Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes

Abstract

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence–practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre–post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation of the new model of care. Economic analysis determined system-level impact. The baseline clinical audit (n = 98) revealed barriers including reactive nutrition care, lack of familiarity with EBGs or awareness of intensive nutrition care needs as well as infrastructure and dietetic resource limitations. Post-implementation data (n = 34) demonstrated improved process and clinical outcomes: pre-treatment dietitian assessment; use of a validated nutrition assessment tool before, during and after treatment. Patients receiving the new model of care were significantly more likely to complete prescribed radiotherapy and systemic therapy. Differences in mean percentage weight change were clinically relevant. At the system level, the new model of care avoided 3.92 unplanned admissions and related costs of $AUD121K per annum. Focus groups confirmed clear support at the multidisciplinary team level for continuing the new model of care. Implementing an evidence-based nutrition model of care in patients with HNC is feasible and can improve outcomes. Benefits of this model of care may be transferrable to other patient groups within cancer settings.

Translating Evidence-Based Guidelines into Practice—Are We Getting It Right? A Multi-Centre Prospective International Audit of Nutrition Care in Patients with Foregut Tumors (INFORM)

“…The benefits of successful implementation of evidence-based nutrition care in line with best-practice in high-risk tumor groups are now well-documented. Australian-led implementation studies have demonstrated adherence to an evidence-based schedule of dietitian visits throughout treatment for HNC and recovery leads to improved outcomes for patients including nutritional status, weight maintenance, quality of life, treatment completion, and unplanned admissions [ 37 , 38 , 47 ]. Britton et al [ 37 , 48 ] and McCarter et al [ 47 , 49 ] uniquely demonstrated that dietitian-led delivery of motivational interviewing and cognitive behavioral therapy as part of an Eating as Treatment (EAT) intervention improved a range of patient outcomes.…”

“…The remainder of the adherence criteria are reported as a proportion of included patients and by participating site. The optimum degree of adherence to EBGs has not been determined; however, adherence rates of 80% to set criteria has been proposed [ 14 ] and applied in recent studies [ 37 , 38 ]. In this study, adherence to EBG recommendations was categorized as good (≥80%), moderate (≥60 to 80%) and poor (60%).…”

“…A Canadian-led international qualitative study exploring the barriers and enablers to nutrition care of patients with foregut tumors identified, firstly, a need to improve the evidence base and, secondly, to establish a minimum data set with a view to developing standardized nutrition care pathways with defined roles and responsibilities [ 36 ]. Recent Australian-led studies demonstrated that the multi-strategic implementation of innovative models of care increased adherence to EBGs for nutritional management of patients with HNC [ 8 ] resulted in improvements in nutritional status, quality of life [ 37 ], treatment completion, unplanned hospital admissions and associated costs of care [ 38 ]. This study aimed to (i) describe and evaluate current international nutrition care practices compared with the best-available evidence from published EBGs for patients with foregut tumors at high risk of malnutrition and (ii) determine any critical points where evidence–practice gaps persist and identify opportunities for improvement in nutrition care processes.…”

Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience

“…This VRP group developed a Value Framework (VF) with specific projects identified under each of the three pillars of evidence-based care, care management, and care after cancer, as shown in Figure 1 . These pillars are derived from the key components identified in the medical oncology home and OCM models as well as several value-based payer initiatives which have shown value [ 6 , 7 , 8 , 11 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. A full discussion of our value-based care initiative is beyond the scope of this paper; however, we present our value framework and highlights of several other key projects within the framework to show the interdependence of those projects in advancing the implementation and evolving outcome analytics of multidisciplinary oncology pathways.…”

“…Oncology pathways are a major component of these programs, with studies of implemented pathway programs showing equal or improved outcomes with lower costs in medical oncology [ 12 , 13 , 14 , 15 , 16 , 17 ], as well as in other disciplines including surgery, radiation oncology, supportive care, and end of life [ 18 , 19 , 20 , 21 , 22 , 23 ]. The evaluation and adoption of oncology pathways were further stimulated by Center for Medicare and Medicaid Services (CMS)’s oncology care MIPPs and Oncology Care Model (OCM) alternate payment programs and private payer pilots with academic and community-based networks and various private payors [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”