TABLE 2.

Summary of the impact of multidisciplinary team (MDT) discussion in interstitial lung disease (ILD) diagnosis and treatment

Author (year) [ref.]	Number of patients	MDT members	Results for diagnosis	Results for treatment
Flaherty et al. (2004) [12]	58	Three pulmonologists, two radiologists and two pathologists	Increased level of interobserver agreement in suspected IIP Pathologists changed their original diagnosis in 19% of cases once the clinical and radiological data became available	No information provided
Flaherty et al. (2007) [9]	39	Clinicians, radiologists and pathologists	An interactive approach between clinicians, radiologists and pathologists improved interobserver agreement at both community and academic sites Interobserver agreement was higher in academic centres (κw=0.55–0.71) than within community centres (κw=0.32–0.44)	No information provided
Mittoo et al. (2009) [91]	114	Evaluation at an ILD clinic	34 (30%) patients in an interdisciplinary ILD programme were found to have CTD •  17 patients presented with an established CTD, and 17 patients were newly diagnosed following their evaluation at the ILD clinic	No information provided
Castelino et al. (2011) [92]	50	Concurrent evaluation of patients with ILD by a pulmonologist and a rheumatologist	Of the patients with a final diagnosis of CTD-ILD, 28% were referred with a diagnosis of IPF 36% of CTD-ILD patients had their diagnosis changed to an alternate CTD-ILD	IPF: change in therapy in 27% of patients (4/15) CTD-ILD: changes in therapy in 80% of patients (20/25) (mostly to a combination of CSs with immunomodulatory agent)
Walsh et al. (2016) [10]	70 patients included in the final study cohort	Clinician, pathologist and radiologist	Inter-MDT meeting agreement on diagnostic likelihoods was good for IPF (κw=0.71) and CTD-ILD (κw=0.73), moderate for NSIP (κw=0.42) and fair for HP (κw=0.29)	No information provided
Chaudhuri et al. (2016) [42]	318	Two respiratory physicians, one radiologist, one pathologist, one specialist nurse, one MDT coordinator and one ILD pharmacist	Consensus diagnosis made in 57/75 (76%) of unclassifiable ILDs IPF diagnoses were correct in 50/107 (47%) cases and incorrect in 57/107 (53%) cases Other ILD diagnoses were correct in 91/136 (67%) cases and incorrect in 45/136 (33%) cases	IPF: MDT discussion resulted in a change of treatment for 50% of patients (53/107) (stopping immunosuppressant therapies and initiating pirfenidone) Other ILDs: MDT discussion resulted in a change of treatment in 39% (53/136) of cases (starting or discontinuing immunosuppressant therapies)
Tomassetti et al. (2016) [28]	117	Two clinicians, two radiologists and two pathologists	The overall inter-observer agreement in IPF diagnosis was similar for both BLC (overall kappa: 0.96) and SLB (overall kappa: 0.93) After the addition of histopathological information in an MDT: •  17% of cases in the BLC group were reclassified as IPF •  19% of cases in the SLB group were reclassified as IPF	No information provided
Jo et al. (2016) [46]	90	One pulmonologist, one rheumatologist, one radiologist, one pathologist and one immunologist	CTD-ILD: diagnoses increased from 10% to 21% HP: diagnoses increased from 3% to 16% IPF: 7 patients with unclassifiable ILD or NSIP had diagnosis changed to IPF	Recommendation for CS use decreased from 36% to 28% (p=0.26) Recommendation for nonsteroid immunosuppression increased from 10% to 17% (p=0.16) Recommendation for pulmonary vasodilators increased from 0% to 4% (p=0.046) Recommendation for antifibrotic therapy increased from 3% to 21% (p=0.0002) Recommendation for clinical trials increased from 0% to 3% (p=0.08) Recommendation for oxygen increased from 6% to 10% (p=0.046)
Burge et al. (2017) [93]	71	Pathologists, radiologists, clinicians and a clinical nurse specialist	MDT changed the original histological diagnoses in 30% of patients (95% CI 19.3–41.6) •  UIP diagnosis: 21 patients identified in MDT compared with 16 in the histology report •  HP: eight patients identified in MDT compared with two in histology report Strengthened diagnoses from probable to confident in 17% of patients (95% CI 9.1–27.7)	No information provided
De Sadeleer et al. (2018) [45]	938	Experts in pulmonology, radiology and histopathology (and other specialities when needed)	MDT discussions provided a definite diagnosis in 80.5% of the cases MDT discussions changed the diagnosis in 191 patients with a pre-MDD diagnosis (41.9%) Sarcoidosis (n=82): 62% confirmed by MDT, 6% changed by MDT Other ILD (n=31): 39% confirmed by MDT, 23% changed by MDT IPF (n=326): 38% confirmed by MDT, 6% changed by MDT CTD-ILD (n=60): 27% confirmed by MDT, 20% changed by MDT Drug-/exposure-related ILD (n=42): 26% confirmed by MDT, 21% changed by MDT Non-ILD (n=65): 22% confirmed by MDT, 37 changed by MDT HP (n=77): 21% confirmed by MDT, 31% changed by MDT COP (n=17): 18% confirmed by MDT, 18% changed by MDT RB-ILD/DIP (n=22): 14% confirmed by MDT, 18% changed by MDT iNSIP (n=33): 12% confirmed by MDT, 27% changed by MDT	No information provided
Levi et al. (2018) [94]	60	MDT of pulmonologists, radiologists, pathologists and rheumatologists	Rheumatologist assessment following routine MDT diagnosis led to: 21% of IPF diagnoses reclassified as CTD Number of CTD-ILD cases with autoimmune features increased by 77%	No information provided
Biglia et al. (2019) [15]	150	Two pulmonologists, one chest radiologist, one rheumatologist, one surgeon and one histopathologist	Total: 42% of diagnoses were revised between pre-MDD and post-MDD, leading to a significant reduction in unclassifiable ILD IPF: diagnoses increased from seven to 35 cases HP: diagnoses increased from 11 to 20 cases Unclassifiable: diagnoses decreased from 56 to 15 cases (p<0.0001)	MDD led to a change or initiation of treatment in 54% of cases
Fujisawa et al. (2019) [82]	524	One pulmonologist, one radiologist and one pathologist	MDT resulted in a change in diagnosis for 219 patients (47%) IPF (n=227): 59 cases (26%) were reclassified as unclassifiable IIPs, while 151 (67%) were confirmed as IPF iNSIP: 42 cases (43%) were recategorised as unclassifiable IIPs, 17 (17%) as IPF and three (3%) as CTD-ILD	No information provided
Grewal et al. (2019) [84]	209 internal patients 91 external patients	Pulmonologists, radiologists and pathologists	Internal patients IPF (n=54): diagnosis changed in 33% of patients iNSIP (n=4): diagnosis changed in 75% of patients HP (n=21): diagnosis changed in 14% of patients CTD-ILD (n=15): diagnosis changed in 20% of patients Other ILD (n=11): diagnosis changed in 27% of patients Unclassifiable (n=104): diagnosis changed in 43% of patients External patients IPF (n=12): diagnosis changed in 42% of patients iNSIP (n=6): diagnosis changed in 100% of patients HP (n=10): diagnosis changed in 40% of patients CTD-ILD (n=6): diagnosis changed in 50% of patients Other ILD (n=10): diagnosis changed in 40% of patients Unclassifiable (n=47): diagnosis changed in 36% of patients	After MDT review, treatment was initiated in 45% of patients on no ILD therapy and treatment was changed in 45% of patients on ILD therapy Internal patients Antifibrotic (n=7): treatment changed in 14% of patients CS (n=14): treatment changed in 86% of patients SSA (n=9): treatment changed in 11% of patients CS and SSA (n=12): treatment changed in 17% of patients No treatment (n=167): treatment changed in 49% of patients External patients Antifibrotic (n=2): treatment changed in 50% of patients CS (n=11): treatment changed in 73% of patients SSA (n=2): treatment not changed in patients CS and SSA (n=1): treatment changed in 100% of patients No treatment (n=75): treatment changed in 36% of patients
Han et al. (2019) [54]	56	Four pulmonologists, one radiologist and one pathologist	Follow-up data changed the original MDD diagnosis in 10.7% (6/56) of patients and changed the consensus level in 25% (14/56) of patients	No information provided
Tirelli et al. (2020) [95]	119	Six pulmonologists, three rheumatologists, two radiologists and one pathologist	A multidisciplinary approach was useful for identifying underlying CTD-ILD/IPAF in patients referred for ILD: • 15% had underlying CTD • 33% had IPAF • 52% had ILD without detectable CTD	No information provided
Ageely et al. 2020 [96]	126	Respirologists, one registered nurse, one thoracic pathologist and one thoracic radiologist	MDD altered the diagnosis in 37% (47/126) of cases IPF: diagnoses increased from 24 to 34 cases HP: diagnoses increased from 20 to 21 cases Sarcoidosis: diagnoses decreased from four cases to one case Nonspecified ILD: diagnoses decreased from 52 to 0 cases IPAF: diagnoses increased from 0 to five cases Unclassifiable ILD: diagnoses increased from 0 to 27 cases No ILD: diagnoses increased from 0 to six cases	Management was changed in 39% (50/126) of patients Among concordant pre-MDT and post-MDT diagnoses, management was changed in 46% (24/52) of cases
De Lorenzis, 2020 [97]	151	Minimal attendance: two pulmonologists, two chest radiologists and one pathologist Extended MDT meeting: included two extra rheumatologists	The agreement between rheumatologists and pulmonologists was moderate for the detection of autoimmunity test positivity (κw=0.475, p<0.001) and family history of SARD (κw=0.491, p<0.001), and fair for the identification of extrapulmonary symptoms (κw=0.225, p=0.064) or routine laboratory abnormalities consistent with SARD (κw=0.101, p=0.081) The agreement between rheumatologist and extended MDT for the identification of ILD progression was moderate (κw=0.436, p<0.001)	Therapeutic strategy changed in 72 patients (55.5%) following the extended MDT (with rheumatologists) Immunosuppressive drug (cyclophosphamide, azathioprine or mycophenolate mofetil with or without prednisone) prescribed in 50/72 (40.3%) patients Other immunosuppressants (rituximab or tocilizumab) prescribed in 13/72 (10.3%) patients Antifibrotic treatment (nintedanib or pirfenidone) prescribed in 9/72 (7.3%) patients

BLC: bronchoscopic lung cryobiopsy; CI: confidence interval; COP: cryptogenic organising pneumonia; CS: corticosteroid; CTD: connective tissue disease; DIP: desquamative interstitial pneumonia; HP: hypersensitivity pneumonitis; IIP: idiopathic interstitial pneumonia; iNSIP: idiopathic nonspecific interstitial pneumonia; IPAF: interstitial pneumonia with autoimmune features; IPF: idiopathic pulmonary fibrosis; κw: Cohen's weighted kappa; MDD: multidisciplinary discussion; NSIP: nonspecific interstitial pneumonia; RB: respiratory bronchiolitis; SARD: systemic autoimmune rheumatic disease; SLB: surgical lung biopsy; SSA: steroid-sparing agent; UIP: usual interstitial pneumonia.