Hypothesis / aims of study
Following the publication of the NICE guidelines in the management pelvic floor dysfunction, articles speculating the benefits and costs of local and regional multi-disciplinary teams have been circulating. The main rationale behind establishing regional MDTs is to provide an equal expert assessment to all patients and a broader range of management plans while removing dangers of traditional, focused and organ-specific approaches to managing complex cases. However, arguments have been made that MDTs are costly, time-consuming and may delay management and affect the efficacy of treatment. Despite these concerns, there has been no formal assessment of the impact of a regional MDT on patient management in urogynaecology. This study aims to evaluate the structure and impact of the Regional MDT on the management of women with pelvic floor dysfunction.
Study design, materials and methods
Throughout the existence of our Regional Continence MDT, between May 2010 and December 2015, 60 patients were discussed. Data on all 60 patients were collected and anonymised. Information gathered included time between referral, discussion, investigation and implementation of the management plan, patients’ presenting condition, reason for referral to MDT, pre and post-MDT management plans and treatment outcomes. The efficacy of the MDT was analysed by comparing the original recommendation by referring clinicians to the MDT recommendation and whether there was a clinical improvement.
The average age of patients discussed was 52.6 years (range 21-91). All meetings had at least a urogynaecologist, a gynecologist, a reconstructive urologist, a urodynamicist and on average 3 continence nurses, 4 physiotherapists, a clinical librarian, and the secretary. It took an average of 101.45 days between date of referral to MDT discussion, 263.55 days between MDT discussion to surgical treatment, 203.47 days between MDT discussion and results of recommended further investigations. The majority of the referrals dealt with Urinary Incontinence (n=34) and there were 8 patients who presented with mesh complications alongside other pelvic floor disorders. The MDT made changes to the original management plans in at least 25 (41.7%). 22 (36.7%) of all patients discussed were reported as cured or improved in their condition following MDT-recommended management.
Interpretation of results
The composition of our team largely matches NICE recommendations despite being established before the NICE publications in April 2019. It included all the team members recommended by NICE except the care of the elderly physician. This study demonstrates that Regional MDTs are both feasible and useful to patient care. The challenges ahead include resources, particularly administrative support and including time for MDT meetings in individual professional job plans. The presence of a clinical librarian provided access to the evidence-based support to address any scientific uncertainty, formulating research questions and conducting and circulating the literature search to the MDT members. The ‘clinical librarian initiative’ provided the principles upon which MDT participation of our librarian was established.
Our regional MDT was robust and has made a significant impact on the healthcare provided to women with complex urogynaecology and female urology conditions. The MDT recommended a change in the original management plan by the referring professional in 25 cases (41.7%). The conditions discussed by our group largely match the referral criteria recommended by NICE. The majority of women presented with either recurrent stress incontinence and/or mesh complications following continence surgery. Among 28 patients who required surgery, the MDT recommended alternative surgical treatment in 12 patients (42.9%). MDT meetings were also a gateway against more invasive testing including video urodynamics and UPPs.
Our experience with regional Urogynaecology MDT suggests that adequate administrative support is key in its success, as well as the appropriate allocation of time in job plans for healthcare professionals to be able to prepare, attend and act upon the actions of the MDT meetings. Regional MDTs offer excellent opportunities to train junior doctors to run MDT.
Following the NICE recommendation for regional MDT, our model could be used to draft a care pathway for a referral to regional MDTs. The size of MDT reflects the size of the catchment area it serves.