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Lancet Respir Med. 2016 Jul;4(7):557-565. doi: 10.1016/S2213-2600(16)30033-9. Epub 2016 May 11.

Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study.

Author information

1
Department of Radiology, London, UK. Electronic address: slfwalsh@gmail.com.
2
Interstitial Lung Disease Unit, London, UK.
3
King's College Hospital NHS Foundation Trust, London, UK.
4
Department of Diseases of the Thorax, GB Morgagni Hospital, Forlì, Italy.
5
Department of Radiology, GB Morgagni Hospital, Forlì, Italy.
6
Department of Surgical Pathology, Morgagni Pierantoni Hospital, Forlì, Italy.
7
Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Avicenne, Bobigny, France.
8
Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Service de Radiologie, Hôpital Avicenne, Bobigny, France.
9
Service d'Anatomie Pathologique, Hôpital Avicenne, Bobigny, France.
10
Serviço de Pneumologia, Porto, Portugal; Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
11
Centro Hospitalar São João, Porto, Portugal.
12
Pathology Department, Porto, Portugal.
13
ILD Center of Excellence St Antonius Hospital, Division Heart and Lungs, University, Medical Centre Utrecht, Netherlands.
14
Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands.
15
Department of Pathology, St Antonius Hospital, Nieuwegein, Netherlands.
16
Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark.
17
Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.
18
Department of Pathology, Aarhus University Hospital, Aarhus, Denmark.
19
Division of Asthma, Allergy and Lung Biology, King's College London, London, UK.
20
Department of Cellular Pathology, University College Hospital London, London, UK.
21
Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan.
22
Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
23
Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, Itami, Japan.
24
National Heart and Lung Institute, Imperial College London, London, UK.
25
Brighton and Sussex University Hospitals Trust, Brighton, UK.
26
Royal Brompton and Harefield NHS Foundation Trust, London, UK.
27
Department of Pathology, University of Michigan, Ann Arbor, MI, USA.
28
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
29
Department of Radiology, London, UK.

Abstract

BACKGROUND:

Diffuse parenchymal lung disease represents a diverse and challenging group of pulmonary disorders. A consistent diagnostic approach to diffuse parenchymal lung disease is crucial if clinical trial data are to be applied to individual patients. We aimed to evaluate inter-multidisciplinary team agreement for the diagnosis of diffuse parenchymal lung disease.

METHODS:

We did a multicentre evaluation of clinical data of patients who presented to the interstitial lung disease unit of the Royal Brompton and Harefield NHS Foundation Trust (London, UK; host institution) and required multidisciplinary team meeting (MDTM) characterisation between March 1, 2010, and Aug 31, 2010. Only patients whose baseline clinical, radiological, and, if biopsy was taken, pathological data were undertaken at the host institution were included. Seven MDTMs, consisting of at least one clinician, radiologist, and pathologist, from seven countries (Denmark, France, Italy, Japan, Netherlands, Portugal, and the UK) evaluated cases of diffuse parenchymal lung disease in a two-stage process between Jan 1, and Oct 15, 2015. First, the clinician, radiologist, and pathologist (if lung biopsy was completed) independently evaluated each case, selected up to five differential diagnoses from a choice of diffuse lung diseases, and chose likelihoods (censored at 5% and summing to 100% in each case) for each of their differential diagnoses, without inter-disciplinary consultation. Second, these specialists convened at an MDTM and reviewed all data, selected up to five differential diagnoses, and chose diagnosis likelihoods. We compared inter-observer and inter-MDTM agreements on patient first-choice diagnoses using Cohen's kappa coefficient (κ). We then estimated inter-observer and inter-MDTM agreement on the probability of diagnosis using weighted kappa coefficient (κw). We compared inter-observer and inter-MDTM confidence of patient first-choice diagnosis. Finally, we evaluated the prognostic significance of a first-choice diagnosis of idiopathic pulmonary fibrosis (IPF) versus not IPF for MDTMs, clinicians, and radiologists, using univariate Cox regression analysis.

FINDINGS:

70 patients were included in the final study cohort. Clinicians, radiologists, pathologists, and the MDTMs assigned their patient diagnoses between Jan 1, and Oct 15, 2015. IPF made up 88 (18%) of all 490 MDTM first-choice diagnoses. Inter-MDTM agreement for first-choice diagnoses overall was moderate (κ=0·50). Inter-MDTM agreement on diagnostic likelihoods was good for IPF (κw=0·71 [IQR 0·64-0·77]) and connective tissue disease-related interstitial lung disease (κw=0·73 [0·68-0·78]); moderate for non-specific interstitial pneumonia (NSIP; κw=0·42 [0·37-0·49]); and fair for hypersensitivity pneumonitis (κw=0·29 [0·24-0·40]). High-confidence diagnoses (>65% likelihood) of IPF were given in 68 (77%) of 88 cases by MDTMs, 62 (65%) of 96 cases by clinicians, and in 57 (66%) of 86 cases by radiologists. Greater prognostic separation was shown for an MDTM diagnosis of IPF than compared with individual clinician's diagnosis of this disease in five of seven MDTMs, and radiologist's diagnosis of IPF in four of seven MDTMs.

INTERPRETATION:

Agreement between MDTMs for diagnosis in diffuse lung disease is acceptable and good for a diagnosis of IPF, as validated by the non-significant greater prognostic separation of an IPF diagnosis made by MDTMs than the separation of a diagnosis made by individual clinicians or radiologists. Furthermore, MDTMs made the diagnosis of IPF with higher confidence and more frequently than did clinicians or radiologists. This difference is of particular importance, because accurate and consistent diagnoses of IPF are needed if clinical outcomes are to be optimised. Inter-multidisciplinary team agreement for a diagnosis of hypersensitivity pneumonitis is low, highlighting an urgent need for standardised diagnostic guidelines for this disease.

FUNDING:

National Institute of Health Research, Imperial College London.

PMID:
27180021
DOI:
10.1016/S2213-2600(16)30033-9
[Indexed for MEDLINE]
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