Implementation of a lung cancer multidisciplinary team standardised template for reporting to general practitioners: a mixed-method study.

OBJECTIVES: Few interventions have been designed that provide standardised information to primary care clinicians about the diagnostic and treatment recommendations resulting from cancer multidisciplinary team (MDT) (tumour board) meetings. This study aimed to develop, implement and evaluate a standardised template for lung cancer MDTs to provide clinical information and treatment recommendations to general practitioners (GPs). Specific objectives were to (1) evaluate template feasibility (acceptability, appropriateness and timeliness) with GPs and (2) document processes of preimplementation, implementation and evaluation within the MDT setting.
DESIGN: A mixed-method study design using structured interviews with GPs and qualitative documentation of project logs about implementation processes.
SETTING: Two hospitals in Central Sydney, New South Wales, Australia. PARTICIPANTS: 61 GPs evaluated the template. Two lung cancer MDTs, consisting of 33 clinicians, and eight researchers participated in template development and implementation strategy.
RESULTS: The MDT-reporting template appears to be a feasible way of providing clinical information to GPs following patient presentation at a lung cancer MDT meeting. Ninety-five per cent of GPs strongly agreed or agreed that the standardised template provided useful and relevant information, that it was received in a timely manner (90%) and that the information was easy to interpret and communicate to the patient (84%). Implementation process data show that the investment made in the preimplementation stage to integrate the template into standard work practices was a critical factor in successful implementation.
CONCLUSIONS: This study demonstrates that it is feasible to provide lung cancer MDT treatment recommendations to GPs through implementation of a standardised template. A simple intervention, such as a standardised template, can help to address quality gaps and ensure that timely information is communicated between tertiary and primary care healthcare providers. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

To the best of our knowledge, this is the first study to report on the implementation of a lung cancer multidisciplinary team standardised template for general practitioners.

The study highlights the importance of integrating the template into existing work practices to ensure uptake and longer term sustainability.

Implementation science frameworks are useful in guiding research efforts to integrate standardised templates into routine practice.

Limitations of conducting the study in two sites are acknowledged, as is the low response rate from general practitioners.

Introduction

Multidisciplinary care is considered the best practice in lung cancer management,1 2 providing a comprehensive model within hospital settings that facilitates pathways to diagnosis and treatment.3 The benefits of lung cancer multidisciplinary care have been demonstrated across numerous studies.4 These include a greater likelihood of treatment receipt or palliative care referral,5 guideline-adherent care, improved documentation of disease stage and performance status,5 6 reduction in time between diagnosis and treatment6 and improved patient outcomes and practice patterns.7 However, few studies have focused on testing the best practice interventions in lung cancer multidisciplinary team (MDT) settings.8 9

Primary care providers play a significant role in coordinating cancer care10 but may not have opportunities to directly participate in hospital-based MDT meetings or processes.11 This can limit general practitioners (GPs) access to information about a lung cancer patient’s diagnosis and treatment decision-making at times of greatest need; these are identified as following presentation at MDT meetings when clinical decisions are being made,12 discharge from hospital, changes in a patient’s condition and reaching treatment milestones.13 In a recent lung cancer qualitative study with GPs, we identified that lack of timely receipt of information from MDTs was a significant source of frustration, and was perceived as impacting on the GP’s ability to support the patient and provide timely information.14

GPs are the first contact point for many people prior to a lung cancer diagnosis.15–19 A study of Australian GPs reported that timely information following presentation of their patient’s case at lung cancer MDT meetings is needed, including essential information about diagnosis, and treatment recommendation(s) and intent.13 A MDT meeting summary has been suggested as a strategy to facilitate information transfer between GPs and hospital-based clinicians.20 Two recent studies have pilot-tested template implementation in a breast cancer MDT setting21 and synoptic reporting in colorectal cancer.22 There are no previous studies in lung cancer, and thus, it is necessary to first establish intervention feasibility and acceptability prior to full-scale implementation. Frameworks from the implementation science literature provide a basis for documenting the stages of intervention development and testing, which can be summarised as preimplementation, implementation and evaluation.23–25

Therefore, the aim of this study was to develop, implement and evaluate a lung MDT meeting standardised template to provide a patient’s clinical information and treatment recommendations to the GP following a lung cancer MDT meeting. The specific objectives were to evaluate implementation outcomes of feasibility, timeliness, acceptability and appropriateness and to document the stages of implementation development to enable sustainability and adaptation for other tumour groups.

Methods

Study design

This implementation study used a mixed-method design. We used a structured survey instrument to collect evaluation data from GPs about the template intervention. Qualitative data were collected using a project log to document implementation activities across stages of preimplementation, implementation and evaluation. This study was conducted under the auspices of Cancer Australia’s Lung Cancer Demonstration Project, which seeks to develop an evidence-based framework to support national uptake of the ‘Principles for best-practice management of lung cancer in Australia’.2

Setting and participants

The study was conducted within two hospitals located within Sydney Local Health District (SLHD) in metropolitan Sydney, New South Wales. Site A is a large tertiary referral and teaching hospital (over 900 beds) with thoracic surgery, radiation and chemotherapy services provided on site; and, site B is a smaller 750-bed tertiary teaching hospital that provides radiation, chemotherapy and specialised palliative care services. Thoracic oncology MDTs are held weekly at both hospitals, with more than 700 lung cancer cases being presented annually. A ‘hub and spoke’ model of care was established during the 1980s based on the availability of specialist cardiothoracic surgical procedures at the larger hospital. Two regional hospitals present patient cases on alternate weeks at site A. Participants in the template development and implementation were members of the two lung cancer MDTs (n=33) and the research team (n=8).

Participants in the evaluation component were the GPs of patient cases presented at MDT meetings between May 2014 and May 2015. GPs contact details were obtained through Cerner PowerChart electronic medical record (eMR) and entered into an Excel spreadsheet. A project officer contacted every GP office to determine the preferred mode for receiving the template and study documents (via fax, mail or email).

Implementation and evaluation frameworks

The authors selected the knowledge to action (KTA) cycle framework for our research programme,25 in which we have identified significant evidence-practice gaps in lung cancer management, adapted knowledge to the local context through a consensus-driven priority-setting exercise and reported on pathways to diagnosis from patient and GP perspectives via qualitative interviews.4 14 26 27 The MDT template project was one implementation strategy pilot tested in the ‘select, tailor and implement interventions’ component of the KTA cycle. Our approach was informed by guidance from the UK Medical Research Council,28 health evaluation theory,29 Proctor’s implementation outcomes framework30 and the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies.31

Preimplementation: Selecting and tailoring the intervention

Selection of the intervention

A self-assessment task was undertaken at project commencement by the authors to identify current gaps in lung cancer management according to a defined set of best practice principles in lung cancer.2 32 Our team identified that there was no direct MDT reporting to GPs; this was the responsibility of each patient’s coordinating clinician. MDT discussion and consensus about recommended treatment outcomes was typically recorded as free text within the patient’s eMR. However, information was inconsistent (that is, no standardisation in items recorded) and was not routinely extracted for reporting to GPs. A generic (non-tumour specific) MDT reporting template had been developed and pilot tested and evaluated with GPs in NSW by one team member (LJT).33

Tailoring the generic template

We commenced tailoring of the generic template to be specific for lung cancer through a consultative process with key stakeholders, consisting of 33 MDT members; five local GPs, contacted via the Primary Health Network located in inner western Sydney; three consumers (patients with a previous cancer diagnosis who formed a consumer panel); and three local champions (two MDT Chairs, the Director of Cancer Services, SLHD). All MDT clinicians across the two sites (n=33) gave feedback on the template content and format during a MDT meeting or via email. Standardised items that were routinely reported or discussed during the MDT meeting regarding the patient’s history and discussion/consensus about treatment plan were selected. The template underwent a final revision by the authors and was approved by the Director of Cancer Services, and subsequently submitted to eMR team of the Information Management and Technology Division of SLHD for integration into PowerChart eMR.

Intervention content

As shown in figure 1, the template consists of four sections: preliminary information (15 items), presenting medical officer’s information (2 items), clinical items (7 items) and summary discussion (3 items).

Figure 1

Lung cancer multidisciplinary team (MDT) standardised template. DOB, date of birth; ECOG, Eastern Cooperative Oncology Group; GP, general practitioner; MDT, multidisciplinary team; MRN, medical record number; NSW, New South Wales; PET, positron emission tomography; Pt, patient.

Implementation processes for template completion

Integration of the template into eMR systems enabled existing information to be used to prepopulate preliminary items for each patient. Items were checked by a medical registrar (respiratory medicine, medical oncology) during meeting preparation time (about 5 days prior); the remaining items were completed during the meeting. A project officer was responsible for checking the item completeness (GKC). The template content was verified by the nursing case manager for thoracic surgery within 48 hours of the meeting and any missing information was completed (CMB). The MDT Chairs had overall clinical responsibility and answered any queries in the event of missing information.

Measures, recruitment and procedures for evaluation

Quantitative measure

A structured interview for GPs was developed by the team and reviewed by GPs (n=5) and the consumer stakeholders described earlier (n=3). The interview asked GPs to evaluate template feasibility according to: (1) appropriateness, (2) timeliness, (3) ease of interpretation and (4) usefulness of treatment recommendations. The interview schedule was pilot tested with the first five participants and responses were reviewed by a second author (NMR) before further interviews were administered. The MDT template and study documents (letter of invitation, information sheet and consent form) were sent to GPs by fax or postal mail with the completed template. No incentive or financial reimbursement was offered for participation and the researchers had no prior relationships with any participating GPs. Consenting GPs were contacted at their workplace by telephone within 2 weeks of the template being sent out. The interview took an average of 10 min to complete.

Qualitative measures

The project officer maintained a weekly project log in Microsoft Excel to document processes in each implementation stage, using two information sources: MDT meeting minutes and project field notes. Field notes comprised any observations made during MDT meetings about activities that contributed to template completion or implementation processes.

Data collection and analyses

Quantitative data

The project officer recorded interview data in an Excel database during each phone call with GPs. A list of GP contact details was maintained in a separate spreadsheet to deidentified data collected from the surveys. Descriptive statistics were generated in Microsoft Excel and comparative statistics (χ2 test) in SPSS V.11.

Qualitative data

Project log data were extracted by arranging content into monthly summaries and analysed for content at the project conclusion by two authors (GKC and NMR). Key activities were grouped into the stages of preimplementation, implementation and evaluation through an iterative process of discussion between authors. The activities were then matched against a compendium of implementation strategies, as described by Powell et al.31

Results

Patient demographics

Table 1 illustrates the demographic characteristics of the patients presented at lung MDT meetings. Differences in patients’ area of residence across the two hospital sites are shown; more patients residing in regional areas were presented at site A, which is consistent with organisation of services. The patient’s presenting specialist varied across the sites, with most cases presented by specialist surgeons at site A (53%) or by respiratory physicians at site B (68%).

Table 1

Patient demographics, multidisciplinary team (MDT) reporting and general practitioners (GP) responses

	Hospital site A		Hospital site B		Total
Patient demographics
Patients presented at MDT	442		290		732
Age (mean, range)	64 (20–91)		71 (25–96)		–
Residence (based on area code)	N	%	N	%
Major city  Inner regional  Outer regional  Remote  Very remote  Overseas or interstate	254 55 113 7 7 6	57 12 26 2 2 1	274 4 7 0 0 5	95 1 2 0 0 2
Presenting specialist	N	%	N	%
Cardiothoracic surgeon  Respiratory physician  Medical oncologist  Radiation oncologist  Other	234 110 81 17 0	53 25 18 4 0	0 197 83 8 2*	0 68 28 3 1

*‘Other’ includes one palliative care specialist and one emergency department physician.

GP evaluation

As shown in table 2, the MDT template was completed for 687 of 732 patients (94%); of these, 492 patients had a GP listed in their eMR (72%). All 492 GPs were approached and 61 GPs participated (12%). Demographic information shows that GPs were evenly split across male and female, were from metropolitan (57%) and regional settings (43%) and had an average of 21 years’ primary care experience (median 20 years; IQR=10, 30; SD=13.3). Nearly all participants (98%) preferred to receive the report by fax.

Table 2

Multidisciplinary team (MDT) meeting data and general practitioner (GP) demographics

	Hospital site A		Hospital site B		Total
MDT meeting data	N	%	N	%
MDT reports generated	442	100	245*	84	687
MDT reports sent to GPs	324	73	168	69	492
GP survey completed	52	16	9	5	61
GP demographics
Sex	N	%	N	%
Female	26	50	4	44
Male	26	50	5	56
Years as GP (mean, range)	19 (1–48)		32 (16–52)
GP location	N	%	N	%
Metropolitan	26	50	9	100
Rural	26	50	0	0

There were two reasons for not sending a GP report: (1) no current GP was listed for the patient, or (2) the patient resided overseas.

*n=45 cases incomplete for MDT reporting.

As shown in table 3, nearly all GPs strongly agreed or agreed that the template information was useful and appropriate, and was received in a timely manner. A large majority of GPs responded that the report would be used for planning the patient’s treatment pathway and coordination (agree, 54%; strongly agree, 32.5%). More than 80% thought that the clinical information provided in the lung MDT report was easy to interpret and communicate to the patient. There were no significant differences in the responses across GPs from metropolitan and regional locations.

Table 3

GP responses to evaluation survey items (n=61)

	Strongly disagree N (%)	Disagree N (%)	Neither agree nor disagree N (%)	Agree N (%)	Strongly agree N (%)
The information provided in the lung MDT report useful and relevant	1 (1.6)	1 (1.6)	1 (1.6)	31 (51)	27 (44)
The report was received in a timely manner	1 (2)	2 (3)	3 (5)	20 (33)	35 (57)
The clinical information provided in the lung MDT report easy to interpret and communicate to the patient	1 (2)	2 (3)	7 (11.5)	30 (49)	21 (34.5)
The report be used for patient treatment pathway and coordination of the treatment plan	1 (2)	2 (3.5)	5 (8)	33 (54)	20 (32.5)
Additional information and/or explanation was required to effectively relay the information to the patient	19 (31)	21 (34.5)	11 (18)	10 (16.5)	0

GP, general practitioner; MDT, multidisciplinary team.

Two-thirds of GPs reported that no additional information and/or explanation was required to effectively relay the information to the patient (66%). Ten GPs reported wanting additional information, with the remaining (18%) being unsure (‘neither agree nor disagree’). During the study period, less than 5 of the 492 GPs who received the template chose to contact the thoracic nursing case manager to request further information and/or clarification. Data about whether these GPs contacted a specialist medical clinician about the template were not available.

GPs were asked one open-ended question to give additional feedback about the template. Fourteen participants gave positive feedback that focused on timeliness and content (eg, good timing, quick report, good treatment plan and summary, good to be informed, helpful and relevant). Nineteen participants gave suggestions for improvement about: content (n=13); delivery (n=4) or presentation style (n=2). Ten of the ‘content’ suggestions were for further information (eg, future tests, appointments, referrals and treatment planning; chemotherapy regimens; psychosocial information). The four ‘delivery’ suggestions were to instead receive the template from the referring specialist or by phone call. We note that a small group of GPs will prefer receipt of a specialist letter over a standardised template. Saturation of responses was reached after completion of approximately 35 interviews.

Implementation processes

Documentation of strategies, activities and outcomes in the stages of preimplementation, implementation and evaluation are summarised in table 4. In preimplementation stage (period of 7 months), we undertook activities that correspond with 10 different strategies to implement new practices, as described in the ERIC compilation.31 For example, MDT meetings were observed by the project officer to map out reporting process of meetings at both hospital sites, in order to assess for readiness for change and identify barriers and facilitators. The mapping process documented the data items that were currently being discussed but not formally captured. The MDT Chairs (local champions) highlighted the importance of training for medical registrars who would be responsible for populating the template and capturing consensus discussion about diagnostic and treatment decision-making. Prior to implementation commencement, a clinical leadership forum was held, consisting of a 1 hour video-conference session that engaged participants from site B and the two regional hospitals sites (which was part of a ‘conduct educational meetings’ strategy). The purpose was to promote awareness of the project aims to oncology health providers prior to template implementation. The benefits of integration with existing information technology systems were identified by forum participants as crucial to preimplementation, to avoid duplication and ensure compliance with relevant policies and procedures (strategy: provide local technical assistance).

Table 4

Summary of key activities by project phase captured in project data log

Strategies*	Key activities	Outcomes
Preimplementation (October 2014–April 2015)
Assess for readiness and identify barriers and facilitators	Focused literature review: implementation strategies using templates in oncology	Review highlighted lack of lung cancer studies using templates
	Review examples of hospital reporting templates within organisation; review generic example from primary care	Review notes that useful templates are integrated into eMR system
Conduct local needs assessment	Conduct process mapping to identify gaps in lung cancer MDT information and communication provision	Process mapping highlighted lack of systematic reporting to GPs apart from medical specialist letters
Build a coalition/conduct educational meetings	Discuss staff roles and responsibilities for template completion (project officer, specialist nurses, registrars and chairperson)	Team identified that registrars would complete majority of items and clinical staff required to sign off
Develop a formal implementation blueprint	Project protocol and methodology documented	Protocol written to document project aims and methods
	Human Research Ethics Committee approval granted	Ethics clearance gained to facilitate publication of results
Provide local technical assistance	Request submitted to SLHD Information Management and Technology Division (IM&TD) to initiate project	Project complies with policy requirements to receive in-house IM&TD development support
Prepare patients/consumers to be active participants	Draft lung MDT template developed and reviewed by MDT, GPs and consumers	Core team determines items for inclusion through consultation
Develop and implement tools for quality monitoring	Development of survey instrument for the evaluation component	Evaluation survey mapped to theoretical approach (Proctor et al 30)
	Template finalised and built into Cerner PowerChart by IM&TD	Final checks to align selected items with source data within Cerner
Conduct ongoing training	IM&TD provides training for clinical staff in template use including data migration	IM&TD staff train registrars, project officer and specialist nurse
Conduct educational meetings	Clinical leadership forum held to promote implementation of the template	Leaders from project sites engage in group discussion
Implementation (May 2015–May 2016)
Mandate change, revise professional roles	Lung MDT template ‘launched’ across SLHD by local champions	All MDT members informed about template use and MDT Chairs note this during weekly MDT meetings
Implement tools for quality monitoring	Templates and study documents sent to individual GPs within 48 hours of MDT meeting conclusion	Project officer and nurse specialist confirm data and send out template to GPs for 56-week period
Data collection	Evaluation survey administered by telephone with GPs begin	Concurrent weekly data collection via phone call with consenting GPs
	Ongoing data collection and database management	Project officer enters GP evaluation data following survey completion Project officer logs team discussion about efficiencies in completing patient data
	Preliminary results analysed and presented at local meetings	Initial data tabulated and summary results presented to team, cancer services staff within the LHD
Evaluation (June 2016–December 2016)
	Evaluation surveys completed, data entered and cleaned	All data entered and anomalies corrected; generate results tables; coding of qualitative responses
	Data analysis and summary reporting, preparation of conference abstracts	Data analysed and interpreted, project results prepared as an abstract and presentation slides
	Sustainability of reporting process discussed by SLHD representatives and research team	Team engages with cancer services team to discuss sustainability of the project and potential adaptation for other tumour streams

*Strategies as listed in the Expert Recommendations for Implementing Change implementation strategy compilation.31

eMR, electronic medical record; GP, general practitioner; LHD, local health district; MDT, multidisciplinary team; SLHD, Sydney Local Health District.

During implementation (13-month period), the local MDT Chairs mandated change for the routine introduction of the template. The project officer and nurse specialist ensured that each individual template was complete and distributed to the GP within 48 hours (n=493). The project officer collected GP consent forms and conducted evaluation surveys by telephone (n=61). The project officer also logged weekly notes about changes in team efficiency in documenting patients’ clinical information, including diagnostic staging and discussion about treatment options. It was noted that the MDT Chairs improved their efficiency to ensure that consensus about diagnosis and treatment recommendations were clearly articulated (or in cases where consensus could not be reached without further investigations) to facilitate clear communication to the registrar who was entering data into each patient’s eMR.

The evaluation period (7 months) included analysis of GP survey data and initiation of discussion about longer term sustainability of the template within the lung MDT setting and potential adaptation for other tumour groups.

Discussion

This study aimed to develop, implement and evaluate a standardised template for lung cancer MDT meetings that reports clinical information and treatment recommendations to GPs, following the MDT meeting. The findings show that GPs consider the MDT template to be feasible, appropriate and acceptable; it is delivered in a timely way and contains appropriate information about lung cancer diagnosis and treatment recommendations. It appears that this type of standardised template can be integrated into MDT meeting practice and has the potential to improve information and communication flow across primary and tertiary healthcare sectors. The evaluation data suggest that the template may facilitate discussion between the primary care provider and their patients about diagnosis and treatment options at a time when GPs report most needing this information.13

To our knowledge, this is the first study to report on the introduction of a standardised template in lung cancer for GPs. A recent study that introduced a template within a multidisciplinary breast cancer meeting found an increase in recorded adherence rates to national treatment guidelines21; however, this study did not use the template as a strategy for communicating with primary care clinicians. Our study demonstrates that a key component preimplementation was template integration into standard MDT workflow practices and electronic systems; this finding is consistent with the breast cancer study, which showed a period of approximately 5 months before the template was fully integrated into workflow practices.21 Our findings support the need to introduce electronic solutions to improve access to clinical information by multidisciplinary health professionals.20 Ideally, future implementation would include electronic transmission of the template direct to GPs. This is not currently feasible in Australia, which lacks an integrated system of sharing data across all healthcare sectors.34

The study’s strengths include that we used 10 different preimplementation strategies that engaged key stakeholders (health professionals, information technology staff and consumers), including the conduct of local needs assessment, educational meetings and ongoing training for staff. The standardised template was integrated into existing eMR systems, thus avoiding duplication of resources and facilitated routine collection of data items and reporting to GPs as part of standard component of the best practice. These changes may have encouraged clinical staff to document treatment recommendations into the patient’s eMR more thoroughly. Future activities could include an audit and feedback process to report any improvements in practices to the MDTs. We postulate that these steps will contribute to longer term sustainability following the completion of the research project. The project engaged a collaborative team of researchers working in implementation science and oncology and thoracic healthcare professionals and reflects the advantages of interdisciplinary collaboration.

Limitations include that the study was conducted in two hospitals within one health district. However, during the 13-month implementation stage, more than 700 lung cancer cases were presented at MDT meetings. Testing the template in a relatively contained setting helped to show that successful implementation can be achieved across two busy hospital settings. The GP consent rate to participate in evaluation activities was low, and we have previously encountered challenges in engaging GPs in research activities.14 We did not have access to data about the non-responding GPs and are therefore unable to comment on whether there were any differences across the groups, or whether this affected the validity of our findings. However, we appear to have reached a broadly representative sample of GPs and heterogeneous spread of responses to evaluation items. We noted qualitative feedback from four GPs that they prefer a specialist letter in preference to a standardised template; the MDT members did not perceive that the template would replace the letter, but instead is delivered as a means of timely communication to the GP. Template information about treatment recommendations may become redundant if patient preferences are not in alignment; however, the GP will have a record of the recommendations to include in the patient’s medical history. These limitations of the intervention, rather than of the implementation design, should be canvassed with MDTs if they consider adapting the template for local use. Future improvements could include an item to document which clinician will take responsibility for communicating the MDT recommendation to the patient.

This project provides evidence about the feasibility and acceptability of a standardised template for GP reporting for lung cancer MDTs. Improvements to patient care and management needs to be evaluated to include the impact on patient–GP communication about diagnosis and recommended treatment(s). The template can be readily adapted for other MDT tumour groups, as can the processes for implementation and evaluation. Within SLHD, four other tumour groups (two hepatocellular, one haematology and one upper gastrointestinal) have commenced work to modify the template to suit their needs and replicate implementation processes. The template could also support collection of data for reporting against key performance indicators to government cancer control agencies.

Conclusions

This study demonstrates that it is feasible to implement a template for GPs reporting clinical information and treatment recommendations for patients with lung cancer discussed at a MDT meeting. Communication between hospital-based MDTs and primary care clinicians can be addressed through implementation of a template intervention. Evaluation of the intervention showed that it was delivered in a manner that was timely, acceptable and appropriate. It is anticipated that it will benefit GPs in communicating the outcomes of MDT treatment recommendations to their patients. The template can be translated to other MDTs for different tumour groups.