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Invited Commentary
Health Policy
May 5, 2020

The Role Of Multidisciplinary Team Comanagement of the Surgical Patient—It Takes A Village

Author Affiliations
  • 1Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
  • 2Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
JAMA Netw Open. 2020;3(5):e204354. doi:10.1001/jamanetworkopen.2020.4354

Shaw et al1 report a systematic review and meta-analysis of 14 studies, including 35 800 adults undergoing surgery, in which they investigated the association of preplanned internal medicine (IM) physician involvement (with 13 142 participants in intervention groups) with length of stay, mortality, and readmissions compared with standard surgical care (with 22 658 participant in control groups). The authors found studies from various subspecialties with IM physician (hospitalist or internist) comanagement, including orthopedic surgery, neurosurgery, vascular surgery, colorectal surgery, thoracic surgery, ophthalmology, otolaryngology, and trauma surgery. There was no association of IM comanagement with adjusted length of stay (adjusted mean difference, −0.05 days; 95% CI, −0.84 to 0.74 days; P = .90). Similarly, there was no association of IM physician comanagement with mortality (odds ratio, 0.79; 95% CI, 0.56 to 1.11; P = .18) or readmissions (odds ratio, 0.89; 95% CI, 0.68 to 1.16; P = .39). However, there was significant statistical between-study heterogeneity for all outcomes. The authors further looked at the intervention characteristics and found wide variability in terms of patient selection, rounding, IM physician availability, use of standardized order sets, preoperative screening, and division of labor between surgical and medical teams. These findings and the lack of randomized trials in the analysis suggest low quality of evidence for this finding and highlight the need for more rigorous higher-quality prospective studies to be conducted with well-defined comanagement protocols for patients undergoing surgery and detailed capture of structure and process indicators for these comanagement interventions.

Interestingly, in a subgroup analysis, the authors found that, compared with the physician-only model, the physician-led multidisciplinary team (MDT) model, which appeared in 7 studies, was associated with significantly reduced postoperative mortality (odds ratio, 0.67 [95% CI, 0.51 to 0.88]; P = .004 vs odds ratio, 0.98 [95% CI, 0.40 to 2.41]; P = .96) and length of stay (mean difference, −2.03 [95% CI, −4.05 to −0.01] days; P = .05 vs mean difference, 0.21 [95% CI, −1.05 to 1.48] days; P = .74).1 While the roles of other members in these MDT studies were not clear from the study, the findings provide compelling evidence to suggest the importance of integrated surgical care models with experts from varied backgrounds. Two studies included MDT members from specialties such as family medicine, pharmacy, respiratory care, rehabilitation, social work, nutrition, or case management to improve outcomes.

There is evidence of multidisciplinary care models being effective in complex patients in practices such as oncology,2,3 wound care,4 and geriatrics.5 In these models, instead of patients seeking multiple specialists, experts come together in a structured manner to discuss the best course of action to improve clinical and quality outcomes while providing patient-centered care. The concept of a tumor board in the clinical workflow of oncology is considered best practice because it involves multiple stakeholders when delineating optimal treatment plans. Studies have shown that multidisciplinary review in tumor boards lead to change in diagnosis and management plans in 20% to 40% of patients2 and allow for the implementation of clinical practice guidelines.3 A 2020 systematic review4 showed that MDT models with a coordinated approach addressing glycemic control, local wound management, vascular disease, and infection for patients with diabetic foot ulcerations led to a significant reduction in amputations in 94% of studies. Geriatric literature5 shows that MDT models for older adults with chronic conditions lead to significantly improved quality, efficiency, and health-related outcomes of care. Therefore, it seems intuitive that MDT models would provide better outcomes in the comanagement of surgical cases.

The comanagement of surgical cases with internists and hospitalists was first adopted by orthopedic surgery, and evidence shows that geriatric comanagement of orthopedic patients older than 65 years results in greater functional improvement, reduced length of stay, and fewer complications.1 With an aging surgical population and an increasing number of surgical procedures, surgical safety for high-risk patients and patients with frailty has become paramount.6,7 The inclusion criteria for most of the studies in the review by Shaw et al1 were either being older than 65 years or having multiple comorbidities. Hence, further evaluation of MDT comanagement with long-term geriatric outcomes for surgery, including functional recovery, is an important area of investigation. The American College of Surgeons Geriatric Surgery Verification Program standards highly recommend interdisciplinary preoperative and postoperative care models to improve outcomes, suggesting that surgical teams need to make active and committed efforts to incorporate nutrition, rehabilitation, geriatrics, and palliative care in the care of the geriatric patient.8 Although Shaw et al1 focused on the postoperative involvement of IM physicians, there is immense potential to explore the role of comanagement in the preoperative period to inform prehabilitation and shared decision-making for older and frail patients. Furthermore, half the studies were orthopedic-based, and there is a need to improve the involvement of comanagement in other subspecialties for high-risk patients.

Careful planning is essential to develop protocols before the initiation of MDT programs and to study the effectiveness of such interventions. Comanagement is a partnership and demands taking responsibility of the patients’ well-being. It must be noted that it is not an opportunity to abdicate patient care to other members. Although Shaw et al1 described structure and process indicators, an in-depth exploration of the level and quality of involvement by medical specialists on MDTs is needed. Terms of engagement, roles, and checklists would be very useful to build a robust and successful structure. Furthermore, homogenous quality, process, and outcome measure indicators should be collected to monitor program results, implementation, and reproducibility.

The meta-analysis by Shaw et al1 provides encouraging evidence of the effectiveness of MDT models for care of patients undergoing surgery. Narrowing the focus of the intervention to high-risk older and frail patients undergoing surgery may provide a more homogenous study sample for future trials. Prospective randomized clinical trials are needed to test the effectiveness of an MDT intervention for patients undergoing surgery with a rigorous study of process and structure implementation measures.

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Article Information

Published: May 5, 2020. doi:10.1001/jamanetworkopen.2020.4354

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Kashikar A et al. JAMA Network Open.

Corresponding Author: Shipra Arya MD, SM, Division of Vascular Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Always M121-P, MC 5639, Stanford, CA 94305 (sarya1@stanford.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Shaw  M, Pelecanos  AM, Mudge  AM.  Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes: a systematic review and meta-analysis.   JAMA Netw Open. 2020;3(5):e204088. doi:10.1001/jamanetworkopen.2020.4088Google Scholar
2.
Thenappan  A, Halaweish  I, Mody  RJ,  et al.  Review at a multidisciplinary tumor board impacts critical management decisions of pediatric patients with cancer.   Pediatr Blood Cancer. 2017;64(2):254-258. doi:10.1002/pbc.26201PubMedGoogle ScholarCrossref
3.
El Saghir  NS, Keating  NL, Carlson  RW, Khoury  KE, Fallowfield  L.  Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide.   Am Soc Clin Oncol Educ Book. 2014:e461-e466. doi:10.14694/EdBook_AM.2014.34.e461Google Scholar
4.
Musuuza  J, Sutherland  BL, Kurter  S, Balasubramanian  P, Bartels  CM, Brennan  MB.  A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers.   J Vasc Surg. 2020;71(4):1433-1446.e3.PubMedGoogle ScholarCrossref
5.
Boult  C, Green  AF, Boult  LB, Pacala  JT, Snyder  C, Leff  B.  Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “Retooling for an Aging America” report.   J Am Geriatr Soc. 2009;57(12):2328-2337. doi:10.1111/j.1532-5415.2009.02571.xPubMedGoogle ScholarCrossref
6.
Arya  S, Varley  P, Youk  A,  et al.  Recalibration and external validation of the risk analysis index: a surgical frailty assessment tool.   Ann Surg. 2019. doi:10.1097/SLA.0000000000003276PubMedGoogle Scholar
7.
Shinall  MC  Jr, Arya  S, Youk  A,  et al.  Association of preoperative patient frailty and operative stress with postoperative mortality.   JAMA Surg. 2019:e194620. doi:10.1001/jamasurg.2019.4620PubMedGoogle Scholar
8.
Hornor  MA, Tang  VL, Berian  J,  et al.  Optimizing the feasibility and scalability of a geriatric surgery quality improvement initiative.   J Am Geriatr Soc. 2019;67(5):1074-1078.PubMedGoogle ScholarCrossref
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