title: Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  National Institute of Health Research, Imperial College London.
authors.affiliation: Department of Radiology, London, UK. Electronic address: slfwalsh@gmail.com.
authors.forename: Simon L F
authors.initials: SLF
authors.lastname: Walsh
authors.affiliation: Interstitial Lung Disease Unit, London, UK.
authors.forename: Athol U
authors.initials: AU
authors.lastname: Wells
authors.affiliation: King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Sujal R
authors.initials: SR
authors.lastname: Desai
authors.affiliation: Department of Diseases of the Thorax, GB Morgagni Hospital, Forlì, Italy.
authors.forename: Venerino
authors.initials: V
authors.lastname: Poletti
authors.affiliation: Department of Radiology, GB Morgagni Hospital, Forlì, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Piciucchi
authors.affiliation: Department of Surgical Pathology, Morgagni Pierantoni Hospital, Forlì, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Dubini
authors.affiliation: 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.
authors.forename: Hilario
authors.initials: H
authors.lastname: Nunes
authors.affiliation: 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.
authors.forename: Dominique
authors.initials: D
authors.lastname: Valeyre
authors.affiliation: Université Paris, Sorbonne Paris Cité, EA2363 Réponses cellulaires et fonctionnelles à l'hypoxie, Bobigny, France; Service de Radiologie, Hôpital Avicenne, Bobigny, France.
authors.forename: Pierre Y
authors.initials: PY
authors.lastname: Brillet
authors.affiliation: Service d'Anatomie Pathologique, Hôpital Avicenne, Bobigny, France.
authors.forename: Marianne
authors.initials: M
authors.lastname: Kambouchner
authors.affiliation: Serviço de Pneumologia, Porto, Portugal; Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
authors.forename: António
authors.initials: A
authors.lastname: Morais
authors.affiliation: Centro Hospitalar São João, Porto, Portugal.
authors.forename: José M
authors.initials: JM
authors.lastname: Pereira
authors.affiliation: Pathology Department, Porto, Portugal.
authors.forename: Conceição Souto
authors.initials: CS
authors.lastname: Moura
authors.affiliation: ILD Center of Excellence St Antonius Hospital, Division Heart and Lungs, University, Medical Centre Utrecht, Netherlands.
authors.forename: Jan C
authors.initials: JC
authors.lastname: Grutters
authors.affiliation: Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: van den Heuvel
authors.affiliation: Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Hendrik W
authors.initials: HW
authors.lastname: van Es
authors.affiliation: Department of Pathology, St Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Matthijs F
authors.initials: MF
authors.lastname: van Oosterhout
authors.affiliation: Department of Pathology, St Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Cornelis A
authors.initials: CA
authors.lastname: Seldenrijk
authors.affiliation: Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Bendstrup
authors.affiliation: Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Finn
authors.initials: F
authors.lastname: Rasmussen
authors.affiliation: Department of Pathology, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Line B
authors.initials: LB
authors.lastname: Madsen
authors.affiliation: Division of Asthma, Allergy and Lung Biology, King's College London, London, UK.
authors.forename: Bibek
authors.initials: B
authors.lastname: Gooptu
authors.affiliation: Department of Cellular Pathology, University College Hospital London, London, UK.
authors.forename: Sabine
authors.initials: S
authors.lastname: Pomplun
authors.affiliation: Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Taniguchi
authors.affiliation: Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
authors.forename: Junya
authors.initials: J
authors.lastname: Fukuoka
authors.affiliation: Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, Itami, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Johkoh
authors.affiliation: National Heart and Lung Institute, Imperial College London, London, UK.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Nicholson
authors.affiliation: Brighton and Sussex University Hospitals Trust, Brighton, UK.
authors.forename: Charlie
authors.initials: C
authors.lastname: Sayer
authors.affiliation: National Heart and Lung Institute, Imperial College London, London, UK.
authors.forename: Lilian
authors.initials: L
authors.lastname: Edmunds
authors.affiliation: Royal Brompton and Harefield NHS Foundation Trust, London, UK.
authors.forename: Joseph
authors.initials: J
authors.lastname: Jacob
authors.affiliation: Interstitial Lung Disease Unit, London, UK.
authors.forename: Maria A
authors.initials: MA
authors.lastname: Kokosi
authors.affiliation: Department of Pathology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Myers
authors.affiliation: Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Flaherty
authors.affiliation: Department of Radiology, London, UK.
authors.forename: David M
authors.initials: DM
authors.lastname: Hansell
mesh_terms: D000368:Aged; D000542:Alveolitis, Extrinsic Allergic / Q000175:diagnosis; D000066491:Clinical Decision-Making / Q000379:methods*; D015331:Cohort Studies; D003937:Diagnosis, Differential; D005060:Europe; D005260:Female; D006801:Humans; D054990:Idiopathic Pulmonary Fibrosis / Q000175:diagnosis*; D033183:Interdisciplinary Communication; D007564:Japan; D017563:Lung Diseases, Interstitial / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010348:Patient Care Team; D018579:Patient Selection; D011336:Probability; D016016:Proportional Hazards Models; D012044:Regression Analysis