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

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Summary

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.

Introduction

Diffuse parenchymal lung disease represents a diverse and challenging group of pulmonary disorders with varied prognoses and different management options. A consistent diagnostic approach to these diseases is essential if clinical trial data are to be reliably applied to individual patients. With the 2014 licensing of two new antifibrotic idiopathic pulmonary fibrosis (IPF) drugs (pirfenidone1 and nintedanib2), accurate and consistent diagnosis of IPF is of particular importance to achieve clinical benefits for patients. In 2002, a joint statement by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) on the classification of idiopathic interstitial pneumonias advocated a multidisciplinary diagnostic approach, involving integration of clinical, radiological, and, in cases for which lung biopsy material is available, pathological data.3 This approach has been emphasised by several studies4, 5, 6, 7 in the past 12 years and was restated in the 2013 ATS/ERS update8 on idiopathic interstitial pneumonia classification. Although this recommendation specifically applies to idiopathic interstitial pneumonia, a multidisciplinary approach has been widely used as the diagnostic gold standard for diffuse parenchymal lung disease in general.4, 6 Several studies4, 5, 6, 9 have evaluated inter-observer agreement for diagnosis in the setting of diffuse parenchymal lung disease. However, most of these studies pre-date the 2013 ATS/ERS update,8 the 2011 joint ATS/ERS/Japanese Respiratory Society/Latin American Thoracic Association statement10 on the diagnosis and management of IPF, and the availability of novel antifibrotic IPF drugs (pirfenidone1 and nintedanib2), all of which might affect diagnostic decisions. Furthermore, many of these studies focused on individual observers rather than agreement between multidisciplinary teams.4, 5, 6, 9, 11 In this study, we aimed to evaluate the level of inter-multidisciplinary team diagnostic agreement between seven international centres for diagnosis of diffuse parenchymal lung disease.

Section snippets

Study design, patients, and multidisciplinary team selection

For this case-cohort study we selected consecutive patients who presented to the interstitial lung disease unit of the Royal Brompton and Harefield NHS Foundation Trust (London, UK; host institution) and patients with challenging diagnosis had MDTM characterisation, between March 1, 2010, and Aug 31, 2010. Only patients who had all their clinical investigations (serology, high-resolution CT, and, when required, surgical lung biopsy) completed at the host institution were included. Seven

Results

We identified 113 consecutive new patient referrals, who required local MDTM characterisation, from the clinical database of the host institute between March 1, 2010, and Aug 31, 2010. We excluded 43 (38%) of 113 referrals on the basis that their initial work-up high-resolution CT scan (29 patients), lung function (four patients), or surgical lung biopsy (ten patients) were completed by the referring institution (appendix). The remaining 70 (62%) of 113 patient referrals were included as the

Discussion

We have shown that an acceptable level (based on κ>0·40 is deemed clinically acceptable) of diagnostic agreement exists between multidisciplinary teams in the setting of diffuse parenchymal lung disease. Additionally, we showed that this agreement was validated by the non-significant increases towards greater prognostic separation of an IPF diagnosis made by multidisciplinary teams than by individual clinicians or radiologists. Furthermore, MDTMs make the diagnosis of IPF with high confidence

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