Multidisciplinary team meetings or MDTs

In an era when high-efficacy DMTs are increasingly being prescribed first-line, MDTs should be changed to focus on patients wanting to start low—or moderate-efficacy DMTs. Yes or no?

Do you know if the management of your multiple sclerosis (MS) with a disease-modifying therapy (DMT) was ever presented at a multidisciplinary team meeting (MDT)? NHS England mandates this happens for all patients starting on high-efficacy treatments but not for low or moderate-efficacy DMTs such as injectables and oral treatments (cladribine, fingolimod and siponimod excluded).

Are MDTs important? 

Yesterday, I chaired an MS Academy Debate on whether or not all patients with MS should have their cases reviewed at a multidisciplinary team meeting (MDT) or not which is current practice. 

MOTION: “In an era when high-efficacy DMTs are increasingly being prescribed first-line, MDTs should be changed to focus on patients wanting to start low—or moderate-efficacy DMTs”.

 FOR: “We need to change the NHS MDT meeting and discuss all patients” – Dr Wallace Brownlee

Vs.

AGAINST: “We need to keep the current NHS MDT process” – Dr Tarunya Arun

Before the debate, 70% were for the motion and 30% against it. After the debate and discussion, the split was 78% for and 22% against the motion. I think this is a good result. There is now a strong case for all pwMS to have their cases discussed in MDTs. 

Photo by Matteo Vistocco on Unsplash

Pros and cons of an MDT

MDTs lead to better outcomes for patients and healthcare professionals (HCPs) in several ways, including:

• Improved communication: MDTs can share information and results with patients and their carers, which can help improve trust and understanding between team members. However, this does not always happen. I am aware of several pwMS who have never been told the process and outcome of their MDT process. Please note that very few MDTs include pwMS. The reason is patient confidentiality. 

• Better access to services: MDTs can help ensure that patients don't have to wait a long time for referrals and have access to necessary services. This is hypothetical, as many MDTs have waiting lists, and it may take months for the case to be discussed at the MDT. However, starting a low- or moderate-efficacy treatment can happen much quicker locally if an individual HCP prescribes the therapy and does not present the case to an MDT. This is why pwMS assessed at smaller centres called spokes are more likely to be treated with low-efficacy DMTs than pwMS evaluated and managed at large neuroscience centres called hubs. The so-called hub-and-spoke model of NHS care entrenches post-code prescribing and is one of the main reasons there is such large variability in prescribing DMTs on the NHS. 

• More effective use of resources: MDTs can help reduce duplication and increase productivity. This is not necessarily true. One of the reasons given against expanding the MDT to all patients is related to resources, i.e., there are simply too many patients and not enough radiologists and neurologists to review all patients with MS starting or switching treatment. 

• More person-centred care: MDTs can help to recognise and address health and social inequalities. This may happen, but centres must proactively prevent cognitive biases from impacting decisions. Dr Brownlee quoted research in France showing that women with MS were more likely not to be prescribed DMTs and were less likely to be on high-efficacy DMTs compared to men. This is just one example of an inequality that must be addressed in the MDT. Apart from gender, many other biases affect access to DMTs, e.g. age, ethnicity, education, etc.

• Better patient outcomes: MDTs can improve cancer patients' survival rates and reduce unplanned hospital admissions for older people and those with long-term conditions. Whether the oncology experience translates to MS is unknown. We need data comparing pwMS reviewed at an MDT to those not reviewed via an MDT.

• Improved professional well-being: MDTs can help improve morale and reduce stress for HCPs. This can be due to greater autonomy, knowledge sharing, and skill enhancement. This is important, and MDTs are an excellent forum for education. However, MDTs are known for groupthink, in which one dominant decision-maker may make all the decisions. Similarly, lone wolves may not engage with the MDT and may work out ways to continue practising the way they want without the checks and balances a good MDT provides. There is a large malpractice case going on at the moment in the UK in which a neurologist was a lone wolf and had no feedback from his colleagues about his MS practice. As a result, many patients were misdiagnosed and mistreated with MS DMTs. This would not have happened if the centre involved had an MDT to review his cases and his DMT prescribing practice. 

In the discussion, someone raised the point that patients should have their treatments reviewed intermittently at MDTs so that, if necessary, they can have their treatment changed and escalated. It was agreed that this made sense but was simply not feasible considering the current staffing restrictions. 

I would like to know if you were aware of MDTs before this newsletter, whether or not your case was discussed at an MDT, and, if so, what the outcome was. Do you have any ideas on improving the MDT and your interaction with it? 

Please note that the MS Academy recorded the debate and will put it online shortly. However, the content is for HCPs only and not pwMS. This is due to the ABPI (the Association of the British Pharmaceutical Industry)) regulations and not the MS Academy. 

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General Disclaimer

Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.