Sax Institute, Haymarket, Australia.
School of Public Health, University of Sydney, Camperdown, Australia.
Implement Sci. 2018 Mar 12;13(1):43. doi: 10.1186/s13012-018-0733-x.
This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations.
Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability.
Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%).
The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.
Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.
本研究评估了以多学科团队（MDT）为中心的理论概念化的定制干预措施是否能增加临床医生的转诊行为，使其符合临床实践指南的建议。
澳大利亚新南威尔士州（NSW）的 9 个医院参与了这项实用的阶梯式楔形、聚类随机实施试验，这些医院拥有泌尿科 MDT，并参与了全州性的泌尿科临床网络。干预策略包括病理学家、临床领导、教育、个人和研究站点实践的审核和反馈来标记高危患者。主要结局是前列腺切除术后 4 个月内转至放射肿瘤学的患者比例。次要结局为术后 4 个月内讨论 MDT 会议的患者比例；在 6 个月内咨询放射肿瘤学家的患者比例；以及在 6 个月内开始放射治疗的患者比例。在干预前后，调查了泌尿科医生对辅助放疗的态度。一项过程评估衡量了干预的一致性、对干预措施的反应以及影响实施和可持续性的背景因素。
对 37 名泌尿科医生进行的 1071 例高危前列腺切除术后患者的记录进行了回顾：505 例为对照期；407 例为干预期。MDT 会议讨论的患者比例从对照期的 17%增加到干预期的 59%（调整后的 RR=4.32；95%CI [2.40 至 7.75]；p<0·001）。调整后，放射肿瘤学转诊无显著差异（干预组 32%，对照组 30%；调整后的 RR=1.06；95%CI [0.74 至 1.51]；p=0.879）。MDT 讨论比例增加幅度最大的站点往往也有更大的转诊增加（p=0·001）。在干预阶段，MDT 建议转诊的患者中，泌尿科医生未能为超过一半的患者提供转诊（140 例中有 78 例；56%）。
干预措施显著增加了 MDT 讨论的患者数量。然而，MDT 的建议并未得到统一记录或遵循。尽管 MDT 之间的实践差异很大，但干预措施并没有导致转诊率的显著总体变化，这可能反映出泌尿科医生态度没有改变。我们的结果表明，关注能够实现卫生系统层面改变的结构和过程的干预措施，而不是关注个人层面改变的干预措施，可能会产生最大的效果。
澳大利亚新西兰临床试验注册（ANZCTR）：ACTRN12611001251910。2011 年 12 月 6 日注册。
