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The multidisciplinary approach Q4
Giuseppe Benagiano, MD, Professor a, Ivo Brosens, MD, Professor b, * a
Q1
b
Department of Gynecology, Obstetrics and Urology, Sapienza University of Rome, Rome, Italy Leuven Institute of Fertility and Embryology & Catholic University of Leuven, Leuven, Belgium
Keywords: solid organ transplantation multidisciplinary approach risk pregnancy
Complex pathologies associated with chronic health conditions must be dealt in a coordinated way and the ‘multidisciplinary team’ approach (MDTA) represents the most efficacious way of managing these patients. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded and this article reviews some of the conditions in which the MDTA has found useful application. This has been the case in fields as diverse as primary healthcare, oncology, diabetes, cardiovascular, chronic kidney diseases and high-risk pregnancy. In the latter situation, an MDTA can offer clear advantages for pregnancies in solid organ recipient women. In these patients, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternalefoetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy and should cope with all their reproductive health needs. © 2014 Published by Elsevier Ltd.
Introduction During the second half of the twentieth century, advances in biomedical research and its applications in clinical management made it inevitable that medical and surgical disciplines once lumped
* Corresponding author. Leuven Institute for Fertility and Embryology, Tiensevest 168, B-3000 Leuven, Belgium. Tel.: þ32 16270190; Fax: þ32 16270197. E-mail address: [email protected] (I. Brosens).
http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006 1521-6934/© 2014 Published by Elsevier Ltd.
Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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together under the common name of ‘internal medicine’ and ‘general surgery’ be subdivided into dozens of specialties. Even disciplines once considered ‘a specialty’ were subdivided into subspecialties. Subdividing fields of research and clinical practice into a myriad of diverse compartments presented clear advantages and contributed in a major way to the incredible accumulation of knowledge that took place around the turn of the millennium. In spite of this, it was soon realised that even the ‘world of specialties’ had its drawbacks, as complex pathologies associated with chronic health conditions had to be dealt in a coordinated way. This reality convinced many that in specific cases the health-care system had to redesign the way to deliver the best care to critically ill patients. The diverse needs of certain types of patients forced specialists to come together to meet the high demands of these cases and to best utilise available resources. Indeed, from a public health perspective, at a time when every health system around the world is under pressure to optimise spending, the rational use of resources has become mandatory. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded, as e if properly implemented e a cooperative approach to all the needs of an individual complex patient provides positive results that can be objectively measured. This article looks into the diverse realities of what has come to be known as the ‘multidisciplinary team approach’ (MDTA) and, after providing representative examples of its many applications, focuses on how multidisciplinary teams (MDTs) can be usefully employed in improving pregnancy outcomes in women with a solid organ transplant and serve their reproductive health needs. The multidisciplinary team approach A few years ago, Baldwin [1] reconstructed the path that led to the creation and development of the interdisciplinary health-care approach in the USA; he believes that the idea came from the success during World War II of multidisciplinary medical and surgical teams. In terms of public health, the applications of the concept were a consequence of President Johnson's vision of ‘The Great Society’ where the poor and underserved had a right to access appropriate health care which could be best achieved through the creation of multidisciplinary community health centres providing comprehensive and continuous care to all citizens. In other parts of the world, as spelt out by Hall and Weaver [2], conceiving a ‘team approach’ was the result of two main factors: the ageing population, particularly evident in Western countries, with a consequential rise in the incidence and prevalence of chronic diseases, and the increasing burden of caring for cancer patients in palliative care. In these situations, the focus of medicine had to be shifted from the concept of ‘curing’ to that of maximising the quality of life and adjusting patients to life with long-term illnesses. Two conflicting requirements had to be coped with: on the one hand, an increasing complexity of skills necessary in providing adequate care to these patients, and on the other the fact that no single, specialised health professional could deliver such care. Often, specialists prefer to stay within their specific discipline where everyone utilises the same specialised vocabulary and shares the same theoretical basis in addressing and interpreting problems encountered during their work. The educational and conceptual approach followed by individual specialists has been defined as the ‘cognitive map’ of a discipline and may lead to an unwanted consequence: members of two separate specialties may well look at the same issue and simply ‘not see the same thing’ [3]. This may lead to challenging communication problems and even open conflict within a team; the ways to confront and resolve such conflicts have been presented by Drinka and Clark who called for ‘creative approaches to intra-team conflicts’ [4]. The same group [5] has now developed a conceptual framework to analyse the different types of ethical issues involved in inter-professional teamwork, which hopefully will help in confronting and resolving any possible conflicts. To break down barriers, Lary et al. [6] have advocated the creation of ‘multidisciplinary education models’ for students, concluding that utilising concepts of problem-based learning may offer a solution. An important variable in the functioning of a medical team is the interaction with the patient's family, especially when, as it should happen, care moves out of medical institutions and the patient attempts to regain normality in her/his life. [7] Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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In order to offer appropriate solutions to this multitude of issues, going beyond the ‘classic’ patientephysician relationship became necessary and the MDTA was born. As the name implies, these teams are composed of specialists from different disciplines coming together to achieve a common goal. They can be of invaluable help in a variety of settings: health care (including mental health) is certainly a field where they can play a critical role; however, MDTs have been employed also in education and criminal justice, addressing a specific problem from all angles, providing comprehensive solutions capable of offering the best chance of accomplishing the set goal. There are many perceived benefits to this approach [8]: first, it gives a patient access to the right team of health-care professionals, who work together to plan the most suitable care option; second, it allows a full review of all the factors that may affect the treatment and help prevent unexpected problems; third, it may reduce delays in treatment and referral to services and less duplication of medical tests; and fourth, it facilitates transfer of appropriate and consistent information to the patient, as a holistic view of the situation can be provided. In recent years, interest in the MDTA has increased exponentially and, since 2008, a specific forum exists for interdisciplinary studies: The Journal of Multidisciplinary Healthcare (JMDH) which aims to represent and publish research in health-care areas jointly delivered by practitioners of different disciplines. Examples of MDTAs Over the years, the MDTA has been applied to a number of areas in medical care. The following are examples of useful applications of the concept. Primary health care By the end of the last century, ample research in primary health-care settings had singled out a number of benefits when professionals are working as part of a supportive, well-functioning team [9], including better mental health and increased team effectiveness. Some 20 years ago, Poulton and West [10] began to investigate barriers to effective teamwork, outlined theories leading to team effectiveness and explored ways of applying these theories to primary health care. Their aim was the development of a model of effectiveness for primary health-care teams (PHCTs), which can be used to guide teams in their work. They compiled effectiveness criteria in four major areas: consumer outcomes, quality of care, team viability and organisational issues. Subsequently, they described four models to achieve team effectiveness: the goal model, the internal process model, the systems resource model and the constituency approach. The last seems to be the most appropriate for the working of PHCTs [11]. They described applications of the constituency approach in developing measures of PHTCs' effectiveness and outlined the disadvantages of the model exploring the next steps in research towards developing an improved model of primary health team effectiveness. Finally, they addressed the question of what predicts the effectiveness of PHCTs and found that clarity of and commitment to team objectives was the key factor in forecasting the overall effectiveness of the PHTC. [12] Oncology An area where the need for MDT work is widely accepted is oncology and a country that pioneered this approach is the UK. Following the publication in 1995 of the Calman-Hine report [13] dealing with the reorganisation of cancer services in that country, the new approach has been adopted in many centres in the hope of providing patients with the best care. Guidelines were issued specifically stressing the need for good communication between health-care professional members of an MDT, and between the MDT and patients to improve efficiency, bolster morale and provide better work satisfaction. [14,15] In 2001, Jenkins et al. [16] published the results of a survey of the expectation of the role of members of an MDT working on breast cancer in providing information to female patients. They found that in most cases health professionals in a team were able to fulfil their roles and identified two or three Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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individuals as the main providers of information for each topic, although the breast nurse invariably played a major ‘unseen’ role. The study concluded that in order for patients to receive comprehensive and consistent information, MDTs will require extra training, especially in communication skills and in how to effectively work together. The same group subsequently analysed the different roles in conveying information to patients played by members of multidisciplinary cancer teams [17]. The results show that, whereas the role of the surgeon, oncologist, radiologist and clinical nurse specialist was well recognised, the role of the other team members was less well understood. A point worth mentioning is the high level of emotional exhaustion in team leaders and nurses and the feeling of low-level personal accomplishment experienced by histopathologists and radiologists. Today, in the UK, standard practise requires that treatment for cancer patients be planned at an MDT meeting, and it is now mandatory to treat cancer patients through MDTs. This approach is perceived as being capable of improving communication, coordination and decision making between health-care professionals and patients, especially at the time treatment options are evaluated [18]. In addition, the MDT approach ensures better adherence to evidence-based guidelines, better decision concerning treatment and e more importantly e an association with better clinical outcomes including survival. [19,20] In spite of progress in this field, a study conducted a few years ago indicated that many practical barriers to the successful implementation of the MDTA still exist and that despite the increased delivery of cancer services by this method, research showing the effectiveness of MDT working is scarce. [21] Studies have also addressed the issue of assessing MDT working effectiveness and an observational tool has been developed that may contribute to the evaluation of their performance [22e24]. Finally, relatively recently, the new and evolving role of MDT coordinators has been established. The duties of coordinators involve selecting topics and guiding discussions at MDT meetings, facilitating and coordinating logistics for such meetings and playing a crucial role in bridging the communication gaps. Their functioning has been investigated with the aim to assess their needs; the study identified unmet areas and training requirements, such as oncology, anatomy and physiology; audit and research; peer review; and leadership skills [25]. An interesting trial was conducted in the UK using telemedicine to carry out multidisciplinary meetings of an MDT managing breast cancer patients. Results were comparable to those obtained by on-site meetings and, if passing the threshold of 40 meetings per year, this approach became cheaper [26].
Diabetes Uncontrolled diabetes represents a leading health risk for morbidity, disability and premature mortality, between 18% and 31% of patients also having undiagnosed or undertreated depression [27]. For this reason, for years, a multi-disciplinary approach has been advocated for the long-term management of these subjects. Back in 1995, a Scandinavian group [28] published the results of a retrospective study aimed at evaluating the effect of a multidisciplinary programme for the prevention and treatment of diabetic foot ulcers in southern Sweden on diabetes-related lower extremity amputations over a 12-year period. They found that the annual number of amputations at all levels decreased from 38 to 21, with a decrease in incidence from 19.1 to 9.4/100,000 inhabitants (p ¼ 0.001). In addition, reamputation rates decreased from 36% to 22% (p < 0.05) between the first and last 3-year period. They concluded that the introduction of an MDTA produced a sustained long-term decrease in the incidence of major amputations, as well as a decrease in the total incidence of amputations in diabetic patients. The MDTA to the long-term management of diabetic patients is now widely applied, and recently an American group [27] reported on an effective team approach to the complex ambulatory care of these patients, with special emphasis on the coexistence of psychosocial and physical disorders. The management team, which included resident and faculty physicians, a pharmacist, social worker, nurses, Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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behavioural medicine interns, office scheduler and an information technologist, developed a package for the integrative care of diabetic patients during routine office visits. An interesting variant of the MDTA is one provided through a mobile clinic in Israel for patients with poorly controlled type 2 diabetes. In these subjects, Maislos and Weisman [29] conducted a randomised, controlled intervention comparing an interdisciplinary and a traditional treatment. At the 6month follow-up, they observed significant improvements in plasma glucose (1.5 mmol/l; p ¼ 0.003) and HbA(1C) (1.8%; p ¼ 0.00001) in the intervention group, but not in the control group. The compliance and response rates were 85% and 71% for the intervention group and 32% and 35% for the control group, respectively. Cardiovascular diseases In 1996, Hill and Houston-Miller [30] noted that the dramatic reduction in cardiovascular morbidity and mortality obtained through changes in lifestyle and modification of other risk factors in controlled trials could not be achieved in clinical practice. They concluded that one major reason was that the MDTA used in clinical trials was insufficiently incorporated into standard clinical practice, and they cited the 1995 American Heart Association consensus statement ‘Preventing Heart Attack and Death in Patients with Coronary Disease’ [31] stressing that the proportion of patients continuing proper interventions over the long term “can be significantly increased by a team approach in which healthcare professionals including physicians, nurses, and dieticians manage risk reduction therapy by using follow-up techniques that include office or clinic visits and telephone contact. In many healthcare settings, the team approach will be the preferred technique for optimising risk reduction.” The same year, almost as an answer to the call by Hill and Houston-Miller, the Kaiser Permanente integrated managed care consortium Colorado Branch, created the Collaborative Cardiac Care Service (CCCS) made up of a nursing and a pharmacy team in which patient care activities complemented each other. The CCCS MDT brings together primary care physicians, cardiologists and other health-care professionals and focuses on activities that have been shown to improve patient outcomes. They recognise that managing cardiovascular risk factors is a complex, multifactorial process, requiring sustained interventions over many decades of single or multiple risk factors within the context of coexisting biological, psychological and social factors. They also acknowledge that patients' active collaboration is required not only to adopt but also to sustain health-promoting behaviours indefinitely, adhering to both medication regimens and lifestyle modifications. An essential component of the programme is the training of health professionals in behavioural sciences and in making multiple contacts with their patients. [32] Another example of MDT intervention in the field of cardiovascular diseases is that created at the Albany Medical College in the USA [33]. Their approach is based on the idea that patients could improve the benefits to be obtained by the multiple specialists commonly involved with patients with systemic cardiovascular disease if their interventions are properly coordinated. This insures that atherosclerosis prevention through risk factor modification, as well as diagnosis and therapy for the presenting problems, can be simultaneously managed. A novel approach to cardiovascular disease prevention through an MDT approach has been in place at the Albert Einstein-Montefiore Hospital in New York [34]. They have taken on the challenge presented by various inherited cardiovascular conditions and created an interdisciplinary model of care addressing the complex genetic, psychological, ethical and medical issues involved in treatment. As the genetic basis of many complex conditions is discovered, the advantages of an interdisciplinary approach for delivering personalised medicine seem to become more evident. Chronic kidney diseases In 2000, Levin [35] stated that, when dealing with renal diseases, three concomitant strategies should be in place: (1) early identification of patients with chronic renal failure, (2) initiation of treatment at the earliest possible stage in order to delay progression of the condition and co-morbid diseases, and (3) proper determination of the optimal time required to prepare these patients for renal dialysis should be made. He believed that to achieve these objectives the timeliness of referral to a Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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multidisciplinary renal care team is of paramount importance, and he mentioned that, in Canada, diabetes and/or hypertension cause renal disease in up to 40% of patients requiring dialysis. Given that these patients were often monitored by internists, endocrinologists or cardiologists, a substantial proportion (20e50%) of them started dialysis without consultation with a nephrologist. This is unsatisfactory as guidelines for the initiation of renal replacement therapy change with time [36]. Levine's recommendations have been recently substantiated by Bayliss et al. [37] who implemented an MDTA to chronic kidney disease management to decrease the rate of decline of glomerular filtration rate (GFR). Using a 4-year historical cohort, they compared 1769 persons referred to an outside nephrologist to 233 referred to an MDT consisting of a nephrologist, a pharmacy specialist, a diabetes educator, a dietician, a social worker and a nephrology nurse. Both groups received the usual primary care. In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m2 for the usual care. They concluded that the MDT was responsible for the slower decline in GFR in patients subjected to this approach. High-risk pregnancy When pregnancy represents a risk condition, an MDTA may be beneficial and there are several examples of its advantages. The team approach seems very useful for pregnant adolescents. Over 15 years ago in the USA, a comparative study analysed the outcome of pregnancy in adolescents and single young women who attended or did not to attend a non-urban, antenatal multidisciplinary clinic providing education about pregnancy, childbirth, infant care, contraception and healthy lifestyles [38]. Investigators observed that maternal weight gain and infant birth weight were significantly higher in the MDT group, while preterm labour, intrauterine growth retardation and anaemia were significantly higher in the non-clinic group. Among the latter adolescents, the likelihood of a caesarean section was almost three times higher and the need for neonatal intensive care unit transfer arose only in this group. The team model is also important in the management of cardiovascular complications in pregnancy: In 1997, the National Institutes of Health of the USA convened a workshop to carry out a systematic review of information and develop recommendations for research and education of peripartum cardiomyopathy, a rare life-threatening cardiomyopathy occurring in previously healthy women, with diagnosis confined to a narrow period and requiring echocardiographic evidence of left ventricular systolic dysfunction. They concluded that symptomatic patients should receive standard therapy for heart failure, managed by an MDT [39]. In 1999, an Israeli group used an MDT in counselling a pregnant patient with myotonic dystrophy, a rare autosomal, dominant, degenerative neuromuscular and neuroendocrine disease. As pregnancy can aggravate the maternal disease, pregnancy management becomes critical and the contribution of various specialists mandatory, because complications include stillbirth, premature labour, polyhydramnios, abnormal presentation, prolonged labour, increased operative delivery, postpartum haemorrhages and anaesthetic accidents [40]. Finally, excellent results were obtained through an MDT in patients with spontaneous coronary dissection, a rare and potentially life-threatening condition usually occurring late in pregnancy [41]. Already 20 years ago, Perry [42] advocated an MDTA to the management of pregnant patients with end-stage renal disease focussing on the obstetric nursing plan of care. This model seems to have been successful, with a recent review by Bili et al. [43] showing that, in the majority of patients with mild renal function impairment and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of the disease. A combined multidisciplinary effort led to advances in knowledge about the interaction of pregnancy and renal function resulting in the improvement of foetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease maintained on dialysis. One application of the MDT approach to pregnant women that needs to be mentioned is breast cancer diagnosed during gestation. A Spanish group recently assessed maternal and neonatal outcome in 25 of these women and concluded that they present a high incidence of complications unrelated to antineoplastic treatment, requiring an individualised MDT team approach to achieve satisfactory neonatal outcomes [44]. Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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Management of pregnancy in women with solid organ transplantation One area where there is unanimous agreement for the need of a fully multidisciplinary approach is satisfying the desire for children by women who are recipients of a solid organ (TxR). In these subjects, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternalefoetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy. Critical issues relating to pregnancy in transplanted women are the object of this issue of the journal; therefore, here only aspects where the MDTA is mandatory are briefly mentioned. Initially, an opinion should be sought from the transplant surgeon as to whether the TxR woman should or should not pursue her desire for motherhood, as there may be instances when pregnancy would be absolutely contraindicated. Even when contraindications are relative, future mothers need to be helped in reflecting on the significance of the parenting role, the existence or not of social support and the overall future relationship with the child, including survival prospects for the TxR. In addition, there seems to be a consensus that, to minimise risks, a TxR should wait a minimum of 18 months and preferably 2 years before achieving pregnancy [45]. Depending on the age of the woman, this mandatory delay may pose problems, as spontaneous fertility decreases sharply around the age of 40 [46]. In such a circumstance, women should be advised of the various forms of assisted reproduction technology (ART) available and of the risks connected with each of them. At any rate, fertility may have been maintained in some of these women even before transplantation, or it may return quickly after grafting; thus, proper advice about the choice of the best method of contraception becomes vital, as there may be relative or absolute contraindications of specific methods. For this reason, contraceptive counselling may be in order already at the time of transplant evaluation of a woman of reproductive age [45]. Preconception counselling is also mandatory: TxRs need to reflect on major indicators such as survival rates, the ability to manage the future infant and later child and overall post-transplantation quality of life [47]. Women need to be informed of the risks connected with the various immunosuppressive regimens and in particular with the possible consequences of emergency treatments if acute organ rejection occurs [48]. Once pregnancy has been achieved, close monitoring of the TxR is mandatory from the first trimester as major obstetrical syndromes in these patients are more frequent than in the general population and seem to be more frequent in certain types of transplants [49]. Close monitoring should be continued throughout pregnancy and particular care is required during labour and delivery, although there is no specific need to recur to caesarean section in these patients. Finally, medical and psychological support should continue after delivery, as these women seem prone to depression even after giving birth to a healthy baby. In this connection, data indicate that women experience poorer mental health-related quality of life and lower vitality post transplantation [50]. As part of the team approach, there is also a need to make each participating physician aware and sensitive of the possibility of TxR to be under special forms of stress and anxiety, and e without overmedicalising these gestations e of the need for a close monitoring. Conclusions The MDTA has gained momentum as the best therapeutic strategy not only in the event of complex and chronic pathologies but also in a number of other special conditions. In the management of reproductive health needs of women who received a solid organ and specifically in the event of a pregnancy, the MDTA seems the only valid overall strategy capable of minimising the risks inherent in such a gestation. The many facets of the management of these women is the scope of this article and, hopefully, the reader will find the appropriate response for most, if not all, of her/his questions. Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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Disclosure I.B. has nothing to disclose. G.B. has nothing to disclose.
Conflict of interest The authors report no conflict of interest.
Practice points The multidisciplinary team’ approach (MDTA) represents the most efficacious way of managing complex pathologies associated with chronic health conditions that must be dealt in a coordinated way. The MDTA has been successfully utilised in fields as diverse as primary health care, oncology, diabetes and cardiovascular and chronic kidney diseases. In the event of pregnancies complicated by high-risk condition, the MDTA represents the strategy that can best allow a proper management of these patients. In pregnancies occurring in solid-organ-recipient women, a close collaboration is mandatory between a series of dedicated physicians and, for this reason, the MDTA can offer clear advantages.
Research agenda Studies on the applications of a multidisciplinary team approach to pregnancies in women who received a solid organ are lacking and should be instituted.
References Q2
[1] Baldwin Jr DC. Some historical notes on inter-disciplinary and inter-professional education and practice in health care in the USA. J Interprof Care 2007;21:23e37. [2] Hall P, Weaver L. Interdisciplinary education and teamwork: a long and winding road. Med Educ 2001;35:867e75. [3] Petrie HG. Do you see what I see? the epistemology of interdisciplinary inquiry. J Aesthetic Educ 1976;10:29e43. [4] Drinka TJK, Clark PG. Health care teamwork: interdisciplinary practice and teaching. Westport, CT, USA: Greenwood Publ. Group; 2000. [5] Clark PG, Cott C, Drinka TJK. Theory and practice in interprofessional ethics: a framework for understanding ethical issues in health care teams. J Interprof Care 2007;21:591e603. [6] Lary MJ, Lavigne SE, Muma RD, et al. Breaking down barriers: multidisciplinary education model. J Allied Health 1997;26: 63e9. [7] Opie A. “Nobody's asked me for my view”: users' empowerment by multidisciplinary health teams. Qual Health Res 1998; 8:188e206. [8] Multi-Disciplinary Team (MDT) http://adventistoncologycentre.com/ facilities/what-is-multi-disciplinary-team-mdtapproach. [9] Carter AJ, West MA. Sharing the burden: teamwork in health care settings. In: Firth-Cozens J, Payne R, editors. Stress in health professionals. Hoboken, NJ, USA: Wiley; 1999. p. 191e202. [10] Poulton BC, West MA. Effective multidisciplinary teamwork in primary health care. J Adv Nurs 1993;18:918e25. [11] Poulton BC, West MA. Primary health care team effectiveness: developing a constituency approach. Health Soc Care 1994; 2:77e84. [12] Poulton BC, West MA. The determinants of effectiveness in primary health care teams. J Interprof Care 1999;13:7e18. [13] Calman K, Hine D. Expert Advisory Group on Cancer. A policy framework for commissioning cancer services. London: Department of Health; 1995. [14] National Health Service. Improving outcomes in breast cancer. London: National Health Service; 1996. [15] Scottish Intercollegiate Network (SIGN). Breast cancer in women. A national clinical guideline. Edinburgh: Scottish Intercollegiate Network; 1998. [16] Jenkins VA, Fallowfield LJ, Poole K. Are members of multidisciplinary teams in breast cancer aware of each other’s informational roles? Qual Health Care 2001;10:70e5. [17] Catt S, Fallowfield L, Jenkins V, et al. The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. Brit J Cancer 2005;93:1092e7.
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[18] Do H. Manual of cancer services. London: Department of Health; 2004. [19] National Cancer Action Team. The characteristics of an effective multi-disciplinary team. London: Department of Health; 2012. [20] Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: where are we now? Brit Med J 2010; 340:c951. [21] Lamb B, Brown K, Nagpal K, et al. Team decision making by cancer care multidisciplinary teams: a systematic review. Ann Surg Oncol 2011;18:2116e25. [22] Fleissig A, Jenkins V, Catt S, et al. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006;7: 935e43. [23] Taylor C, Atkins L, Richardson A. Ruth Tarrant R, Amanda-Jane RamirezA-J. Measuring the quality of MDT working: an observational approach. BMC Cancer 2012;12:202. [24] Taylor C, Brown K, Lamb B, et al. Developing and testing TEAM (Team Evaluation and Assessment Measure), a selfassessment tool to improve cancer multidisciplinary teamwork. Ann Surg Oncol 2012;19:4019e27. [25] Rozh Jalil R, Lamb B, Russ S, et al. The cancer multi-disciplinary team from the co-ordinators’ perspective: results from a national survey in the UK. BMC Health Serv Res 2012;12:457. [26] Kunkler IH, Prescott RJ, Lee RJ, et al. TELEMAM: a cluster randomised trial to assess the use of telemedicine in multidisciplinary breast cancer decision making. Eur J Cancer 2007;43:2506e14. [27] Tapp H, Phillips SE, Waxman D, et al. Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic. Am Board Fam Med 2012;25:245e6. € m A, Apelqvist J, et al. Decreasing incidence of major amputation in diabetic patients: a consequence of a [28] Larsson J, Stenstro multidisciplinary foot care team approach? Diabet Med 1995;12:770e6. [29] Maislos M, Weisman D. Multidisciplinary approach to patients with poorly controlled type 2 diabetes mellitus: a prospective, randomized study. Acta Diabetol 2004 Jun;41:44e8. [30] Hill MN, Houston Miller N. Compliance enhancement. A call for multidisciplinary team approaches. Circulation 1996;93: 4e6. [31] American Heart Association. Consensus Panel Statement. Preventing heart attack and death in patients with coronary disease. Circulation 1995;92:2e4. [32] Sandhoff BG, Kuca S, Rasmussen J, John A Merenich JA. Collaborative cardiac care service: a multidisciplinary approach to caring for patients with coronary artery disease. Perm J 2008;12:4e11. [33] Darling RC, Shah DM, Stainken BF, et al. The multidisciplinary approach to prevention and treatment of cardiovascular disease: creation of a vascular care network. Semin Vasc Surg 2001;14:64e71. [34] Erskine KE, Griffith E, DeGroat N, et al. An interdisciplinary approach to personalized medicine: case studies from a cardiogenetics clinic. Per Med 2013;10:73e80. [35] Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant 2000;15(Suppl. 3):8e13. [36] Nesrallah GE, Mustafa RA, Clark WF, et al., Canadian Society of Nephrology. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. Can Med Ass J 2014;186:112e7. [37] Bayliss EA, Bhardwaja B, Ross C, et al. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011;6:704e10. [38] Van Winter JT, Harmon MC, Atkinson EJ, et al. Young moms' clinic: a multidisciplinary approach to pregnancy education in teens and in young single women. J Pediat Adolesc Gynecol 1997;10:28e33. [39] Pearson GD, Veille J-C, Rahimtoola S, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. J Am Med Ass 2000;283: 1183e8. [40] Atlas I, Smolin A. Combined maternal and congenital myotonic dystrophy managed by a multidisciplinary team. Eur J Obstet Gynecol Reprod Biol 1999;87:175e8. [41] Sherif HM, Nguyen HC, Sarter BH, et al. Spontaneous coronary dissection in late pregnancy: a multidisciplinary approach to management. Ann Thorac Surg 2008;85:1793e4. [42] Perry LA. A multidisciplinary approach to the management of pregnant patients with end-stage renal disease. J Perinat Neonatal Nurs 1994;8:12e9. [43] Bili E, Tsolakidis D, Stangou S, et al. Pregnancy management and outcome in women with chronic kidney disease. Hippokratia 2013;17:163e8. rdoba O, Llurba E, Saura C, et al. Multidisciplinary approach to breast cancer diagnosed during pregnancy: maternal and [44] Co neonatal outcomes. Breast 2013;22:515e9. [45] The Practive Committee of the American Society of Reproductive Medicine. Aging and infertility in women. Fertil Steril 2006;86(Suppl. 4):s248e52. [46] Josephson MA, Dianne B, McKay DB. Women and transplantation: fertility, sexuality, pregnancy, contraception. Adv Chronic Kidney Dis 2013;20:433e40. [47] McKay DB, Adams PL, Bumgardner GL, et al. Reproduction and pregnancy in transplant recipients: current practices. Prog Transplant 2006;16:129e32. [48] Josephson MA, Editorial. Pregnancy in renal transplant recipients: more questions answered, still more Asked. Clin J Am Soc Nephrol 2013;8:182e3. [49] Brosens I, Pijnenborg R, Benagiano G. Risk of obstetrical complications in organ transplant recipient pregnancies. Transplantation 2013;96:227e33. [50] Olbrish ME, Ashe K, Levenson JL. Psychological assessment and care of organ transplant patients. J Consult Clin Psychol 2002;70:771e85.
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The multidisciplinary approach Q4
Giuseppe Benagiano, MD, Professor a, Ivo Brosens, MD, Professor b, * a
Q1
b
Department of Gynecology, Obstetrics and Urology, Sapienza University of Rome, Rome, Italy Leuven Institute of Fertility and Embryology & Catholic University of Leuven, Leuven, Belgium
Keywords: solid organ transplantation multidisciplinary approach risk pregnancy
Complex pathologies associated with chronic health conditions must be dealt in a coordinated way and the ‘multidisciplinary team’ approach (MDTA) represents the most efficacious way of managing these patients. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded and this article reviews some of the conditions in which the MDTA has found useful application. This has been the case in fields as diverse as primary healthcare, oncology, diabetes, cardiovascular, chronic kidney diseases and high-risk pregnancy. In the latter situation, an MDTA can offer clear advantages for pregnancies in solid organ recipient women. In these patients, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternalefoetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy and should cope with all their reproductive health needs. © 2014 Published by Elsevier Ltd.
Introduction During the second half of the twentieth century, advances in biomedical research and its applications in clinical management made it inevitable that medical and surgical disciplines once lumped
* Corresponding author. Leuven Institute for Fertility and Embryology, Tiensevest 168, B-3000 Leuven, Belgium. Tel.: þ32 16270190; Fax: þ32 16270197. E-mail address: [email protected] (I. Brosens).
http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006 1521-6934/© 2014 Published by Elsevier Ltd.
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together under the common name of ‘internal medicine’ and ‘general surgery’ be subdivided into dozens of specialties. Even disciplines once considered ‘a specialty’ were subdivided into subspecialties. Subdividing fields of research and clinical practice into a myriad of diverse compartments presented clear advantages and contributed in a major way to the incredible accumulation of knowledge that took place around the turn of the millennium. In spite of this, it was soon realised that even the ‘world of specialties’ had its drawbacks, as complex pathologies associated with chronic health conditions had to be dealt in a coordinated way. This reality convinced many that in specific cases the health-care system had to redesign the way to deliver the best care to critically ill patients. The diverse needs of certain types of patients forced specialists to come together to meet the high demands of these cases and to best utilise available resources. Indeed, from a public health perspective, at a time when every health system around the world is under pressure to optimise spending, the rational use of resources has become mandatory. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded, as e if properly implemented e a cooperative approach to all the needs of an individual complex patient provides positive results that can be objectively measured. This article looks into the diverse realities of what has come to be known as the ‘multidisciplinary team approach’ (MDTA) and, after providing representative examples of its many applications, focuses on how multidisciplinary teams (MDTs) can be usefully employed in improving pregnancy outcomes in women with a solid organ transplant and serve their reproductive health needs. The multidisciplinary team approach A few years ago, Baldwin [1] reconstructed the path that led to the creation and development of the interdisciplinary health-care approach in the USA; he believes that the idea came from the success during World War II of multidisciplinary medical and surgical teams. In terms of public health, the applications of the concept were a consequence of President Johnson's vision of ‘The Great Society’ where the poor and underserved had a right to access appropriate health care which could be best achieved through the creation of multidisciplinary community health centres providing comprehensive and continuous care to all citizens. In other parts of the world, as spelt out by Hall and Weaver [2], conceiving a ‘team approach’ was the result of two main factors: the ageing population, particularly evident in Western countries, with a consequential rise in the incidence and prevalence of chronic diseases, and the increasing burden of caring for cancer patients in palliative care. In these situations, the focus of medicine had to be shifted from the concept of ‘curing’ to that of maximising the quality of life and adjusting patients to life with long-term illnesses. Two conflicting requirements had to be coped with: on the one hand, an increasing complexity of skills necessary in providing adequate care to these patients, and on the other the fact that no single, specialised health professional could deliver such care. Often, specialists prefer to stay within their specific discipline where everyone utilises the same specialised vocabulary and shares the same theoretical basis in addressing and interpreting problems encountered during their work. The educational and conceptual approach followed by individual specialists has been defined as the ‘cognitive map’ of a discipline and may lead to an unwanted consequence: members of two separate specialties may well look at the same issue and simply ‘not see the same thing’ [3]. This may lead to challenging communication problems and even open conflict within a team; the ways to confront and resolve such conflicts have been presented by Drinka and Clark who called for ‘creative approaches to intra-team conflicts’ [4]. The same group [5] has now developed a conceptual framework to analyse the different types of ethical issues involved in inter-professional teamwork, which hopefully will help in confronting and resolving any possible conflicts. To break down barriers, Lary et al. [6] have advocated the creation of ‘multidisciplinary education models’ for students, concluding that utilising concepts of problem-based learning may offer a solution. An important variable in the functioning of a medical team is the interaction with the patient's family, especially when, as it should happen, care moves out of medical institutions and the patient attempts to regain normality in her/his life. [7] Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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In order to offer appropriate solutions to this multitude of issues, going beyond the ‘classic’ patientephysician relationship became necessary and the MDTA was born. As the name implies, these teams are composed of specialists from different disciplines coming together to achieve a common goal. They can be of invaluable help in a variety of settings: health care (including mental health) is certainly a field where they can play a critical role; however, MDTs have been employed also in education and criminal justice, addressing a specific problem from all angles, providing comprehensive solutions capable of offering the best chance of accomplishing the set goal. There are many perceived benefits to this approach [8]: first, it gives a patient access to the right team of health-care professionals, who work together to plan the most suitable care option; second, it allows a full review of all the factors that may affect the treatment and help prevent unexpected problems; third, it may reduce delays in treatment and referral to services and less duplication of medical tests; and fourth, it facilitates transfer of appropriate and consistent information to the patient, as a holistic view of the situation can be provided. In recent years, interest in the MDTA has increased exponentially and, since 2008, a specific forum exists for interdisciplinary studies: The Journal of Multidisciplinary Healthcare (JMDH) which aims to represent and publish research in health-care areas jointly delivered by practitioners of different disciplines. Examples of MDTAs Over the years, the MDTA has been applied to a number of areas in medical care. The following are examples of useful applications of the concept. Primary health care By the end of the last century, ample research in primary health-care settings had singled out a number of benefits when professionals are working as part of a supportive, well-functioning team [9], including better mental health and increased team effectiveness. Some 20 years ago, Poulton and West [10] began to investigate barriers to effective teamwork, outlined theories leading to team effectiveness and explored ways of applying these theories to primary health care. Their aim was the development of a model of effectiveness for primary health-care teams (PHCTs), which can be used to guide teams in their work. They compiled effectiveness criteria in four major areas: consumer outcomes, quality of care, team viability and organisational issues. Subsequently, they described four models to achieve team effectiveness: the goal model, the internal process model, the systems resource model and the constituency approach. The last seems to be the most appropriate for the working of PHCTs [11]. They described applications of the constituency approach in developing measures of PHTCs' effectiveness and outlined the disadvantages of the model exploring the next steps in research towards developing an improved model of primary health team effectiveness. Finally, they addressed the question of what predicts the effectiveness of PHCTs and found that clarity of and commitment to team objectives was the key factor in forecasting the overall effectiveness of the PHTC. [12] Oncology An area where the need for MDT work is widely accepted is oncology and a country that pioneered this approach is the UK. Following the publication in 1995 of the Calman-Hine report [13] dealing with the reorganisation of cancer services in that country, the new approach has been adopted in many centres in the hope of providing patients with the best care. Guidelines were issued specifically stressing the need for good communication between health-care professional members of an MDT, and between the MDT and patients to improve efficiency, bolster morale and provide better work satisfaction. [14,15] In 2001, Jenkins et al. [16] published the results of a survey of the expectation of the role of members of an MDT working on breast cancer in providing information to female patients. They found that in most cases health professionals in a team were able to fulfil their roles and identified two or three Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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individuals as the main providers of information for each topic, although the breast nurse invariably played a major ‘unseen’ role. The study concluded that in order for patients to receive comprehensive and consistent information, MDTs will require extra training, especially in communication skills and in how to effectively work together. The same group subsequently analysed the different roles in conveying information to patients played by members of multidisciplinary cancer teams [17]. The results show that, whereas the role of the surgeon, oncologist, radiologist and clinical nurse specialist was well recognised, the role of the other team members was less well understood. A point worth mentioning is the high level of emotional exhaustion in team leaders and nurses and the feeling of low-level personal accomplishment experienced by histopathologists and radiologists. Today, in the UK, standard practise requires that treatment for cancer patients be planned at an MDT meeting, and it is now mandatory to treat cancer patients through MDTs. This approach is perceived as being capable of improving communication, coordination and decision making between health-care professionals and patients, especially at the time treatment options are evaluated [18]. In addition, the MDT approach ensures better adherence to evidence-based guidelines, better decision concerning treatment and e more importantly e an association with better clinical outcomes including survival. [19,20] In spite of progress in this field, a study conducted a few years ago indicated that many practical barriers to the successful implementation of the MDTA still exist and that despite the increased delivery of cancer services by this method, research showing the effectiveness of MDT working is scarce. [21] Studies have also addressed the issue of assessing MDT working effectiveness and an observational tool has been developed that may contribute to the evaluation of their performance [22e24]. Finally, relatively recently, the new and evolving role of MDT coordinators has been established. The duties of coordinators involve selecting topics and guiding discussions at MDT meetings, facilitating and coordinating logistics for such meetings and playing a crucial role in bridging the communication gaps. Their functioning has been investigated with the aim to assess their needs; the study identified unmet areas and training requirements, such as oncology, anatomy and physiology; audit and research; peer review; and leadership skills [25]. An interesting trial was conducted in the UK using telemedicine to carry out multidisciplinary meetings of an MDT managing breast cancer patients. Results were comparable to those obtained by on-site meetings and, if passing the threshold of 40 meetings per year, this approach became cheaper [26].
Diabetes Uncontrolled diabetes represents a leading health risk for morbidity, disability and premature mortality, between 18% and 31% of patients also having undiagnosed or undertreated depression [27]. For this reason, for years, a multi-disciplinary approach has been advocated for the long-term management of these subjects. Back in 1995, a Scandinavian group [28] published the results of a retrospective study aimed at evaluating the effect of a multidisciplinary programme for the prevention and treatment of diabetic foot ulcers in southern Sweden on diabetes-related lower extremity amputations over a 12-year period. They found that the annual number of amputations at all levels decreased from 38 to 21, with a decrease in incidence from 19.1 to 9.4/100,000 inhabitants (p ¼ 0.001). In addition, reamputation rates decreased from 36% to 22% (p < 0.05) between the first and last 3-year period. They concluded that the introduction of an MDTA produced a sustained long-term decrease in the incidence of major amputations, as well as a decrease in the total incidence of amputations in diabetic patients. The MDTA to the long-term management of diabetic patients is now widely applied, and recently an American group [27] reported on an effective team approach to the complex ambulatory care of these patients, with special emphasis on the coexistence of psychosocial and physical disorders. The management team, which included resident and faculty physicians, a pharmacist, social worker, nurses, Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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behavioural medicine interns, office scheduler and an information technologist, developed a package for the integrative care of diabetic patients during routine office visits. An interesting variant of the MDTA is one provided through a mobile clinic in Israel for patients with poorly controlled type 2 diabetes. In these subjects, Maislos and Weisman [29] conducted a randomised, controlled intervention comparing an interdisciplinary and a traditional treatment. At the 6month follow-up, they observed significant improvements in plasma glucose (1.5 mmol/l; p ¼ 0.003) and HbA(1C) (1.8%; p ¼ 0.00001) in the intervention group, but not in the control group. The compliance and response rates were 85% and 71% for the intervention group and 32% and 35% for the control group, respectively. Cardiovascular diseases In 1996, Hill and Houston-Miller [30] noted that the dramatic reduction in cardiovascular morbidity and mortality obtained through changes in lifestyle and modification of other risk factors in controlled trials could not be achieved in clinical practice. They concluded that one major reason was that the MDTA used in clinical trials was insufficiently incorporated into standard clinical practice, and they cited the 1995 American Heart Association consensus statement ‘Preventing Heart Attack and Death in Patients with Coronary Disease’ [31] stressing that the proportion of patients continuing proper interventions over the long term “can be significantly increased by a team approach in which healthcare professionals including physicians, nurses, and dieticians manage risk reduction therapy by using follow-up techniques that include office or clinic visits and telephone contact. In many healthcare settings, the team approach will be the preferred technique for optimising risk reduction.” The same year, almost as an answer to the call by Hill and Houston-Miller, the Kaiser Permanente integrated managed care consortium Colorado Branch, created the Collaborative Cardiac Care Service (CCCS) made up of a nursing and a pharmacy team in which patient care activities complemented each other. The CCCS MDT brings together primary care physicians, cardiologists and other health-care professionals and focuses on activities that have been shown to improve patient outcomes. They recognise that managing cardiovascular risk factors is a complex, multifactorial process, requiring sustained interventions over many decades of single or multiple risk factors within the context of coexisting biological, psychological and social factors. They also acknowledge that patients' active collaboration is required not only to adopt but also to sustain health-promoting behaviours indefinitely, adhering to both medication regimens and lifestyle modifications. An essential component of the programme is the training of health professionals in behavioural sciences and in making multiple contacts with their patients. [32] Another example of MDT intervention in the field of cardiovascular diseases is that created at the Albany Medical College in the USA [33]. Their approach is based on the idea that patients could improve the benefits to be obtained by the multiple specialists commonly involved with patients with systemic cardiovascular disease if their interventions are properly coordinated. This insures that atherosclerosis prevention through risk factor modification, as well as diagnosis and therapy for the presenting problems, can be simultaneously managed. A novel approach to cardiovascular disease prevention through an MDT approach has been in place at the Albert Einstein-Montefiore Hospital in New York [34]. They have taken on the challenge presented by various inherited cardiovascular conditions and created an interdisciplinary model of care addressing the complex genetic, psychological, ethical and medical issues involved in treatment. As the genetic basis of many complex conditions is discovered, the advantages of an interdisciplinary approach for delivering personalised medicine seem to become more evident. Chronic kidney diseases In 2000, Levin [35] stated that, when dealing with renal diseases, three concomitant strategies should be in place: (1) early identification of patients with chronic renal failure, (2) initiation of treatment at the earliest possible stage in order to delay progression of the condition and co-morbid diseases, and (3) proper determination of the optimal time required to prepare these patients for renal dialysis should be made. He believed that to achieve these objectives the timeliness of referral to a Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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multidisciplinary renal care team is of paramount importance, and he mentioned that, in Canada, diabetes and/or hypertension cause renal disease in up to 40% of patients requiring dialysis. Given that these patients were often monitored by internists, endocrinologists or cardiologists, a substantial proportion (20e50%) of them started dialysis without consultation with a nephrologist. This is unsatisfactory as guidelines for the initiation of renal replacement therapy change with time [36]. Levine's recommendations have been recently substantiated by Bayliss et al. [37] who implemented an MDTA to chronic kidney disease management to decrease the rate of decline of glomerular filtration rate (GFR). Using a 4-year historical cohort, they compared 1769 persons referred to an outside nephrologist to 233 referred to an MDT consisting of a nephrologist, a pharmacy specialist, a diabetes educator, a dietician, a social worker and a nephrology nurse. Both groups received the usual primary care. In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m2 for the usual care. They concluded that the MDT was responsible for the slower decline in GFR in patients subjected to this approach. High-risk pregnancy When pregnancy represents a risk condition, an MDTA may be beneficial and there are several examples of its advantages. The team approach seems very useful for pregnant adolescents. Over 15 years ago in the USA, a comparative study analysed the outcome of pregnancy in adolescents and single young women who attended or did not to attend a non-urban, antenatal multidisciplinary clinic providing education about pregnancy, childbirth, infant care, contraception and healthy lifestyles [38]. Investigators observed that maternal weight gain and infant birth weight were significantly higher in the MDT group, while preterm labour, intrauterine growth retardation and anaemia were significantly higher in the non-clinic group. Among the latter adolescents, the likelihood of a caesarean section was almost three times higher and the need for neonatal intensive care unit transfer arose only in this group. The team model is also important in the management of cardiovascular complications in pregnancy: In 1997, the National Institutes of Health of the USA convened a workshop to carry out a systematic review of information and develop recommendations for research and education of peripartum cardiomyopathy, a rare life-threatening cardiomyopathy occurring in previously healthy women, with diagnosis confined to a narrow period and requiring echocardiographic evidence of left ventricular systolic dysfunction. They concluded that symptomatic patients should receive standard therapy for heart failure, managed by an MDT [39]. In 1999, an Israeli group used an MDT in counselling a pregnant patient with myotonic dystrophy, a rare autosomal, dominant, degenerative neuromuscular and neuroendocrine disease. As pregnancy can aggravate the maternal disease, pregnancy management becomes critical and the contribution of various specialists mandatory, because complications include stillbirth, premature labour, polyhydramnios, abnormal presentation, prolonged labour, increased operative delivery, postpartum haemorrhages and anaesthetic accidents [40]. Finally, excellent results were obtained through an MDT in patients with spontaneous coronary dissection, a rare and potentially life-threatening condition usually occurring late in pregnancy [41]. Already 20 years ago, Perry [42] advocated an MDTA to the management of pregnant patients with end-stage renal disease focussing on the obstetric nursing plan of care. This model seems to have been successful, with a recent review by Bili et al. [43] showing that, in the majority of patients with mild renal function impairment and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of the disease. A combined multidisciplinary effort led to advances in knowledge about the interaction of pregnancy and renal function resulting in the improvement of foetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease maintained on dialysis. One application of the MDT approach to pregnant women that needs to be mentioned is breast cancer diagnosed during gestation. A Spanish group recently assessed maternal and neonatal outcome in 25 of these women and concluded that they present a high incidence of complications unrelated to antineoplastic treatment, requiring an individualised MDT team approach to achieve satisfactory neonatal outcomes [44]. Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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Management of pregnancy in women with solid organ transplantation One area where there is unanimous agreement for the need of a fully multidisciplinary approach is satisfying the desire for children by women who are recipients of a solid organ (TxR). In these subjects, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternalefoetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy. Critical issues relating to pregnancy in transplanted women are the object of this issue of the journal; therefore, here only aspects where the MDTA is mandatory are briefly mentioned. Initially, an opinion should be sought from the transplant surgeon as to whether the TxR woman should or should not pursue her desire for motherhood, as there may be instances when pregnancy would be absolutely contraindicated. Even when contraindications are relative, future mothers need to be helped in reflecting on the significance of the parenting role, the existence or not of social support and the overall future relationship with the child, including survival prospects for the TxR. In addition, there seems to be a consensus that, to minimise risks, a TxR should wait a minimum of 18 months and preferably 2 years before achieving pregnancy [45]. Depending on the age of the woman, this mandatory delay may pose problems, as spontaneous fertility decreases sharply around the age of 40 [46]. In such a circumstance, women should be advised of the various forms of assisted reproduction technology (ART) available and of the risks connected with each of them. At any rate, fertility may have been maintained in some of these women even before transplantation, or it may return quickly after grafting; thus, proper advice about the choice of the best method of contraception becomes vital, as there may be relative or absolute contraindications of specific methods. For this reason, contraceptive counselling may be in order already at the time of transplant evaluation of a woman of reproductive age [45]. Preconception counselling is also mandatory: TxRs need to reflect on major indicators such as survival rates, the ability to manage the future infant and later child and overall post-transplantation quality of life [47]. Women need to be informed of the risks connected with the various immunosuppressive regimens and in particular with the possible consequences of emergency treatments if acute organ rejection occurs [48]. Once pregnancy has been achieved, close monitoring of the TxR is mandatory from the first trimester as major obstetrical syndromes in these patients are more frequent than in the general population and seem to be more frequent in certain types of transplants [49]. Close monitoring should be continued throughout pregnancy and particular care is required during labour and delivery, although there is no specific need to recur to caesarean section in these patients. Finally, medical and psychological support should continue after delivery, as these women seem prone to depression even after giving birth to a healthy baby. In this connection, data indicate that women experience poorer mental health-related quality of life and lower vitality post transplantation [50]. As part of the team approach, there is also a need to make each participating physician aware and sensitive of the possibility of TxR to be under special forms of stress and anxiety, and e without overmedicalising these gestations e of the need for a close monitoring. Conclusions The MDTA has gained momentum as the best therapeutic strategy not only in the event of complex and chronic pathologies but also in a number of other special conditions. In the management of reproductive health needs of women who received a solid organ and specifically in the event of a pregnancy, the MDTA seems the only valid overall strategy capable of minimising the risks inherent in such a gestation. The many facets of the management of these women is the scope of this article and, hopefully, the reader will find the appropriate response for most, if not all, of her/his questions. Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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Disclosure I.B. has nothing to disclose. G.B. has nothing to disclose.
Conflict of interest The authors report no conflict of interest.
Practice points The multidisciplinary team’ approach (MDTA) represents the most efficacious way of managing complex pathologies associated with chronic health conditions that must be dealt in a coordinated way. The MDTA has been successfully utilised in fields as diverse as primary health care, oncology, diabetes and cardiovascular and chronic kidney diseases. In the event of pregnancies complicated by high-risk condition, the MDTA represents the strategy that can best allow a proper management of these patients. In pregnancies occurring in solid-organ-recipient women, a close collaboration is mandatory between a series of dedicated physicians and, for this reason, the MDTA can offer clear advantages.
Research agenda Studies on the applications of a multidisciplinary team approach to pregnancies in women who received a solid organ are lacking and should be instituted.
References Q2
[1] Baldwin Jr DC. Some historical notes on inter-disciplinary and inter-professional education and practice in health care in the USA. J Interprof Care 2007;21:23e37. [2] Hall P, Weaver L. Interdisciplinary education and teamwork: a long and winding road. Med Educ 2001;35:867e75. [3] Petrie HG. Do you see what I see? the epistemology of interdisciplinary inquiry. J Aesthetic Educ 1976;10:29e43. [4] Drinka TJK, Clark PG. Health care teamwork: interdisciplinary practice and teaching. Westport, CT, USA: Greenwood Publ. Group; 2000. [5] Clark PG, Cott C, Drinka TJK. Theory and practice in interprofessional ethics: a framework for understanding ethical issues in health care teams. J Interprof Care 2007;21:591e603. [6] Lary MJ, Lavigne SE, Muma RD, et al. Breaking down barriers: multidisciplinary education model. J Allied Health 1997;26: 63e9. [7] Opie A. “Nobody's asked me for my view”: users' empowerment by multidisciplinary health teams. Qual Health Res 1998; 8:188e206. [8] Multi-Disciplinary Team (MDT) http://adventistoncologycentre.com/ facilities/what-is-multi-disciplinary-team-mdtapproach. [9] Carter AJ, West MA. Sharing the burden: teamwork in health care settings. In: Firth-Cozens J, Payne R, editors. Stress in health professionals. Hoboken, NJ, USA: Wiley; 1999. p. 191e202. [10] Poulton BC, West MA. Effective multidisciplinary teamwork in primary health care. J Adv Nurs 1993;18:918e25. [11] Poulton BC, West MA. Primary health care team effectiveness: developing a constituency approach. Health Soc Care 1994; 2:77e84. [12] Poulton BC, West MA. The determinants of effectiveness in primary health care teams. J Interprof Care 1999;13:7e18. [13] Calman K, Hine D. Expert Advisory Group on Cancer. A policy framework for commissioning cancer services. London: Department of Health; 1995. [14] National Health Service. Improving outcomes in breast cancer. London: National Health Service; 1996. [15] Scottish Intercollegiate Network (SIGN). Breast cancer in women. A national clinical guideline. Edinburgh: Scottish Intercollegiate Network; 1998. [16] Jenkins VA, Fallowfield LJ, Poole K. Are members of multidisciplinary teams in breast cancer aware of each other’s informational roles? Qual Health Care 2001;10:70e5. [17] Catt S, Fallowfield L, Jenkins V, et al. The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. Brit J Cancer 2005;93:1092e7.
Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
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[18] Do H. Manual of cancer services. London: Department of Health; 2004. [19] National Cancer Action Team. The characteristics of an effective multi-disciplinary team. London: Department of Health; 2012. [20] Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: where are we now? Brit Med J 2010; 340:c951. [21] Lamb B, Brown K, Nagpal K, et al. Team decision making by cancer care multidisciplinary teams: a systematic review. Ann Surg Oncol 2011;18:2116e25. [22] Fleissig A, Jenkins V, Catt S, et al. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol 2006;7: 935e43. [23] Taylor C, Atkins L, Richardson A. Ruth Tarrant R, Amanda-Jane RamirezA-J. Measuring the quality of MDT working: an observational approach. BMC Cancer 2012;12:202. [24] Taylor C, Brown K, Lamb B, et al. Developing and testing TEAM (Team Evaluation and Assessment Measure), a selfassessment tool to improve cancer multidisciplinary teamwork. Ann Surg Oncol 2012;19:4019e27. [25] Rozh Jalil R, Lamb B, Russ S, et al. The cancer multi-disciplinary team from the co-ordinators’ perspective: results from a national survey in the UK. BMC Health Serv Res 2012;12:457. [26] Kunkler IH, Prescott RJ, Lee RJ, et al. TELEMAM: a cluster randomised trial to assess the use of telemedicine in multidisciplinary breast cancer decision making. Eur J Cancer 2007;43:2506e14. [27] Tapp H, Phillips SE, Waxman D, et al. Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic. Am Board Fam Med 2012;25:245e6. € m A, Apelqvist J, et al. Decreasing incidence of major amputation in diabetic patients: a consequence of a [28] Larsson J, Stenstro multidisciplinary foot care team approach? Diabet Med 1995;12:770e6. [29] Maislos M, Weisman D. Multidisciplinary approach to patients with poorly controlled type 2 diabetes mellitus: a prospective, randomized study. Acta Diabetol 2004 Jun;41:44e8. [30] Hill MN, Houston Miller N. Compliance enhancement. A call for multidisciplinary team approaches. Circulation 1996;93: 4e6. [31] American Heart Association. Consensus Panel Statement. Preventing heart attack and death in patients with coronary disease. Circulation 1995;92:2e4. [32] Sandhoff BG, Kuca S, Rasmussen J, John A Merenich JA. Collaborative cardiac care service: a multidisciplinary approach to caring for patients with coronary artery disease. Perm J 2008;12:4e11. [33] Darling RC, Shah DM, Stainken BF, et al. The multidisciplinary approach to prevention and treatment of cardiovascular disease: creation of a vascular care network. Semin Vasc Surg 2001;14:64e71. [34] Erskine KE, Griffith E, DeGroat N, et al. An interdisciplinary approach to personalized medicine: case studies from a cardiogenetics clinic. Per Med 2013;10:73e80. [35] Levin A. Consequences of late referral on patient outcomes. Nephrol Dial Transplant 2000;15(Suppl. 3):8e13. [36] Nesrallah GE, Mustafa RA, Clark WF, et al., Canadian Society of Nephrology. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. Can Med Ass J 2014;186:112e7. [37] Bayliss EA, Bhardwaja B, Ross C, et al. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011;6:704e10. [38] Van Winter JT, Harmon MC, Atkinson EJ, et al. Young moms' clinic: a multidisciplinary approach to pregnancy education in teens and in young single women. J Pediat Adolesc Gynecol 1997;10:28e33. [39] Pearson GD, Veille J-C, Rahimtoola S, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. J Am Med Ass 2000;283: 1183e8. [40] Atlas I, Smolin A. Combined maternal and congenital myotonic dystrophy managed by a multidisciplinary team. Eur J Obstet Gynecol Reprod Biol 1999;87:175e8. [41] Sherif HM, Nguyen HC, Sarter BH, et al. Spontaneous coronary dissection in late pregnancy: a multidisciplinary approach to management. Ann Thorac Surg 2008;85:1793e4. [42] Perry LA. A multidisciplinary approach to the management of pregnant patients with end-stage renal disease. J Perinat Neonatal Nurs 1994;8:12e9. [43] Bili E, Tsolakidis D, Stangou S, et al. Pregnancy management and outcome in women with chronic kidney disease. Hippokratia 2013;17:163e8. rdoba O, Llurba E, Saura C, et al. Multidisciplinary approach to breast cancer diagnosed during pregnancy: maternal and [44] Co neonatal outcomes. Breast 2013;22:515e9. [45] The Practive Committee of the American Society of Reproductive Medicine. Aging and infertility in women. Fertil Steril 2006;86(Suppl. 4):s248e52. [46] Josephson MA, Dianne B, McKay DB. Women and transplantation: fertility, sexuality, pregnancy, contraception. Adv Chronic Kidney Dis 2013;20:433e40. [47] McKay DB, Adams PL, Bumgardner GL, et al. Reproduction and pregnancy in transplant recipients: current practices. Prog Transplant 2006;16:129e32. [48] Josephson MA, Editorial. Pregnancy in renal transplant recipients: more questions answered, still more Asked. Clin J Am Soc Nephrol 2013;8:182e3. [49] Brosens I, Pijnenborg R, Benagiano G. Risk of obstetrical complications in organ transplant recipient pregnancies. Transplantation 2013;96:227e33. [50] Olbrish ME, Ashe K, Levenson JL. Psychological assessment and care of organ transplant patients. J Consult Clin Psychol 2002;70:771e85.
Please cite this article in press as: Benagiano G, Brosens I, The multidisciplinary approach, Best Practice & Research Clinical Obstetrics and Gynaecology (2014), http://dx.doi.org/10.1016/j.bpobgyn.2014.08.006
