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Table 4 Variation in the organization of clinical pathways on regional, local, and patient level

From: Clinical variation in the organization of clinical pathways in esophagogastric cancer, a mixed method multiple case study

Theme

Subtheme

Category

Summary

Regional level

Arrangements for referral of patients

• Arrangements versus no arrangements

Most hospitals were part of a regional network or collaboration in which agreements regarding referral were established. Other hospitals had no agreements at all

Referral of patients to a resection center

• All patients (including all tumor stages and postoperative patients)

• Selection of patients (e.g., refraining from referral of those with high age, metastasized disease, decreased physical functioning)

• Second opinion

Differences across hospitals were observed regarding patient discussion during the MDTM. Some hospitals discussed all patients, while others who discussed only a selection of patients

Centralization of care

• Knowledge

• Increased experience due to higher exposure to Upper-GI cases in resection centers

• Decreased exposure in referral hospitals (e.g., premature or overdue referral, not aware of possibilities and impossibilities)

More knowledge in resection centers and potential knowledge depletion in referral centers due to differences in exposure

Organization of diagnostics and treatment

• Diagnostics conducted in the referral center and/or resection center

Arrangements regarding conducting diagnostics in the referral or resection center differed and, in most hospitals, this was described in their clinical pathways

Quality of radiological images

• Sufficient versus insufficient

• Protocols versus no protocols

The quality of the radiological images differed per referring hospital. At times if quality was insufficient, repeated radiological imaging was necessary. Some hospitals established protocols to improve the quality of radiological images

• Arrangements about the hospital of treatment

• Referral versus resection center

â–ª Neoadjuvant treatment

â–ª Adjuvant treatment

â–ª Follow-up

Hospitals’ agreements differed considerably regarding the location (resection- and/or referring hospital) of neoadjuvant therapy and follow-up or the location of treatment of complications

Communication

• Consultation between centers

• Difficult cases

Some resection hospitals organized overarching MDTMs with other resection centers in order to discuss difficult cases

Coordination

• Case manager is key figure

The case manager in the resection center was an invaluable asset in the care pathway by facilitating communication between and within centers

Local level

Patient information and diagnostics

• Standard templates with patient information for MDTM

All hospitals used standard templates for patient discussion during an MDTM; however sometimes information was lacking, resulting in postponement of patient presetationto the next MDTM

• Revision of radiological images by dedicated in-house radiologist (e.g., finding of additional metastases in lymph nodes or resulting in conversion of cM1 to cM0 staging)

Standard revision of radiological images of referred patients by an in-house upper-GI radiologist prior to the MDTM could lead to additional findings, such as the identification of additional metastatic locations or resectability, influencing the treatment plan in either direction

• Patient representation by clinician during the MDTM

In some hospitals, the patient is represented by a clinician (e.g., clinician from referral or resection center), while in others, the patient discussion is based on the standard templates

Organization of MDTM

• MDTM Preparation

• Patient summary

• Patient’s seen during outpatient clinic visit prior to MDTM

• Triage (e.g., monitor if all data is accessible prior to MDTM)

Some hospitals conducted triage prior to the MDTM, reviewing and verifying whether all necessary diagnostic modalities were performed and all information was obtained and available, enhancing discussion, resulting in a more efficient workflow during the MDTM. If certain modalities had not been implemented, these examinations were ordered after triage so that patient information would be complete during the MDTM

Setting and buildup of the MDTM

• Dealing with missing clinical information (e.g., complete versus incomplete information)

• Time-related aspects of the MDTM (e.g., attendees being late, last-minute applications)

Complete information available during the MDTM makes treatment decision-making (TDM) feasible. Last-minute application for discussion of patients in the MDTM leads to incomplete information. If attendees are late to attend the MDTM, knowledge remains lacking until all involved medical specialists are present to participate in the MDTM. The maximum time an MDTM should last was mentioned to be 1.5 h, since at the end fatigue set in. Because fatigue sets in toward the end of the MDTM, some hospitals discussed the new cases at the beginning of the MDTM, followed by recurring cases

• Discussed tumor types (e.g., solely upper-GI leads to better focus, gastroenterological cancer patients)

In the majority of the hospitals only oncologic upper-GI patients were discussed during the MDTM, whereas, in some hospitals, other gastroenterological cancers were also discussed

• Attendees (e.g., academic center, dedicated team, referring clinicians, live versus teleconference)

Clinicians may attend the MDTM live or by teleconference. In some non-academic resection hospitals an academic resection hospital was present during the MDTM and in some hospitals the referring clinicians were not present during the MDTM

Patient level

Standardization of clinical examinations

• Histological confirmation of potential metastases

• All centers aim for histological confirmation—centers differ in their action if the results are inconclusive

Hospitals differed on histological confirmation of all potential metastatic disease: some always used histological confirmation, and others used it depending on whether it was important for the decision and according to the reliability of the radiological characteristics

• Patient’s physical functioning

• Fitness test versus medical history and clinical examination

The patient’s physical functioning was assessed differently. Some hospitals conducted fitness tests (CPAP, lung function, ECG), whereas others made an estimation of patient’s physical fitness based on the medical history and clinical examination

• Restaging after neoadjuvant treatment

• Standard

• No restaging

• High-risk patients for interval metastasis

Half of the hospitals performed restaging by PET-CT or CT after neoadjuvant therapy, leading to avoidance of unnecessary surgery in patients diagnosed with interval metastasis

Clinical examination of the patient’s physical and cognitive functioning

• Involving non-upper-GI specialist (e.g., frailty estimation)

• Standard arrangements versus based on clinical assessment

Some hospitals consulted non-upper-GI specialists, such as anesthesiologists, prior to TDM. A geriatric assessment was standard in some hospitals in patients above a certain age, to determine mental fitness and frailty, while others only consulted a geriatrician if deemed necessary

• Pre-habilitation of physical functioning

• Boosting of physical functioning versus less invasive treatment choice

• Active Pre-habilitation programs versus advice/referral

Some hospitals offered a formal pre-habilitation program, including physical therapy and the consultation of a dietician, to improve physical fitness, whereas others only advised patients to improve their physical fitness

  1. Categories in bold are discussed in the result section of this article, TDM Treatment decision-making, MDTM multidisciplinary team meeting