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Evidence reviews for service configuration and delivery – investigations
Evidence review A
NICE Guideline, No. 234
Service configuration & delivery (investigations)
Review question
What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
Introduction
The configuration of services for the investigation and referral of people with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression raises a number of challenges. People may present at different locations (for example at their GP or at secondary care), they may present as an emergency needing urgent investigations, and they may require transfer to another place for investigations such as MRI. This review aims to compare different ways in which these services can be configured effectively.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Service delivery evidence
Included studies
Four observational studies were included for this review, all 4 were retrospective cohort studies (Crnalic 2013, McGivern 2014, Mattes 2020, Pease 2004).
The included studies are summarised in Table 2.
One study compared outcomes according to referral source (Crnalic 2013), two studies compared outcomes before and after implementation of a care pathway (Mattes 2020, Pease 2004), and 1 study assessed compliance with guidance from the Royal College of Radiologists at two time points (McGivern 2014).
Two studies were conducted in the United Kingdom, 1 was conducted in Sweden, and 1 was conducted in the United States.
For the related review of clinical evidence and economic model on service configuration and delivery for management and early rehabilitation see evidence review B.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.
Summary of included studies
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included studies.
See the full evidence tables in appendix D. No meta-analysis was conducted (and so there are no forest plots in appendix E).
Summary of the evidence
There was very low quality evidence of an important benefit in terms of reduced delays to surgery (general reduced delay to surgery as well as reduced delay to surgery from MRI diagnosis) when patients were able to present directly to a cancer centre rather than being referred by a local hospital.
There were important benefits in one study with the use of a clinical care pathway in terms of improved mortality rate and decreased number of people nursed flat. However, another study showed no important difference in waiting times between services/procedures after the implementation of a clinical care pathway (with the exception of timing between MRI and radiotherapy consultation). This evidence was very low to low quality.
Very low to low quality evidence from a UK national audit showed improvements from 2008 to 2012 in access to services (coinciding with the development of referral and care pathways informed by the NICE 2008 MSCC guidance). There were improvements in the number of people with MSCC who had MRI within 24 hours of referral for radiotherapy, who were discussed with a surgeon, and who had radiotherapy within 24 hours of referral for radiotherapy.
There were no studies identified which reported on quality of life, patient satisfaction, time to paralysis, or emergency admission and length of hospital stay.
See the evidence profiles in appendix F.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
A single economic search was undertaken for all topics included in the scope of this guideline. See supplement 2 for details.
Excluded studies
Economic studies not included in this review are listed, and reasons for their exclusion are provided in supplement 2.
Summary of included economic evidence
No economic studies were identified which were applicable to this review question.
Economic model
An economic model was developed for this topic looking at the cost effectiveness of uptraining staff to make complex decisions around people referred to a regional MSCC centre. This was within an MSCC service that was working in accordance with NICE’s 2008 guideline principles including the MSCC coordinator model. As the economic model also covered the review questions in evidence report B, the full economic model is reported in appendix I of that report.
The economic model was based on audit data from January 2018 (the launch of the service) to May 2022 from Clatterbridge Cancer Centre regional MSCC service. The MSCC service was set-up based on recommendations made in the previous guideline.
A before and after study design was used to look retrospectively at differences in survival, QALYs and costs following uptraining of staff to make complex decisions around people referred to the centre. The model was also designed to look at trends in survival and costs since the launch of the service to make inferences about improvements over time. The model also used English Indices of Multiple Deprivation to investigate whether these outcomes differed based on levels of deprivation.
The economic analysis found that after uptraining staff survival increased and costs reduced. Length of survival also increased over the time of the service showing steady improvement. These benefits were not evenly distributed across all deprivation groups with the largest benefits coming in the second and third least deprived quintiles.
There were a number of weaknesses with the economic model which are discussed in detail in the full report in evidence report B (appendix I).
The committee’s discussion and interpretation of the evidence
The outcomes that matter most
Overall survival, quality of life, patient satisfaction and neurological and functional status were chosen as critical outcomes. This is because efficient referral and care pathways should lead to quicker diagnosis and treatment of metastatic spinal disease leading to better patient outcomes. Emergency admission to hospital and length of stay were important outcomes because an inefficient or delayed referral pathway could increase emergency hospital admissions and result in longer hospital stays. Access to services was chosen as an important outcome to capture service availability in terms of geographic location and waiting times for services. Different configurations (for example centralised versus local) mean that patients may have to travel or wait longer for services.
The quality of the evidence
The quality of the evidence was assessed using GRADE, with all outcomes being rated as low or very low quality. This was predominately due to a very serious overall risk of bias in the studies which contributed to each outcome (mainly due to the risk of confounding), and serious or very serious levels of imprecision in the effect estimates.
No evidence was identified which evaluated the impact of different service configuration and delivery systems on quality of life, patient satisfaction, time to paralysis, or emergency admission and length of hospital stay. Even though the evidence was mainly low quality the committee decided that some of the studies were directly applicable to the UK context using data from audits that compare services for example pre and post implementation of the previous NICE guideline (McGivern 2014) and an audit of an MSCC service that was implemented in accordance with the previous guideline and has since evolved to bring in further refinements which showed steady improvements in length of survival over time (audit of the Clatterbridge Cancer Service - see evidence report B for the related clinical and economic evidence). They therefore gave this evidence more weight in their discussion but also used their expertise and experience and considered recommendations from the previous guideline.
Benefits and harms
The committee discussed that the previous guideline set service configuration standards for care with some detailed recommendations about how they should function. The guideline also led to a NICE quality standard for MSCC which featured service configuration as an important driver for improvements in MSCC care with 2 standards relating to the importance of the role of the MSCC coordinator (statements 4 and 5 - Metastatic spinal cord compression in adults – QS56) and two studies referring to the timing of MRI (statements 2 and 3 - Metastatic spinal cord compression in adults – QS56). The committee agreed that these standards ought to be maintained and improved upon where variation still exists. They therefore used the previous guideline’s recommendations as a starting point for their discussion.
Providing a coordinated MSCC service
There was some evidence that referral pathways were associated with better outcomes particularly related to quicker access to services. Whilst it was not clear in the evidence which exact part of the pathway was driving the faster access to services the committee discussed their experience of the care of people with suspected or confirmed spinal metastases or MSCC and that it requires clear pathways and services to address the complex nature and needs of people with the condition. They noted that the evidence was low quality but agreed that having an MSCC service is consistent with previous guidance which set important standards. However, they noted that many such services currently only accept referrals for suspected or confirmed MSCC rather than spinal metastases. Due to this wider group than in the previous guideline the committee recommended that referrals should be made to this service with an appropriate level of urgency (as described in other recommendations related to other evidence reviews – see for example evidence review D for a discussion on timings around recognition) so that services are not overwhelmed. They noted the number of different specialties that have to be involved in the person’s care and that access to all of the different investigations and referral to specialties requires one coordinated service to address the person’s needs, deal with emergency situations and prevent serious adverse events. They agreed that this can only be achieved if a service is well organised and coordinated. Therefore they decided that there has to be an MSCC service and that it needs to be clear how to refer into it so that people with suspected or confirmed spinal metastases, direct malignant infiltration (DMI) of the spine or MSCC receive prompt diagnosis and treatment in a coordinated way. The committee noted that it is particularly important that referral processes into an MSCC service are clear because this is where delays can lead to serious adverse outcomes. So, they decided to specifically highlight referral processes which is an addition to what was in previous guidance and should improve care.
They discussed that have a designated person as the first point of contact is also very important for the MSCC service. This would be the MSCC coordinator or a designated senior clinician. They acknowledged that usually there would only be one MSCC coordinator in most services and therefore when the MSCC coordinator is not working it would usually be the responsibility of a designated clinician with appropriated expertise to carry out this role. They discussed that some knowledge of cancer or MSCC would be needed so usually that would be an on-call oncology registrar, but they decided to give this as an example rather than being prescriptive about this. This would ensure that referrals into the service and coordination of care within the service take place as promptly and efficiently as possible. Some evidence from a UK audit before and after NICE’s 2008 recommendation (which introduced the role of the MSCC coordinator) showed an improvement in access to services with shorter delays to MRI diagnosis and radiotherapy or surgical treatment. The committee noted that there are uncertainties in the evidence because improvements could be a result of many different components of a service. However, they decided that the coordinator role is particularly important to help the person with the condition and the healthcare professionals treating them to navigate the care pathway. Based on their experience of services and how they have evolved and improved since the previous guideline, they recommended that the designated contact is based in the oncology service, as direct access to this speciality can help to minimise delays in triage and treatment planning. The committee agreed that this has clear advantages with ease of access to expertise and knowledge related to a person’s primary tumour and prognosis so that this information can then be disseminated quicker to other specialties that are also involved in the MSCC care pathway.
In line with the previous guideline and based on their experience and knowledge of services in which the role of the MSCC coordinator has become an important part (including the Clatterbridge Cancer service - see the de novo analysis of the audit data in evidence report B), the committee agreed to recommend that each MSCC service should ensure that the role of the MSCC coordinator is covered at all times (24 hours a day, 7 days a week) which would be carried out by the designated clinician with appropriated expertise to carry out this role when the MSCC coordinator is not working.
The committee acknowledged, based on experience, that there is still variation in practice in relation to how the coordination of care for people with MSCC is implemented. They noted that the range of clinical specialities involved in care for people with this condition makes this even more difficult. The committee therefore agreed to recommend that MSCC services make clear arrangements to promote coordinated care, for example, by ensuring that referral criteria and processes are clarified, and that communication and information sharing protocols are understood. This would lead to a more effective collaboration between specialties and between primary care and specialist settings which can speed up investigation and diagnosis which ultimately also leads to timely management.
On the basis of their own experience, the committee agreed that MSCC services work most effectively when a multidisciplinary approach is in place, given the number of specialities involved in the care of people with spinal metastases or MSCC. The committee therefore agreed to recommend that MSCC services use a multidisciplinary approach and that each specialty should designate an individual point of contact (which could be a designated person or designated phone number). Having such a single point of contact makes coordination between specialties easier so that the designated first contact knows who to contact when advice or referral is needed. The committee agreed that this would help to make decision making and care planning more efficient and holistic. There was discussion whether all specialities would have to come together in in-person meetings to make decisions which could cause logistical problems and that it is also possible that not all specialties are needed for every discussion. The committee noted that there are now commonly processes in place to make virtual or phone attendance in meetings possible. They did not want to be prescriptive about the way the multidisciplinary approach is implemented because working practices are generally evolving so they did not specify this.
The committee also considered a new analysis conducted for this guideline of an audit of all people referred to an MSCC service between January 2018 until end of May 2022 in the UK Clatterbridge Cancer Centre (covering a population of 2.4 million people across Cheshire, Merseyside, and the surrounding areas), the details of which are described in the related evidence report B. The committee discussed the analysis of deprivation data in the Clatterbridge Cancer Centre audit data (see the de novo economic model in evidence report B) which showed that people in the higher quintiles of deprivation benefited less from service improvements than people in less deprived areas. They agreed that there were many possible explanations that could lead to such findings, for example having less time or experiencing challenges in accessing health services. However, they also acknowledged that this was not restricted to MSCC alone but also relevant to other conditions. They also discussed this in relation to the equality impact assessment conducted during scoping of the guideline which listed a number of factors including socioeconomic status that lead to different health outcomes in cancer. The committee noted that a lot of the factors that could relate to deprivation and health outcomes are general public health concerns that cannot be addressed in a single guideline but agreed that it is important for healthcare professionals to be aware of the impact of health inequalities on outcomes on particular groups of people with spinal metastases, DMI of the spine or MSCC in their local area (for example deprivation). The committee decided that local services should collect and analyse information related to their services because this could help to identify groups that may access services less or may experience other service inequalities. Investigating such information is important because inequalities vary by region. They acknowledged that healthcare professionals are not always aware of the specific inequalities in their area and that education is therefore needed. They thought that this information and education would enable services to make reasonable adjustments to be made in line with the Equality Act 2010 to help address and reduce inequalities.
Roles in a coordinated MSCC service
The committee agreed on the basis of their own experience, that MSCC services are most effective when roles and responsibilities are clearly defined. They discussed that the condition is an oncological emergency where timing is crucial to prevent serious long term neurological deficits. Having clear roles and responsibilities will speed up processes and make them more efficient so that the person is triaged more quickly to the services they require. They therefore agreed to set out in the recommendations some of the key tasks that the MSCC coordinator would carry out to provide clarity about the role and standardise it. Based on their knowledge of effective coordinated care the committee agreed that having a clear record of all investigations and assessments is one important responsibility of the coordinator. Having this information in one place and being able to provide it to the relevant speciality when needed is an efficient way to support decision making. The MSCC coordinator should ensure that the initial triage regarding the person’s care is carried out. In this way the person will get the investigations and management they need in a timely manner. Information sharing is also a responsibility of the coordinator so that the specialties have all the details of the investigations and assessment ready to plan treatment. The committee also discussed that safe and timely discharge is important and that this would require a lot of coordination between services. They therefore agreed that the planning in relation to this should also be included in the role of the MSCC coordinator.
The committee discussed that MSCC is a condition with many facets and complexities and therefore referring clinicians would need advice on topics that are covered in other sections of the guideline. This would be initial information that is immediately needed to assess the urgency of actions, such as the options for pain management, the factors that may indicate that there is spinal instability, when to immobilise someone, when or whether corticosteroids should be given, and whether or not transfer to specialist services may be needed. The committee discussed that the initial advice could be given by an MSCC coordinator because the role requires a clinical background.
Based on experience the committee noted that being clear that developing a personalised care plan is part of the role of the senior clinician from the multidisciplinary MSCC team would contribute to better coordinated care. They should work with the person and relevant other healthcare professionals to tailor the care plan to the specific identified needs. They agreed that there were a number of potential specialities that have to be contacted for advice (and they gave examples of these) and having someone with a clear responsibility for making a treatment plan would make liaising between specialties more efficient which would also lead to quicker implementation of the plan. They acknowledged that the previous guideline was prescriptive about the time frame for a personalised care plan within 24 hours. The committee decided that it was important to tailor the planning to the individual and gather all relevant information and advice. They also discussed that the previous guideline focused on MSCC only with regards to a treatment plan within 24 hours and that the current guideline also included people with suspected or confirmed spinal metastases which then required more flexibility around timing. They noted that it could take longer for someone with suspected spinal metastases than someone with MSCC who would need an urgent treatment plan and therefore decided not to specify the timing around this.
The committee also agreed to recommend that due to the emergency nature of conditions such as metastatic spinal cord compression; specialist services treating spinal metastases, direct malignant infiltration of the spine, or MSCC should ensure that a senior clinician is available at all times to provide advice to MSCC services. This would ensure the safety of the person so that prompt action can be taken to prevent serious adverse events.
Providing urgent imaging services
Although there were uncertainties in the evidence on the timing of MRI assessments, the committee agreed that earlier scans for people with suspected MSCC, for example, within 24 hours of admission, led to improved patient outcomes. As this was consistent with their own experience and is well established in practice, the committee agreed to be consistent with the 24 hour timeframe of the previous guideline’s recommendation to ensure prompt diagnosis and maintain standards. Based on the audit data which organised services consistent with the previous guideline and knowledge of other current practices they made service organisation recommendations to enable this, for example in relation to availability of MRI outside normal working hours and planning appointment lists.
Providing support
Based on evidence related to the new analysis of audit data (particularly related to deprivation) and the equality impact assessment conducted during scoping of the guideline (raising issues such as different outcomes by age, sex, ethnicity and other factors) the committee noted that there are many potential inequalities in how people access services and how they experience their care once in a service. They acknowledged that it is often difficult to pinpoint what people may experience as barriers when accessing services and that it can be easy for healthcare professionals to make assumptions according to broad group characteristics. The committee decided that services have to learn from people’s experiences which can only happen by having mechanisms to ask for feedback from people with lived experience and their family or carers. This may highlight particular concerns that people have about any parts of the pathway as well as any other circumstances that create difficulties for them which could be social or practical (for example finding it hard to physically get to the service or having disabilities that may impact how they experience services). They agreed that the MSCC service could adapt to better meet the needs of the people using it, by discussing with people and their family or carers about their experience of the service and any concerns that they may have.
Timing of MRI assessments
The committee noted that the previous guideline’s 24 hour MRI turnaround which they decided to adopt because of the emergency nature of the condition, was also based on the previous guideline’s economic model which was consulted on and published alongside the guideline and was found to be cost effective. The committee discussed, based on experience, that currently too many people with suspected MSCC are transferred to specialist centres for MRI investigations. They agreed that this would not be needed and that MRI should if possible be at the local hospital or appropriate centre with direct access imaging facilities, as this would usually be quicker and avoid lengthy and potentially painful transfers for the patient. They acknowledged that local hospitals may not always have the capacity to perform MRIs at short notice and in this case transfer to a tertiary centre would be needed.
The committee agreed that less urgency was required for those with suspected spinal metastases or DMI of the spine but without suspicion of MSCC, and that a 1-week timeframe was reasonable. This is due to the much lower risk of disability in case of a few days’ treatment delay in this group. Given the less urgent nature they agreed that it should be possible to schedule this MRI at the local hospital.
The committee agreed, based on their experience, that most MRIs could be done in-hours but acknowledged that in some cases an out-of-hours MRI would be appropriate in emergency situations where treatment has to start immediately, for example when there are concerns about a potential spinal column collapse.
How the recommendations might affect services
The committee acknowledged that many MSCC services currently only accept referrals for suspected or confirmed MSCC but not for people with spinal metastases without MSCC. This means that the new recommendations will increase activities for MSCC services significantly. The committee discussed that MSCC services should have spinal oversight and bring together the relevant critical expertise which would have clinical and survival benefits. The evidence from the economic model based on a service that was already set up and providing full spinal oversight showed that once implemented it resulted in cost savings per person and increased overall survival, prevented people losing function and maintained their independence (for key points see the section below and for the full economic model see evidence review B). The committee noted that many services already provide advice on the treatment of spinal metastases or suspected MSCC so relevant experience already exists that would help implement this. There have been substantial improvements since the publication of the previous guideline that recommended MSCC services including the role of the MSCC coordinator. One example of how services have developed and improved is that they have their first contact within oncology which makes services quicker and more efficient because knowledge about the primary cancer and the prognosis can be disseminated to other specialists more quickly aiding decision making. Also, the availability of MRI scanning in local hospitals has improved since the previous guideline and so the committee recommended that people are not transferred unnecessarily. The committee noted that there is still variation in the way the roles within the service are implemented and so recommended the roles and responsibilities for key members of the MSCC service should be to provide clarity about their own role as well as to everyone within the team. Having designated contacts for each specialty within the MSCC service is not current practice everywhere but the committee agreed that this would make information sharing and collaboration across teams quicker and more efficient.
Cost effectiveness and resource use
No previous economic evidence was identified in the review of the economic evidence. Therefore, all considerations around cost effectiveness and resource use were drawn from the bespoke economic model developed for this and Evidence Report B and the committee’s own experience and knowledge. The bespoke economic model for the evidence report was a ‘before and after’ study. The ‘before’ service was fully compliant with the previous NICE guideline and the ‘after’ included some upskilling of staff, from a range of disciplines, to become trained MSCC coordinators and strengthen the current working practices. The economic model found that upskilling staff to become MSCC coordinators and be able to make complex decisions around patients referred to a regional MSCC service led to higher survival, greater QALYs and reduced costs. The committee thought these outcomes were plausible even though there were weaknesses with the study due to being unable to adequately control for confounding factors. Extrapolating from this, the committee considered that these cost savings and health improvements came from quicker diagnosis and treatment and that similar interventions to improve these areas would also lead to similar results. The committee also highlighted from the ‘before and after’ study that survival had improved year on year since the creation of the service. This was used as support for a number of recommendations which mirrored the Clatterbridge Cancer Centre MSCC service.
The bespoke economic model for this guideline did not include any costs for setting-up a coordinated service or training more MSCC coordinators. These costs will include the creation of computer systems (to manage people referred to the service, collect audit data and allow for virtual multidisciplinary team meetings), pathways, referral forms and regional guidelines. A new centre will also need communication, engagement and training events with referring organisations to explain and teach the new processes. This will lead to a large one-off cost. There will be opportunities for learning from other centres, like the Clatterbridge Cancer Centre MSCC service, which will provide efficiencies. The bespoke economic model showed that costs decreased per person after the creation of the service and therefore it could be inferred that implementation costs should be regained over the first few years of a newly set up service.
A number of recommendations were made that mirrored the Clatterbridge regional MSCC centre including a designated point of contact for services available 24 hours a day, 7 days a week and coordinated care including common referral criteria and processes clearly communicated to referring centres. Whilst the economic model did not explicitly look at all these interventions it was noted by the committee that the audit data used in the model started at the creation of the regional service (including the aspects above) and that length of survival had increased and cost per person had decreased over time. Pathways need to make sure that people with suspected MSCC are referred promptly to up-trained staff for a treatment or referral decision to realise the benefits of an MSCC coordinator and having more people trained to this level is one way of achieving this. As above there will be some upfront costs from implementing these recommendations such as running events to promote and explain the pathway, but these should be short term and regained from later cost savings.
The committee raised concerns that whilst there would be benefits from these recommendations that they may not be spread equally across all socioeconomic groups based on the health inequalities analysis in the economic model. Recommendations were therefore made that local services should collect, analyse and disseminate information on local health inequalities and that feedback should be sought from service users and their families so that potential concerns about access to services can be addressed. As auditing of services will already be happening for MSCC services this should not require any additional time or resources. Socio-economic data can be added easily to the audit data for example through matching Indices of Multiple Deprivation data to an individual’s postcode.
The committee also recommended that 24-hour MRI should be available locally for urgent cases which potentially require treatment immediately. The committee acknowledged that providing this 24-hours a day leads to higher costs. Out-of-hours services are also difficult to staff. The committee therefore only made this recommendation for these urgent cases where more rapid intervention could lead to large survival and quality of life gains and where costly adverse events (such as paralysis) can be averted.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.1.5 to 1.1.10, 1.1.13, 1.1.15 to 1.1.20, 1.2.8 and 1.5.2 to 1.5.4 in the NICE guideline (see also the related economic model in evidence review B).
References – included studies
Crnalic, 2013
Crnalic S, Hildingsson C, Bergh A, et al. Early diagnosis and treatment is crucial for neurological recovery after surgery for metastatic spinal cord compression in prostate cancer. Acta Oncologica, 52, 809, 2013 [PubMed: 22943387]Mattes, 2020
Mattes M and Nieto J. Quality Improvement Initiative to Enhance Multidisciplinary Management of Malignant Extradural Spinal Cord Compression. JCO Oncology Practice, 16, e829, 2020 [PMC free article: PMC7587429] [PubMed: 32384016]McGivern, 2014
McGivern U, Drinkwater K, Clarke J, et al. A royal college of radiologists national audit of radiotherapy in the treatment of metastatic spinal cord compression and implications for the development of acute oncology services. Clinical Oncology, 26, 453, 2014 [PubMed: 24933650]Pease, 2004
Pease N. Development and audit of a care pathway for the management of patients with suspected malignant spinal cord compression, Physiotherapy, 90, 27, 2004
Service delivery
Appendices
Appendix A. Review protocol
Appendix B. Search strategy (clinical/economic)
Appendix C. Service delivery evidence study selection
Appendix D. Evidence tables
Appendix E. Forest plots
Forest plots for review question: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. GRADE tables
Appendix G. Economic evidence study selection
Study selection for: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No economic evidence was identified which was applicable to this review question.
Appendix H. Economic evidence tables
Economic evidence tables for review question: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
An economic evaluation relevant to this evidence report is reported in appendix I of evidence report B.
Appendix J. Excluded studies
Excluded studies for review question: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
Excluded service delivery studies
Table 9Excluded studies and reasons for their exclusion
| Study | Reason for exclusion |
|---|---|
|
Neurosurgical National Audit Programme (NNAP)
https://www | Publication type does not match review protocol – conference abstract |
| Ashcroft, J., Duran, I., Hoefeler, H. et al. (2018) Healthcare resource utilisation associated with skeletal-related events in European patients with multiple myeloma: Results from a prospective, multinational, observational study. European Journal of Haematology 100(5): 479–487 [PubMed: 29444353] | Population does not match review protocol |
| Barzilai, Ori, Boriani, Stefano, Fisher, Charles G et al. (2019) Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice. Global spine journal 9(1suppl): 98s–107s [PMC free article: PMC6512191] [PubMed: 31157152] | Intervention does not match review protocol |
| Beiser, Erez, Soyfer, Viacheslav, Novikov, Ilyia et al. (2019) A critical assessment of the quality of radiation therapy in Israel: time to initiation of treatment of spinal cord compression as an index of efficiency. Journal of neuro-oncology 143(2): 329–335 [PubMed: 31054096] | Intervention does not match review protocol |
| Bollen, Laurens, Dijkstra, Sander P D, Bartels, Ronald H M A et al. (2018) Clinical management of spinal metastases-The Dutch national guideline. European journal of cancer (Oxford, England : 1990) 104: 81–90 [PubMed: 30336360] | Study design - does not match review protocol |
| Brooks, F M, Ghatahora, Ameet, Brooks, M C et al. (2014) Management of metastatic spinal cord compression: awareness of NICE guidance. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 24suppl1: 255–9 [PubMed: 24806394] | Study design - does not match review protocol |
| Charlton, P., Sabbagh, A., Shakir, R. et al. (2018) Implementation of the Oxford Acute Referral System (OARS) an Electronic System to Document and Manage the Acute Referral of Patients with Metastatic Spinal Cord Compression (MSCC). Clinical Oncology 30: 12–s13 | Study design - does not match review protocol |
| Chen, Albert C; Bonnen, Mark D; Mok, Henry (2017) Onsite versus offsite radiation treatment of malignant spinal cord compression: lessons from a safety net health system. The British journal of radiology 90(1072): 20160922 [PMC free article: PMC5605080] [PubMed: 28181815] | Study design - does not match review protocol |
| Choy, W.J.; Phan, K.; Mobbs, R.J. (2019) Editorial on the integrated multidisciplinary algorithm for the management of spinal metastases. Translational Cancer Research 8(supplement2): 152–s155 [PMC free article: PMC8798189] [PubMed: 35117088] | Study design - does not match review protocol |
| Curtin, Mark, Piggott, Robert P, Murphy, Evelyn P et al. (2017) Spinal Metastatic Disease: A Review of the Role of the Multidisciplinary Team. Orthopaedic surgery 9(2): 145–151 [PMC free article: PMC6584164] [PubMed: 28544780] | Intervention - does not match review protocol |
| Dasenbrock, Hormuzdiyar H, Clarke, Michelle J, Thompson, Richard E et al. (2012) The impact of July hospital admission on outcome after surgery for spinal metastases at academic medical centers in the United States, 2005 to 2008. Cancer 118(5): 1429–38 [PubMed: 22009508] | Study design - does not match review protocol |
| Dasenbrock, Hormuzdiyar H, Pradilla, Gustavo, Witham, Timothy F et al. (2012) The impact of weekend hospital admission on the timing of intervention and outcomes after surgery for spinal metastases. Neurosurgery 70(3): 586–93 [PubMed: 21869727] | Study design - does not match review protocol |
| Debono, Bertrand, Braticevic, Cecile, Sabatier, Pascal et al. (2019) The “Friday peak” in surgical referrals for spinal metastases: lessons not learned. A retrospective analysis of 201 consecutive cases at a tertiary center. Acta neurochirurgica 161(6): 1069–1076 [PubMed: 31037499] | Study design - does not match review protocol |
| Dhamija, B.; Batheja, D.; Balain, B. S. (2021) A systematic review of MIS and open decompression surgery for spinal metastases in the last two decades. Journal of clinical orthopaedics and trauma 22: 101596 [PMC free article: PMC8488238] [PubMed: 34631409] | Intervention - does not match review protocol |
| Dunbar, E.M. (2020) Multidisciplinary spine oncology care across the disease continuum. Neuro-Oncology Practice 7: i1–i4 [PMC free article: PMC7705532] [PubMed: 33299567] | Study design - does not match review protocol |
| Eleraky, Mohammed; Papanastassiou, Ioannis; Vrionis, Frank D (2010) Management of metastatic spine disease. Current opinion in supportive and palliative care 4(3): 182–8 [PubMed: 20671554] | Intervention - does not match review protocol |
| Fenton, M. et al. An electronic proforma to improve documentation for cases of metastatic spinal cord compression: A quality-improvement project. Clinical Oncology, Volume 31, e6 | Publication type does not match review protocol – conference abstract |
| Gao, Z. Y., Zhang, T., Zhang, H. et al. (2021) Effectiveness of pre-operative embolization in patients with spinal metastases: a systematic review and meta-analysis. World neurosurgery [PubMed: 34153484] | Intervention - does not match review protocol |
| Gasbarrini, Alessandro, Li, Haomiao, Cappuccio, Michele et al. (2010) Efficacy evaluation of a new treatment algorithm for spinal metastases. Spine 35(15): 1466–70 [PubMed: 20195197] | Intervention - does not match review protocol |
| Gebhardt, B.J., Rajagopalan, M.S., Gill, B.S. et al. (2015) Impact of dynamic changes to a bone metastases pathway in a large, integrated, National Cancer Institute-designated comprehensive cancer center network. Practical Radiation Oncology 5(6): 398–405 [PubMed: 26432676] | Publication type does not match review protocol – conference abstract |
| Greif, Dylan N, Ghasem, Alexander, Butler, Alexander et al. (2019) Multidisciplinary Management of Spinal Metastasis and Vertebral Instability: A Systematic Review. World neurosurgery 128: e944–e955 [PubMed: 31100530] | Intervention - does not match review protocol |
| Groenen, Karlijn H J, van der Linden, Yvette M, Brouwer, Thea et al. (2018) The Dutch national guideline on metastases and hematological malignancies localized within the spine; a multidisciplinary collaboration towards timely and proactive management. Cancer treatment reviews 69: 29–38 [PubMed: 29870874] | Study design - does not match review protocol |
| Gutt, R., Malhotra, S., Hagan, M.P. et al. (2021) Palliative Radiotherapy within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment. JCO Oncology Practice 17(12): e1913–e1922 [PubMed: 33734865] | Study design - does not match review protocol |
| Guzik, Grzegorz (2018) Analysis of factors delaying the surgical treatment of patients with neurological deficits in the course of spinal metastatic disease. BMC palliative care 17(1): 44 [PMC free article: PMC5842651] [PubMed: 29514666] | Intervention - does not match review protocol |
| Hanchanale S, Neoh K, Waldock J, et al MANAGEMENT OF METASTATIC SPINAL CORD COMPRESSION: AUDIT. BMJ Supportive & Palliative Care 2014;4:A54. | Study design - does not match review protocol |
| Hinojosa-Gonzalez, D. E., Roblesgil-Medrano, A., Villarreal-Espinosa, J. B. et al. (2021) Minimally Invasive versus Open Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis. Asian spine journal [PMC free article: PMC9441425] [PubMed: 34465015] | Intervention - does not match review protocol |
| Hsiue, Peter P, Kelley, Benjamin V, Chen, Clark J et al. (2020) Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014. The spine journal : official journal of the North American Spine Society 20(6): 915–924 [PubMed: 32087389] | Intervention - does not match review protocol |
| Huang, C.W.C., Ali, A., Chang, Y.-M. et al. (2019) Performance of on-call radiology residents in interpreting total spine MRI studies for the detection of spinal cord compression or cauda equina compression. American Journal of Roentgenology 213(6): 1341–1347 [PubMed: 31553657] | Population - does not match review protocol |
| Khan, H.A., Rabah, N.M., Chakravarthy, V. et al. (2021) Predictors of nonelective surgery for spinal metastases: Insights from a national database. Spine 46(24): e1334–e1342 [PubMed: 34474446] | Population - does not match review protocol |
| Kim, Ellen, McClelland, Shearwood 3rd, Jaboin, Jerry J et al. (2021) Disparities in Patterns of Conventional Versus Stereotactic Body Radiotherapy in the Treatment of Spine Metastasis in the United States. Journal of palliative care 36(2): 130–134 [PubMed: 33356987] | Outcomes - do not match review protocol |
| Kumar, Naresh, Thomas, Andrew Cherian, Ramos, Miguel Rafael David et al. (2021) Readmission-Free Survival Analysis in Metastatic Spine Tumour Surgical Patients: A Novel Concept. Annals of surgical oncology 28(5): 2474–2482 [PubMed: 33393052] | Intervention - does not match review protocol |
| Kurisunkal, Vineet; Gulia, Ashish; Gupta, Srinath (2020) Principles of Management of Spine Metastasis. Indian journal of orthopaedics 54(2): 181–193 [PMC free article: PMC7096601] [PubMed: 32257036] | Study design - does not match review protocol |
| Lacey, Craig, Ockwell, Clare, Locke, Imogen et al. (2015) A prospective study comparing radiographer- and clinician-based localization for patients with metastatic spinal cord compression (MSCC) to assess the feasibility of a radiographer-led service. The British journal of radiology 88(1055): 20150586 [PMC free article: PMC4743470] [PubMed: 26283103] | Intervention - does not match review protocol |
| Lawton, Andrew J, Lee, Kathleen A, Cheville, Andrea L et al. (2019) Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review. Journal of clinical oncology: official journal of the American Society of Clinical Oncology 37(1): 61–71 [PubMed: 30395488] | Study design - does not match review protocol |
| Levack, P., Graham, J., Collie, D. et al. (2002) Don’t wait for a sensory level - Listen to the symptoms: A prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology 14(6): 472–480 [PubMed: 12512970] | Comparator - does not match review protocol |
| Lo, S.S.-M., Ryu, S., Chang, E.L. et al. (2015) ACR Appropriateness Criteria Metastatic Epidural Spinal Cord Compression and Recurrent Spinal Metastasis. Journal of Palliative Medicine 18(7): 573–584 [PubMed: 25974663] | Study design - does not match review protocol |
| Lo, Wan-Yu and Yang, Shu-Hua (2017) Metastatic spinal cord compression (MSCC) treated with palliative decompression: Surgical timing and survival rate. PloS one 12(12): e0190342 [PMC free article: PMC5747484] [PubMed: 29287117] | Comparator - does not match review protocol |
| Macdonald, A Graham, Lynch, Daniel, Garbett, Ian et al. (2019) Malignant spinal cord compression. The journal of the Royal College of Physicians of Edinburgh 49(2): 151–156 [PubMed: 31188350] | Comparator - does not match review protocol |
| McLinton A, Hutchison C. Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre. Br J Cancer. 2006 Feb 27;94(4):486–91 [PMC free article: PMC2361169] [PubMed: 16434993] | Comparator - does not match review protocol |
| Newman, William Christopher, Patel, Ankur, Goldberg, Jacob L et al. (2020) The importance of multidisciplinary care for spine metastases: initial tumor management. Neuro-oncology practice 7(suppl1): i25–i32 [PMC free article: PMC7705527] [PubMed: 33299571] | Study design – does not match review protocol |
| Paulino Pereira, N. R., Groot, O. Q., Verlaan, J. J. et al. (2021) Quality of Life Changes After Surgery for Metastatic Spinal Disease: A Systematic Review and Meta-analysis. Clinical spine surgery [PubMed: 34108371] | Intervention – does not match review protocol |
| Pease, N.J et al. Development and audit of a care pathway for the management of patients with suspected malignant spinal cord compression. Physiotherapy, Volume 90, Issue 1, 27 – 34 | Other protocol criteria - duplicate publication |
| Pease, N.J.; Harris, R.J.; Finlay, I.G. (2004) Development and audit of a care pathway for the management of patients with suspected malignant spinal cord compression. Physiotherapy 90(1): 27–34 | Other protocol criteria - duplicate publication |
| Pennington, Zach, Porras, Jose L, Larry Lo, Sheng-Fu et al. (2021) International Variability in Spinal Metastasis Treatment: A Survey of the AO Spine Community. Global spine journal: 21925682211046904 [PMC free article: PMC10448098] [PubMed: 34565202] | Population – does not match review protocol |
| Philipps, L. et al. An Audit of Metastatic Cord Compression Pathways. Clinical Oncology, Volume 30, S4 | Publication type does not match review protocol – conference abstract |
| Pipola, Valerio, Terzi, Silvia, Tedesco, Giuseppe et al. (2018) Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 26(9): 3181–3186 [PubMed: 29600414] | Intervention – does not match review protocol |
| Rades, Dirk, Janssen, Stefan, Conde-Moreno, Antonio Jose et al. (2017) Role of the overall treatment time of radiotherapy with 10 × 3 Gy for outcomes in patients with metastatic spinal cord compression. Journal of medical imaging and radiation oncology 61(3): 388–393 [PubMed: 27804231] | Intervention – does not match review protocol |
| Ratanatharathorn, V. and Powers, W.E. (1991) Epidural spinal cord compression from metastatic tumor: Diagnosis and guidelines for management. Cancer Treatment Reviews 18(1): 55–71 [PubMed: 1933911] | Study design – does not match review protocol |
| Richards, Lena, Misra, Vivek, Verma, Rajat et al. (2017) 86 - Metastatic Spinal Cord Compression (MSCC) – Collaborative Work between the Tertiary Cancer Centre and the Specialist Spinal Centre Since the Introduction of the MSCC Coordinator Service Has Seen a Marked Increase in Surgical Rates, with 20% of Patients Who Presented with MSCC in the First 24 Months Having Spinal Surgery. This Has Resulted in Improved Survival Rates for MSCC Patients in Greater Manchester and Cheshire. Spine Journal 17: 30–s31 | Publication type does not match review protocol – conference abstract |
| Rudra, Soumon, Lauman, Mary K, Stowe, Hayley et al. (2020) Evaluation of the Metastatic Spine Disease Multidisciplinary Working Group Algorithms as Part of a Multidisciplinary Spine Tumor Conference. Global spine journal 10(7): 888–895 [PMC free article: PMC7485068] [PubMed: 32905719] | Comparator – does not match review protocol |
| Schilling, Andrew, Pennington, Zach, Ehresman, Jeff et al. (2021) Impact of Multidisciplinary Intraoperative Teams on Thirty-Day Complications After Sacral Tumor Resection. World neurosurgery 152: e558–e566 [PubMed: 34144170] | Population – does not match review protocol |
| Services, NHS and Mike Hutton GIRFTClinical Lead for, Spinal (2019) Spinal Services GIRFT Programme National Specialty Report. | Population – does not match review protocol |
| Shah, S. et al. (2021) Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK. J. Pers. Med. [PMC free article: PMC7914482] [PubMed: 33572084] | Other protocol criteria – duplicate publication |
| Shah, Sidrah, Kutka, Mikolaj, Lees, Kathryn et al. (2021) Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK. Journal of personalized medicine 11(2) [PMC free article: PMC7914482] [PubMed: 33572084] | Comparator – does not match review protocol |
| Souchon, R., Wenz, F., Sedlmayer, F. et al. (2009) DEGRO practice guidelines for palliative radiotherapy of metastatic breast cancer : BBBone metastases and metastatic spinal cord compression (MSCC). Strahlentherapie und Onkologie 185(7): 417–424 [PubMed: 19714302] | Study design – does not match review protocol |
| Spratt, Daniel E, Beeler, Whitney H, de Moraes, Fabio Y et al. (2017) An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report. The Lancet. Oncology 18(12): e720–e730 [PubMed: 29208438] | Study design – does not match review protocol |
| Steinberger, Jeremy M, Yuk, Frank, Doshi, Amish H et al. (2020) Multidisciplinary management of metastatic spine disease: initial symptom-directed management. Neuro-oncology practice 7(suppl1): i33–i44 [PMC free article: PMC7705525] [PubMed: 33299572] | Study design – does not match review protocol |
| Tabacof, L., Delgado, A., Dewil, S. et al. (2021) Safety and Feasibility of Outpatient Rehabilitation in Patients with Secondary Bone Cancer: A Preliminary Study. Rehabilitation Oncology 39(3): e42–e50 | Comparator – does not match review protocol |
| Tarawneh, Ahmad M; Pasku, Dritan; Quraishi, Nasir A (2021) Surgical complications and re-operation rates in spinal metastases surgery: a systematic review. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 30(10): 2791–2799 [PubMed: 33184702] | Intervention – does not match review protocol |
| Tsukada, Y., Nakamura, N., Ohde, S. et al. (2015) Factors that delay treatment of symptomatic metastatic extradural spinal cord compression. Journal of Palliative Medicine 18(2): 107–113 [PubMed: 25343305] | Intervention – does not match review protocol – study shows treatment is delayed if patients present on weekend |
| van Tol, Floris R, Choi, David, Verkooijen, Helena M et al. (2019) Delayed presentation to a spine surgeon is the strongest predictor of poor postoperative outcome in patients surgically treated for symptomatic spinal metastases. The spine journal : official journal of the North American Spine Society 19(9): 1540–1547 [PubMed: 31005624] | Intervention – does not match review protocol – study shows poorer outcomes for patients where treatment was delayed |
| van Tol, Floris R, Massier, Julie R A, Frederix, Geert W J et al. (2021) Costs Associated With Timely and Delayed Surgical Treatment of Spinal Metastases. Global spine journal: 2192568220984789 [PMC free article: PMC9609516] [PubMed: 33511876] | Intervention – does not match review protocol |
| Vellayappan, B.A., Kumar, N., Chang, E.L. et al. (2018) Novel multidisciplinary approaches in the management of metastatic epidural spinal cord compression. Future Oncology 14(17): 1665–1668 [PubMed: 29939082] | Study design – does not match review protocol |
| Wallace, Adam N, Robinson, Clifford G, Meyer, Jeffrey et al. (2019) The Metastatic Spine Disease Multidisciplinary Working Group Algorithms. The oncologist 24(3): 424 [PMC free article: PMC6519761] [PubMed: 30867318] | Study design – does not match review protocol |
| White, B D, Stirling, A J, Paterson, E et al. (2008) Diagnosis and management of patients at risk of or with metastatic spinal cord compression: summary of NICE guidance. BMJ (Clinical research ed.) 337: a2538 [PubMed: 19039017] | Study design – does not match review protocol |
| Zaveri, Gautam R, Jain, Reetu, Mehta, Nishank et al. (2021) An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian journal of orthopaedics 55(4): 799–814 [PMC free article: PMC8192670] [PubMed: 34194637] | Study design – does not match review protocol |
| Zehri, Aqib H, Peterson, Keyan A, Lee, Katriel E et al. (2022) National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014. Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia 95: 88–93 [PubMed: 34929657] | Intervention – does not match review protocol |
Excluded economic studies
No economic evidence was identified for this review. See supplement 2 for further information.
Appendix K. Research recommendations – full details
Research recommendations for review question: What service configuration and delivery arrangements are effective for the investigation and referral of adults with suspected or confirmed spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No research recommendations were made for this review question.
Final
Evidence review underpinning recommendations 1.1.5 to 1.1.10, 1.1.13, 1.1.15 to 1.1.20, 1.2.8 and 1.5.2 to 1.5.4 in the NICE guideline (see also the related economic model in evidence review B)
These evidence reviews were developed by NICE
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Review Evidence review for service configuration and delivery (management and rehabilitation): Spinal metastases and metastatic spinal cord compression: Evidence review B[ 2023]Review Evidence review for service configuration and delivery (management and rehabilitation): Spinal metastases and metastatic spinal cord compression: Evidence review B. 2023 Sep
- Review Spinal metastases and metastatic spinal cord compression[ 2023]Review Spinal metastases and metastatic spinal cord compression. 2023 Sep 6
- Review Evidence reviews for information and support: Spinal metastases and metastatic spinal cord compression: Evidence review C[ 2023]Review Evidence reviews for information and support: Spinal metastases and metastatic spinal cord compression: Evidence review C. 2023 Sep
- Review A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression.[Health Technol Assess. 2013]Review A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression.Sutcliffe P, Connock M, Shyangdan D, Court R, Kandala NB, Clarke A. Health Technol Assess. 2013 Sep; 17(42):1-274.
- Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management.[Clin Oncol (R Coll Radiol). 1998]Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management.Cook AM, Lau TN, Tomlinson MJ, Vaidya M, Wakeley CJ, Goddard P. Clin Oncol (R Coll Radiol). 1998; 10(1):39-43.
- Evidence reviews for service configuration and delivery – investigationsEvidence reviews for service configuration and delivery – investigations
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