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