BACKGROUND

Multidisciplinary care is universally recommended as a key strategy for improving complex health care delivery. The scarcity of high-quality evidence to support its impact and its potential disruption of existing care delivery infrastructure and relationships inhibit wide implementation. We implemented a multidisciplinary clinic (MDC) in a specific, dedicated physical space with concurrent participation of key specialty providers (colocated) within a community-based, nonacademic health care system and evaluated its impact on the processes and outcomes of lung cancer care.

OBJECTIVES

1. Evaluate the pros and cons of concurrent specialist (multidisciplinary) vs usual, sequential referral-based or serial care (SC) for lung cancer from multiple stakeholder perspectives, identify barriers to multidisciplinary program implementation, and elicit stakeholder-centric benchmarks for program evaluation. 2. Implement a rigorously benchmarked colocated MDC. 3. Conduct a prospective comparative effectiveness study of MDC vs SC for lung cancer.

METHODS

1. Focus groups of lung cancer care stakeholders. 2. Benchmarked program implementation and process engineering. 3. Prospective cohort study with surveys of patients and caregivers, measurement of quality of staging, and appropriateness of care and survival.

RESULTS

. Through 21 focus groups of patients, caregivers, physicians, nurses, health care system executives, and insurance company executives, we found that patients and their caregivers were highly in favor of the multidisciplinary concept, whereas providers, administrators, and payers expressed reservations about threats to practice autonomy and efficient use of time, lack of adequate evidence of benefit, and absence of validated benchmarks of multidisciplinary care. Recommended benchmarks included measures of the quality of communication, measures of levels of patient and caregiver satisfaction, and attainment of care quality benchmarks. . We successfully implemented a colocated MDC with attainment of prespecified stakeholder-recommended performance benchmarks, with good reach across the spectrum of demographics and disease characteristics of patients with lung cancer. We demonstrated the ability to administer questionnaires to patients and caregivers and achieve our target rate of concordance between recommended and actual care of >85%; we verified timely communication of key clinical information to patients/caregivers and their physicians in >90% of cases. . We enrolled 178 patients in the MDC arm and 348 patients in the SC arm of the trial. In the SC arm, 76 patients (22%) had recommendations for care through a Multidisciplinary Thoracic Oncology Conference (MTOC), which was available to any provider and in which all MDC patients were presented. The MTOC subgroup allowed a secondary analysis of care and outcomes between 2 models of multidisciplinary care. After a median 18 months of follow-up, we found no difference in overall survival between MDC and SC patients (adjusted hazard ratio [HR] 1.22; 95% CI,0.92-1.63]). The quality of care for MDC patients was better than the SC patients. Staging was more thorough in the MDC cohort, with odds ratios for invasive stage confirmation, mediastinal nodal stage confirmation, bimodality, and trimodality staging of 2.03 (95% CI, 1.35-3.06; = .007), 1.87 (95% CI, 1.25-2.80; = .002), 3.12 (95% CI, 1.67-5.85; = .0004), and 2.25 (95% CI, 1.50-3.36; < .0001), respectively. Guideline concordant treatment use was higher in the MDC cohort, with an odds ratio (OR) of 1.84 (95% CI, 1.14-2.98; = .013). Although the time from lesion detection to diagnostic biopsy (25 vs 15 days for MDC and SC patients, respectively; = .004) or invasive staging (29 [MDC] vs 20 days [SC]; = .007) was higher in the MDC cohort, we found only a slight, statistically insignificant difference in time to definitive treatment (60 [MDC] vs 57 days [SC]; = .06) The trend toward more timely receipt of definitive treatment in the SC arm than those in the MDC arm was attributable to less use of guideline-recommended staging. MDC patients and their caregivers reported greater satisfaction with the combined quality of care received from all team members than SC patients (15.70 vs 14.18; < .0001) at 6 months. Survival data are immature but reveal no differences between groups.

CONCLUSIONS

1. Implementation of MDC was successful in a community health care system. 2. The MDC patients had better-quality lung cancer care, with significantly more thorough staging and higher rates of stage-appropriate treatment. 3. Surveys of patients and caregivers revealed greater satisfaction with overall care and the timeliness of care in the MDC arm than the SC arm.

LIMITATIONS AND SUBPOPULATION CONSIDERATIONS

This was a nonrandomized trial in a single health care system. MTOC and colocated MDC outcomes were similar.