Mortality – not calculated

              Cost per QALY: not calculated

              Gade et al., 2008, [36] USA

              Palliative care physician, nurse, hospital social worker and chaplain

              A range of life-limiting diseases such as COPD, stroke, cancer; treatment = 280, control = 237

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              Symptom severity, quality of life and survival at 6 months

              Hospitalisation, pharmacologic, study

              Incremental costs of MDT – lower by US$4,855 (£3,016) per patient

              Morbidity – equivalent

              Mortality – equivalent

              Cost per QALY: not calculated

              Rheumatoid arthritis care, stroke care, dementia care

              Van den Hout et al., 2003, [43] The Netherlands

              Nurse, rheumatologist occupational therapist, physical therapist, social worker.

              Rheumatoid arthritis; treatment = 71 (inpatient MDT), 68 (outpatient MDT) control = 71

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              Functional status, quality of life at 6, 12, 26, 52, and 104 weeks

              Hospitalisations, personnel, home nursing care, other health professionals drugs, and appliances, out of pocket, home care informal care, paid and unpaid labour

              Incremental costs of MDT –higher by €5,160 to €10,876 (£4,230 to £8,915) per person

              Morbidity – equivalent

              Mortality – not measured

              Cost per QALY: not calculated

              Yagura et al., 2005, [46] Japan

              Physicians, nurses, physical therapists, occupational therapists, speech therapists, clinical psychologists, social worker

              Stroke; treatment = 91, control = 87

              RCT; cost-consequences analysis

              Usual care i.e. no MDT

              Functional status, impairment status (duration of measurement not stated)

              Hospitalisation

              Incremental costs of MDT –equivalent

              Morbidity – equivalent

              Mortality – not measured

              Cost per QALY: not calculated

              Wolfs et al., 2009, [45] The Netherlands

              Old age psychiatry, geriatric medicine, neuropsychology, physiotherapy, occupational therapy, geriatric nursing and mental health nursing

              Patients suspected of having dementia or a cognitive disorder; treatment = 131, control = 88

              RCT; cost-utility analysis

              Usual care i.e. no MDT

              QALYs, cognition and behavioural problems at 6 months and 12 months

              Medical, informal care, out-of-pocket

              Incremental costs of MDT – higher by €65 (£53) per person

              Morbidity – better for MDT group

              Mortality – not measured

              Cost per QALY: €1,267 (£1,039)

              Other study designs assessing cost-effectiveness of MDTs in non-cancer care

              Timpka et al., 1997, [42] Sweden

              Part-time physicians, psychologist, social workers

              Patients with chronic minor diseases and long-term absence from working life; 239

              Cohort; cost-benefit analysis

              baseline characteristics before start of programme

              Vocational activity, benefits to society at 12 months and 5 years

              Programme, indirect

              Costs – 30,000 SEK (£2,852) per person

              Benefits – 1.25 million SEK (£117,500) per person

              Cost-benefit ratio – 4.9

              Carling et al., 2003, [33] USA

              Clinical pharmacist, infectious diseases physician

              Adults receiving parenteral 3rd generation cephalosporins, aztreonam, parenteral fluoroquinolones, or imipenem; sample size not specified

              B&A; cost-consequences analysis

              Before MDT implemented

              Incidence of nosocomial infections per 1000 patient-days

              Medication

              Incremental costs of MDT – lower by US$200,000 to US$250,000 per year (£124,224 to £155,280)

              Morbidity – better for MDT group

              Mortality – not measured

              Cost per QALY: not calculated

              Studies assessing cost-effectiveness of MDT in cancer care

              Fader et al., 1998, [35] USA

              specialists in dermatology; surgical, medical, & radiation oncology; plastic & dermatologic surgery; otorhinolaryngology; obstetrics/gynecology; ophthalmology, dermatopathology; nuclear medicine; and social work

              Melanoma; treatment = 104, control = 104

              Cohort; cost-consequences analysis

              Usual care i.e. no MDT

              Surgical morbidity at 1 month, survival at 5 years

              Diagnosis and initial management

              Incremental costs of MDT – lower by US$1,595 (£991) per person

              Morbidity – equivalent

              Mortality – equivalent

              Cost per QALY: not calculated

              Hagiwara et al., 2011, [37] Japan

              Hemato-oncologist, nurse, dietitian, pharmacist

              Hematologic malignancies; Before – 67, After – 102

              B&A; cost-consequences analysis

              No MDT

              Number of adverse events, death (duration of measurement not stated)

              Parenteral nutrition, antibiotics, food and nutritional supplement, MDT personnel

              Incremental costs of MDT – lower by 403,600 yen (£3,058) per person

              Morbidity – better for MDT group

              Mortality – equivalent

                     

              Cost per QALY: not calculated

              B&A before and after, CHF chronic heart failure, RCT randomised controlled trial.

              Similarly, there were inconsistent results from two RCTs of MDT care for patients suffering from heart failure. One of them found that MDT care was cost-effective with an incremental cost-effectiveness ratio of US$1,068 per Quality Adjusted Life Year (QALY) (£663/QALY, £1 = US$1.61, rate as at 20 April 2012) [32]. However, the other RCT showed that there was no evidence of a real cost difference but quality of life improved when comparing MDT and no-MDT care [38].

              Two RCTs evaluated MDT care amongst patients with terminal conditions; the results were mixed. One reported that costs were lower for the MDT group by about 30%, but there was no evidence of any differences in measures of symptom control, survival, and quality of life between the MDT and no MDT groups [36]. In contrast, the other study showed that there was no evidence of a real cost difference but some outcome measures such as dyspnea, anxiety, spiritual well-being, improved when comparing MDT and no-MDT care [41].

              The last three RCTs, each of people with a different disease, also showed varied results. One study relating to patients with mental health problems found that MDT care was cost-effective with an incremental cost effectiveness ratio of €1,267/QALY (£1,039/QALY, £1 = €1.22, rate as at 20 April 2012) [45]. However, a RCT concerning stroke patients concluded that there was no evidence of real cost or outcome measures differences [46]. Furthermore, in a study that investigated the impact of MDT care versus no MDT care among patients diagnosed with rheumatoid arthritis, there was no evidence of differences in outcome measures but costs were higher in the MDT care group by approximately 30% to 50% [43].

              Other study designs assessing cost-effectiveness of MDTs in non-cancer care

              A prospective cohort study based in Sweden which considered the effect of MDT on vocational activity among patients with chronic minor diseases and long-term absence from working life, reported a total discounted cost of 7.2 million SEK (£684,410, £1 = 10.52 SEK, rate as at 20 April 2012), total benefits of 35.1 million SEK (£3.3 million), and hence, a positive cost-benefit ratio of 4.9 [42]. No estimate for cost per person was provided. In addition, a ‘before and after’ study found that the rate of infection per 1000 patient days after the implementation of MDT antibiotic management care fell by between 25% to 70% and costs decreased by about 30% [33].

              Studies assessing cost-effectiveness of MDTs in cancer care

              There were two non-randomised studies that reported results of MDTs in cancer care (Table 5). In a retrospective cohort study of MDT versus no MDT care for patients with malignant melanoma, the costs of health care were 33% to 50% lower in patients whose management decisions were made by an MDT [35]. However, there was no evidence of any differences in wound complication and 5-year survival rates. Hagiwara et al. (2011) [37] reported clinical outcomes before and after the introduction of a multidisciplinary nutritional team for patients with haematologic malignancies. It was found that incidences of hepatic complications, hyperglycemia, and central venous catheter infection were lower in the ‘after’ group than in the ‘before’ group, and costs fell by about 20%.

              Discussion

              Summary of findings

              We identified fifteen primary studies on the cost-effectiveness of MDT decision making in secondary care, of which only two concerned cancer and the others covered a wide range of disease types. The characteristics of MDT meetings were diverse. The existing evidence was limited and there was a relatively high risk of bias amongst the studies. Whilst both studies relating to cancer care showed that MDTs were associated with lower costs and better outcomes or outcomes comparable to no MDT care, neither study was a RCT. The results from eleven RCTs assessing the cost-effectiveness of MDTs in non-cancer care were very varied. Only three of these showed that MDT working in secondary care had a positive effect on outcomes and costs. However, the degree of this positive impact varied. Moreover, the positive impact of MDT on some costs components might be offset by the full cost of administering, preparing for and attending an MDT meeting, for which no estimates were reported in the included studies. Therefore, based on existing evidence, it is not possible to determine if MDT working is cost-effective or not in secondary cancer and non-cancer care.

              Strengths and weaknesses of this systematic review

              To our knowledge, we conducted the first systematic review on the cost-effectiveness of MDT working in secondary care, and we explicitly attempted to capture all types of costs, especially the significant costs of supporting MDT working. The limitations of this review need to be borne in mind. Firstly, as with any systematic review, publication bias might be a problem if studies with null findings have not been published. Secondly, this review was not restricted to a particular country or disease type. While this approach is valuable in describing the available evidence from a wide perspective, it restricts the comparability across studies. Given that the studies were diverse, particularly in the type of care offered in the comparison groups, the findings may not be applicable across different healthcare settings where different clinical practices and geographical constraints operate. The operationalising of MDT may also differ in different settings and together with the variability in reporting, there may be studies that have been conceived as MDT, but based on our interpretation, were not. However, we tried to be inclusive in our definition of MDT working so that we did not exclude potentially relevant studies.

              Weaknesses of the evidence

              We have identified four key weaknesses in the existing literature on the cost-effectiveness of MDT working. First, there was no standard definition or operationalisation of MDT working evident in the literature. Most studies did not provide key details of the MDT meeting venue, leadership (i.e. who leads the meeting and or how are decisions made), or administrative support. Without a common definition or clear description of MDTs, it was difficult to compare results between studies or draw conclusions on the cost-effectiveness of MDT decision making. Second, the full costs of administering, preparing for and attending an MDT meeting were not estimated in the included studies. Given that the MDT meeting is a key feature of MDT working, the omission of the associated costs in any cost-effectiveness analysis of MDT could lead to an underestimation of costs, and hence bias in the results. Third, the methodological quality assessment has demonstrated that there was a relatively high risk of bias amongst the studies. This meant that the reliability and reproducibility of the included studies were compromised, and the ability to determine conclusions from our systematic review was restricted. Fourth, the available evidence was limited so that it was not possible to draw firm conclusions as to whether MDT working in cancer or non-cancer care would lead to cost-effective care or not.

              Comparison with other studies

              In their review to determine the critical elements of effective team-working in patient care teams, Bosch et al. [47] concluded that current literature provided little insight into the underlying mechanisms. They reported results relating to costs and resource utilisation but not on cost-effectiveness of MDTs. In comparison, our systematic review focused specifically on full economic evaluations of MDT working, and sought to include studies that estimated the costs of supporting MDT working. In another review examining the association between cancer MDTs and survival, the authors also highlighted the lack of a consistent definition of MDT [21]. This directly hampers any investigation of its effectiveness and costs. While none of the included studies in this review had accounted for the full costs of administering, preparing for and attending an MDT meeting, an audit conducted at a large teaching hospital/cancer centre estimated the average annual cost of MDTs in salaries alone was about £1 million [48]. Time spent preparing for MDT meetings could be considerable. A study examining the participation of pathologists and radiologists in MDT meetings found that the former spent about an average of 2.4 hours, and the latter 2 hours in preparation [49]. Although our review did not find evidence that MDT working is cost-effective in cancer care, there appears to be a growing consensus that telemedicine delivered MDT cancer meetings are more cost-effective than ‘in-person’ meetings [5053].

              Future research

              Based on the findings of our systematic review, we propose that three issues need to be addressed in future research in this area. Firstly, future research should ensure a clear definition of MDT working and detailed reporting of its characteristics. In our systematic review, we found that the description of the two key features of MDT working was so vague that it was difficult to determine whether MDT working had taken place or not. We recommend that studies should provide the characteristics of the MDT meeting as shown in Table 4. Secondly, it is essential to estimate the full costs of administering, preparing for and attending an MDT meeting. Such attempts should take into account two issues. One, all relevant costs should be identified. We recommend that the following costs should be accounted for: time spent by each team member in preparing for the MDT meeting and this should include time spent by team coordinator in providing administrative support to the MDT meeting, time spent on travelling to and from meetings by any team member who is located on a different site than the meeting venue, costs of using tele-conferencing if applicable, and time spent by each member at each meeting. Two, these costs should be measured as accurately as possible. The standard methods used in health services research for workflow assessments are work sampling, time efficiency, and time-and-motion. The first two methods are less resource intensive as compared to the third method but there is evidence to show that the time-and-motion technique may produce the most accurate results [5456]. Thirdly, it remains unclear what models of MDT are cost-effective in secondary care. Therefore, future studies using strong study designs should compare the cost-effectiveness of different models or aspects of MDT working c. For this to be performed accurately there is a need for agreement in the clinical community about which outcomes would be core in the evaluation of MDT working. Whilst some clinical outcomes are important, the inclusion of patient-centred outcomes and satisfaction of health professionals as well as assessment of the quality of decision-making and MDT decision-implementation may also be important [2, 57, 58].

              Policy implications

              Without further research that addresses the three key issues highlighted in the previous section, it would be hard to make firm policy recommendations. The cost-effectiveness of MDT working in secondary care is likely to vary according to many factors, such as cost of supporting MDT working, disease type, treatment selected, and geographical location. The costs of supporting MDT working are directly linked to factors that affect management decisions of MDTs, such as inclusion of time to prepare for MDTs into team-members’ job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel [59]. The commitment of resources to these factors will differ across settings. Therefore, it is likely that there is no ‘one-size-fits-all’ model of MDT working to suit all diseases, treatment modalities and locations.

              Conclusion

              The widespread adoption of MDT working in cancer and non-cancer care has occurred despite a lack of evidence on cost-effectiveness. The available evidence is limited and at relatively high risk of bias. It is not possible to determine if MDT working in cancer and non-cancer care is cost-effective or not. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective care, and the costs of supporting MDT working are required.

              Endnotes

              a Costs can be derived by a bottom-up or top-down approach. In a bottom-up approach, costs are determined by examining individual utilisation. In a top-down approach, costs are apportioned across individuals, and this may be less accurate due to questionable assumptions used in the apportionment of costs.

              b Personal communication with the lead author has confirmed that these costs did not include the full costs of administering, preparing for and attending an MDT meeting.

              c As MDT working is now so prevalent in secondary care, especially cancer care, it might not be possible to compare the cost-effectiveness of no-MDT versus MDT working.

              Appendix 1

              Search Strategy

              EMBASE

              #1. multidisciplinary OR “multidisciplinary team” OR interdisciplinary OR “interdisciplinary team” OR team* OR “patient care team” OR “health care team*” OR “medical care team”

              #2. “cost savings” OR “cost-effective*” OR “cost-benefit” OR “cost-utility” OR “economic evaluation” OR economic* OR “cost analysis” OR “health care costs”

              #3. hospital or “hospital setting” OR “hospital based” OR “secondary care”

              #4. #1 AND #2 AND #3

              #5. limit to (human and English language) AND (article)

              MEDLINE (MeSH terms used)

              #1. (Patient Care Team)

              #2. ((Costs and Cost Analysis) OR (Economic*) OR (Cost-Benefit Analysis) OR (Cost Savings) OR (Health Care Costs) OR (Cost of Illness) OR (Health Services Accessibility) OR (Patient Transfer) OR (Travel) OR (Transportation of Patients)

              #3. #1 AND #2

              #4. limit #3 to (English language and humans)

              NHS EED

              (multidisciplinary OR “multidisciplinary team*” OR interdisciplinary OR “interdisciplinary health team*” OR team* OR “patient care team*” OR “health care team*” OR “medical care team*”) (english:la)

              CINAHL

              #1. multidisciplinary OR “multidisciplinary team*” OR interdisciplinary OR “interdisciplinary health team*” OR team* OR “patient care team*” OR “health care team*” OR “medical care team*”

              #2. “cost savings” OR “cost-effective*” OR “cost-benefit” OR “cost-utility” OR “economic evaluation” OR economic* OR “cost analysis” OR ‘health care costs’ OR access* OR travel OR burden

              #3. #1 AND #2

              #4. limit to English Language; Peer Reviewed; Research Article; Exclude MEDLINE records.

              EconLit

              #1. multidisciplinary OR “multidisciplinary team*” OR interdisciplinary OR “interdisciplinary health team*” OR team* OR “patient care team*” OR “health care team*” OR “medical care team*”

              #2. “cost savings” OR “cost-effective*” OR “cost-benefit” OR “cost-utility” OR “economic evaluation” OR economic* OR “cost analysis” OR ‘health care costs’ OR access* OR travel OR burden

              #3. #1 AND #2

              #4 limit to (English language) AND (article or conference paper)

              Cochrane Library

              multidisciplinary OR “multidisciplinary team*” OR interdisciplinary OR “interdisciplinary health team*” OR team* OR “patient care team*” OR “health care team*” OR “medical care team*” in Title, Abstract or Keyword and “cost savings” OR “cost-effective*” OR “cost-benefit” OR “cost-utility” OR “economic evaluation” OR economic* OR “cost analysis” OR ‘health care costs’ OR access* OR travel OR burden in in Title, Abstract or Keyword

              NHS HMIC

              (multidisciplinary OR “multidisciplinary team*” OR interdisciplinary OR “interdisciplinary health team*” OR team* OR “patient care team*” OR “health care team*” OR “medical care team*”) (english:la)

              Declarations

              Acknowledgements

              This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0707-10034). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

              Authors’ Affiliations

              (1)
              School of Oral and Dental Sciences, University of Bristol
              (2)
              School of Social and Community Medicine, University of Bristol
              (3)
              University Hospitals Bristol NHS Foundation Trust

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              Copyright

              © Ke et al.; licensee BioMed Central Ltd. 2013

              This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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