Adelaide, Australia—Patients with head and neck cancer are at a high risk for malnutrition, but use of a best practice model for nutritional support can improve outcomes and address unmet needs, suspects Merran Findlay, MSc, AdvAPD, Senior Oncology Dietitian, Royal Prince Alfred Hospital, Sydney, Australia. An audit of patients at her center revealed that approximately 50% of unplanned hospital admissions were related to nutritional issues, and patients rarely saw a dietitian.
Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer were published in 2011, “But we still have significant evidence practice gaps, and it’s still important to explore what the barriers and enablers are locally,” Ms Findlay told attendees at the 2016 Multinational Association of Supportive Care in Cancer Annual Meeting on Supportive Care in Cancer.
She and her team sought to evaluate the nutrition care process—appropriate access to care, quality nutrition care, and nutrition monitoring and evaluation—for patients with head and neck cancer undergoing curative radiation with or without another treatment modality. The team used a series of research questions to gauge barriers and enablers to nutritional care among patients and clinicians to implement an innovative, best-practice dietetic care model, and to minimize the detrimental sequelae of malnutrition among patients with head and neck cancer.
Nutritional Support and Hospitalization
The researchers audited 98 patients (75 men, 23 women) from 2013 to 2014 (mean age, 61 years). The majority of patients had treatment with ≥2 modalities, and most were well-nourished at baseline. Approximately 70% of patients required some form of tube feeding throughout their treatment. The unplanned hospital admission rate was 45%; of those, 45% were for nutrition-related morbidity.
The length of stay for nutrition-related morbidity was 28 median days versus 3 days for morbidity unrelated to nutrition, which also increased the intensity of dietetic resources—15 occasions of service in the inpatient setting versus 9 in the outpatient setting—Ms Findlay reported.
Overall, 20% of patients were seen by a dietitian before treatment, “But that’s really only because they were in such a poor state that they were admitted to the hospital, and that’s when they were seen. It wasn’t a dedicated outpatient service,” she added.
During treatment, 55% of patients were seen weekly, but only approximately 12% of patients received reviews 2 weeks posttreatment. Nutritional status was recorded and evaluated with a validated tool in 86% of cases at the initial assessment, but this number dropped during posttreatment.
“There is definitely room for improvement,” Ms Findlay said.
Barriers to Nutritional Support
To assess barriers and enablers to nutritional care, the investigators conducted qualitative interviews with 19 study participants. The interviews revealed that patients and caregivers would like to meet with their dietitian sooner, and the biggest unmet need was integrated and coordinated care.
“They wanted a one-stop shop, where everyone who needs to see a patient is in the same location at the same time. I found it absolutely fascinating that this was the number-one wish,” Ms Findlay said.
The researchers also identified a communication breakdown between nonmedical clinicians and physicians. “While the nonmedical clinicians in the room felt that nutrition care was important, the consensus was that the doctors may not think so, so [the nonmedical clinicians] didn’t want to speak up,” she said. “I found that particularly interesting, because if you speak to oncologists and surgeons, they’d actually welcome more information on nutrition that would facilitate decision-making in the multidisciplinary team,” she added.
On the system level, the investigators identified issues around a proactive versus reactive approach to nutrition care, and the general desire for a better system-level process that triages patients and identifies problems earlier.
Implementing Nutritional Care
Ms Findlay noted that implementation is undoubtedly a science, and effective implementation strategies are evidence-based. Although it can be tempting to want to fix everything, she recommends focusing on a few starting points.
Based on the results of the study, she said the first implementation strategies likely to be used at her institution include establishing a pretreatment clinic for early nutrition assessment and intervention, developing a nutrition care dashboard for integration into weekly multidiscliplinary team discussions, and the development of a nutrition care kit for patients and caregivers.
She stressed the importance of evaluating implementation outcomes. “If you have a failed implementation, you want to know if it’s because the implementation strategies weren’t appropriate, or because they just weren’t delivered as you planned. But I think the obvious answer is to pick an implementation plan that makes sense to you, and to the context in which you’re working,” Ms Findlay said.