Examining Access to Nutrition Care in Outpatient Cancer Centers Proceedings of a Workshop (2016) / Chapter Skim
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3 Models of Care: National and International Perspectives
3 Models of Care: National and International Perspectives
Pages 35-54
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From page 35... ...
More generally, Levin also discussed the goals of oncology nutrition, with a major goal being to increase patients' tolerance of their prescribed treatments; described evidence showing the value of nutrition services for oncology outpatients; and called for the need to develop what she called a "culture of nutrition" among all cancer care staff. Liz Isenring shifted the focus of discussion to international models of care and described several different, mostly hospital-based care pathways being implemented in Australia, one example from Europe, and one example from Canada.
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From page 36... ...
Based on her experience, when the entire care team feels responsible for developing a care pathway, then the entire team is likely to ensure the pathway is implemented and that nutrition is on the agenda. Following these two presentations, Diana Dyer provided a personal perspective on oncology nutrition care based on her experience as both a provider and a patient.
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From page 37... ...
Thus, the overarching goal of oncology nutrition is to tolerate prescribed treatment, or, as Levin put it, "no break, no delays, no dose reductions." Levin identified several specific goals: early identification of pre- achexia c or cachexia states, early identification of involuntary weight loss, early identification of etiology-based malnutrition characteristics, and aggressive r esponses to nutrition impact symptoms to protect both quality of life and the treatment plan. Data collected from the Cancer Nutrition Research Consortium on the incidence of nutrition impact symptoms in 2012 reveal a lengthy list of symptoms: • fatigue (41 percent)
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From page 38... ...
, American Society of Parenteral and Enteral Nutrition, the AND, Association of Community of Cancer Centers, National Cancer Institute (NCI) , National Comprehensive Cancer Network, National Institute for Health and Care Excellence, and Oncology Nursing Society.
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From page 39... ...
Models of Care in the United States One of the most common ways for cancer patients in the United States to access oncology nutrition services, Levin continued, is via a hospital inpatient RD/RDN who often is assigned multiple floors and working on a very tight schedule. Inpatient staff members are often "pulled" to cover outpatient oncology needs on an ad hoc basis, creating a negative cycle where the physician knows it is difficult to pull the dietitian and will therefore wait until they are sure they need one.
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From page 40... ...
© American Academy of Dietetics, Relationship Between Nutrition Status and Morbidity Outcomes and Mortality in Adult Oncology Patients. http://www.andeal.org/files/Docs/ON%20Nutrition%Status%20and%20Outcomes_%20 07022013.pdf, copyright 2013, Academy of Nutrition and Dietetics, Evidence Analysis Library.
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From page 41... ...
Levin mentioned a new dietitian recently assigned to an outpatient oncology clinic who reached out to the AND's Oncology Nutrition Dietetic Practice Group (ONDPG) listserv, which has about 1,500 members, asking for advice on how to proceed and indicating in her email that she was "desperate." That desperate feeling, Levin said, is a very common feeling among oncology dietitians -- not just because you cannot see everyone, but because you cannot see everyone who needs to be seen.
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From page 42... ...
Are they appropriate for complicated oncology patients? Data on Nutrition Care for Cancer Patients Colleen Gill at the University of Colorado conducted surveys of 56 NCI centers in 2011 and 2013 on dietitian FTE compared to patient numbers.
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From page 43... ...
, ultimately creating a burden to society because of a lack of patient access to evidence-based nutrition. Beyond the basic nutrition care that is fundamental to healing among all cancer patients, Levin identified several areas of special interest where what she described as "mounting" evidence indicates that access to ade quate oncology nutrition services would make a difference: nutrition in pediatric oncology treatment, nutrition for pediatric survivorship, nutrition for sarcopenic obesity and sarcopenic weight loss, nutrition for cachexia and pre-cachexia, nutrition for adult survivorship, nutrition for the preven
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From page 44... ...
She repeated the need to train and develop dedicated nutrition staff and emphasized the need to develop what she called a "culture of nutrition" among all cancer care staff, from physicians to radiation therapists, so that everyone is providing surveillance for malnutrition. She also emphasized the importance of using validated malnutrition screening tools on a routine basis in all cancer centers.
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From page 45... ...
Outpatient Models of Care: Examples from Australia The Australian Screen-IT model was developed for use with patients with head and neck cancer by Laurelie Wall and colleagues at the Princess Alexander Hospital in Brisbane. It was developed because, despite good evidence indicating that patients with head and neck cancer benefit from seeing a dietitian weekly throughout their treatment, anecdotal evidence suggested that, while weekly visits might be enough for a couple of weeks, many patients reach a "crash and burn" point when they would likely benefit from several visits per week.
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From page 46... ...
Another model of care being used in Australia, this one at Peter M acCallum, a cancer-specific hospital in Melbourne, similarly uses particular measures to identify high risk patients and determine how frequently patients should be seen (e.g., most head and neck cancer patients at high risk are seen weekly, followed by regular follow-up every couple of weeks,
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From page 47... ...
Outpatient Models of Care: An Example from Europe From Europe, Isenring highlighted efforts by Hinke Kruizenga and the Dutch Malnutrition Steering Group to manage malnutrition in Dutch hospitals. The steering group developed 10 steps to managing nutrition treatment, two key ones being "quick and easy screening tools with treatment plan" and "screening as a mandatory quality indicator." Dutch hospitals use a simple nutrition screening tool called SNAQ (Short Nutritional Assessment Questionnaire)
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From page 48... ...
Outpatient Models of Care: An Example from Canada As a final example of an outpatient model of care from outside the United States, Isenring described a multidisciplinary rehabilitation clinic for patients with cancer in Canada where the patient and family caregivers are at the center of the model and surrounding them is a multidisciplinary team with a dietitian, occupational therapist, oncologist, psychologist, social worker, nurse, and physiotherapist. The model was developed by Martin Chasen and colleagues as part of the Prostate Cancer Intervention Versus Observation Trial (PIVOT)
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From page 49... ...
" He looked at the floor for quite some time before looking up, meeting Dyer's eyes, and saying, "Eat right and exercise." She thought, "Wow, I'm on my own." Even though she was a dietitian with 20 years of experience at the time, working in intensive care units and providing critical nutrition care support, she felt like a "patient floundering by herself in the trenches." She made a call to 3 This section summarizes information and presented by Diana Dyer, M.S., RD, Consultant, Ann Arbor, Michigan.
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From page 50... ...
Although her private practice eventually grew to where she had a months-long waiting list, with people flying from all over the country to see her, Dyer decided to leave her private practice after overhearing a comment by an oncologist at a meeting about how the cancer center where the oncologist worked did not have to do anything about nutrition because, the oncologist said, "We have Diana locally in private practice." That was when Dyer realized that her private practice had been enabling cancer centers to not have dietitians on staff and that she had to do something on a much larger scale to break down the barriers to nutrition care for oncology outpatients. She said, "I don't know what I've personally accomplished, but as a group, the fact that we are here today is an amazing step forward." "Cancer does not happen in a vacuum," Dyer said.
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From page 51... ...
They include everything from medical nutrition therapy to understanding how to sort through dietary supplements. Plus, registered dietitians can now attain board certification as a specialist in oncology nutrition (CSO)
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From page 52... ...
That most costs of that care are provided by public funding may explain why Australia has what she considered "better" models of care. Australia's Medicare scheme allows up to five visits per year for chronic conditions, including cancer, and according to Isenring, she and others were working with general practitioners to try to maximize nutrition care during some of these visits.
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From page 53... ...
That technology is advancing rapidly, he said, and "offers great potential." Robien added that, as a researcher, she would advocate finding a way to somehow feed these collected data back into the evidence base. Validated Nutrition Screening Tool for Pediatric Oncology An audience member asked if there were any validated nutrition screening tools for use in pediatrics or guidelines to help identify patients with the greatest nutritional care needs.
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