Guidelines, lists and templates should be tools of the trade in the multidisciplinary effort to improve the accuracy and consistency of diagnosis in interstitial lung diseases (ILD).
Delegates attending the Respiratory Insights Forum in Melbourne were told that a systematic approach was critical to achieving diagnostic agreement in such a complex set of disorders.
Useful resources to standardise the presentation of clinical data, guide the sequence of discussion at multidisciplinary meetings (MDM) and record outcomes are freely available online in the Lung Foundation Australia’s ILD MDM Toolkit.
Supporting the Thoracic Society of Australia and New Zealand and Lung Foundation Australia’s Position Statement on the MDM1, the resources include lists of common and agreed diagnostic terms and a template for documenting relevant clinical trials.
Associate Professor Ian Glaspole, head of the ILD clinic at the Alfred Hospital, said MDM outcomes relied on good quality CT scanning, serology and discussion.
“Case presentations must be systematic and detailed to enhance discussion. A scripted approach to discussion is helpful.”
He said wherever possible, the use of consensus guidelines would help improve agreement on a diagnosis.
“Where there aren’t guidelines, use expert opinion articles.”
Associate Professor Glaspole told the limbic consensus guidelines were difficult to develop for some conditions because they were so rare and it was hard to determine their hallmark features.
“But we are getting there because there are working papers and white papers and other forms of expert opinion that are the stepping stones to those consensus guidelines.”
He said a broad group of experts was important for the MDM process.
“If you can’t get a rheumatologist for example to come to the meeting, then have a clear pathway for referral.”
He said there was evidence in idiopathic pulmonary fibrosis (IPF) that academic physicians with greater than 20 years clinical experience had better prognostic discrimination than non-university hospital colleagues2. Physicians with no access to multidisciplinary meetings had the lowest level of diagnostic agreement for the diagnosis of IPF.
However, importantly, regular attendance at a multidisciplinary meeting could improve the prognostic accuracy of clinicians to levels achieved by IPF experts.
He urged clinicians to take the opportunity in MDMs to teach and train others interested in ILD.
He added that teleconferencing or videconferencing were options to help make the benefits of multidisciplinary meetings more widely available. MBS item numbers 802-828 may be applied for case conferencing.
While prescription of anti-fibrotic therapies for IPF requires a diagnosis confirmed through a MDM, Associate Professor Glaspole said an accurate diagnosis was also increasingly important as new therapies became available.
“We should try to identify a specific diagnosis so we can tailor therapy. The big dichotomy is IPF versus non-IPF. We know that we need to be able to make that distinction because immune suppression especially with azathioprine and prednisone, is dangerous in that group.”
References
- Prasad JD et al. The interstitial lung disease multidisciplinary meeting: a position statement from the Thoracic Society of Australia and New Zealand and the Lung Foundation Australia. Respirology 2017; 22:1459-1472. https://www.ncbi.nlm.nih.gov/pubmed/28891101
- Walsh SLF et al. Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: an international case–cohort study. Eur Respir J. 2017; 50:1700936. https://www.ncbi.nlm.nih.gov/pubmed/28860269