Development of Clinical Practice Guidelines (CPGs) in Oncology Nutrition

Charitini Orphanidou, MSc, RDN

Regional Professional Practice Leader

Nutrition Services - BCCA

Centre for the Southern Interior

BACKGROUND Mandate by CSCC, HC, and CAPCA for health

disciplines in oncology care to develop Standards of Practice (SOPs) and Clinical Practice Guidelines (CPGs)

In 2003, a national working group of the Oncology Nutrition Network of Dietitians of Canada developed National Oncology Nutrition SOPs

A project was conducted from Jan-April 2003, to provide background for the development of National Oncology Nutrition CPGs

CPGs National Working Group

Charitini Orphanidou Co-Chair BC Karen Biggs Co-Chair

ONT Satnam Sekhon Member BC Angela Martens Member MAN Donna Danelon Member ONT Catherine Morley Contract Work BC

CPGs - What are they?

Systematically developed statements that inform practitioners and patients about the best available research evidence that pertains to the management of a specific clinical condition.

CPGs - Why do we need them? Growing evidence of unexplained and

inappropriate variations in clinical practice patterns.

Concern that further limitations in resources will affect the delivery of high quality health care.

Clinicians have difficulty assimilating evolving scientific evidence into practice.

The Practice Guidelines Development Cycle

8. Scheduled Review

7. Adopt guideline, policies

6. Negotiate practice policies

5. Independent review

1. Select/Frame clinical problem

2. Generate evidence-based-recommendation

(EBR)

3. Ratify EBR

4. Formulate practice guideline

update

LEVELS OF EVIDENCE Level I Evidence

– Review of all relevant RCTs Level II Evidence

– At least one properly designed RCT Level III Evidence

– Evidence obtained from well-designed controlled trials without randomization

Level IVA Evidence– Evidence from descriptive studies of provider

practices, patient behaviors/knowledge/attitudes Level IVB Evidence

– Opinions of respected authorities

CPGs for Oncology Nutrition

How do we start? Where do we focus? What is important?

PURPOSE OF PROJECT To identify key clinical issues in oncology

nutrition care from the perspectives of dietitians working in cancer centres and community settings in order to:

• establish priorities for CPG development• suggest other resources required to

support oncology nutrition practice• inform future CPG development research

projects

FUNDING SOURCES

Lynn Stevenson, BCCA Provincial Practice Leader for Nursing

Oncology Nutrition Network of Dietitians of Canada

Supportive Care Department, Hamilton Regional Cancer Centre

OBJECTIVES Identify key oncology nutrition clinical issues in

cancer centre and community settings requiring CPG development

Recommend directions on study submitted to CFDR

Identify and recommend practice resource needs in oncology nutrition care

Recommend approaches to enhance CPG uptake and use

Recommend a CPG dissemination plan

Identify and report any unanticipated findings

DATA COLLECTION AND ANALYSIS

Interviews and discussion groups with BC dietitians– 14 BCCA dietitians– 14 dietitians working in acute care hospitals and

community settings

Written survey to Ontario oncology dietitians

Review of BCCA Nutrition Services report from Partners in Cancer Care conference, Nov 2002

DATA COLLECTION AND ANALYSIS

Interviews and discussion groups focused on the assessment, intervention, monitoring/outcomes components of care

Use of a modified Delphi Process (present earlier findings to subsequent respondents to more clearly articulate the issues)

FINDINGS

KEY CLINICAL ISSUES REQUIRING CPG DEVELOPMENT

NUTRITION RISK SCREENING

– optimal approaches to screening

– review of available tools

– diagnostic vs predictive role

– use in initial assessment and in evaluation of nutrition intervention outcomes

KEY CLINICAL ISSUES REQUIRING CPG DEVELOPMENT

OPTIMAL ENTERAL NUTRITION SUPPORT

(esp. pertaining to oral and esophageal cancers and dual modality treatments)

- Types of enteral support

- Diagnoses that would most benefit

- Prophylactic or reactive initiation

- Duration of enteral support

CPG DEVELOPMENT STEPS• Systematic review of the literature for each topic to

be investigated

• Definition of literature inclusion/exclusion criteria

• Gather documents to review

• Include published and unpublished materials (include manual searching)

• Determination of document relevance relative to criteria

• Summary preparation of available evidence

CHALLENGES

Evidence available in oncology nutrition care not comparable in volume to that for other disciplines

There are neither the number of researchers nor research funding sources available compared to other disciplines

PRACTICE RESOURCE NEEDSOF CANCER CENTRE RDNs

CPGs and/or evidence summaries

An oncology nutrition practice research program

A Foundations of Oncology Nutrition Care Manual

PRACTICE RESOURCE NEEDS OF RDNs IN COMMUNITY SETTINGS

Primary need is for a Foundations of Oncology Nutrition Care Manual – oncology nutrition care in community settings

mostly involves symptom management for patients prior to cancer diagnosis, or rehabilitating following treatment

Perceived CPGs to be more relevant to cancer centre dietitians

ONCOLOGY NUTRITION PRACTICERESEARCH PROGRAM

For what cancer diagnoses and treatment does nutrition support make the most difference in morbidity and mortality?

What is the role of Nutrition Services in offering support to:

- meet physiologic needs?

- eating changes due to cancer treatment?

- patients confused/overwhelmed about what to eat?

- patients/families in palliative situations?

Oncology Nutrition Research Programcould be framed according to 4 outcome categories:

Biochemical / physical parameters

Performance / functional parameters

Financial considerations (including cost benefit/cost effectiveness assessment)

Client perceptions

FOUNDATIONS OF ONCOLOGY NUTRITION CARE MANUAL

contain evidence based information on best practices

contain information on issues / situations regarding beliefs, meaning of eating, suggestions to counselling approaches

articulate positions or evidence summaries about new and / or controversial aspects of oncology nutrition

DISSEMINATION AND USE OF CPGs

For community RDNs, CPGs simply need to be made available when ready (value BCCA dietitians and resources highly!)

For Cancer centre RDNs, developmental process must be inclusive and collaborative

POTENTIAL USES OF RESOURCES

BCCA RDNs• inform decision making and

planning

• promote consistent practice

• orient new staff

• educate and train interns, graduate students

• provide updates to RDNs in community

• facilitate research agenda

COMMUNITY RDNs• enhance patient care

• enhance communication with BCCA RDNs

• be kept up-to-date on developments

• educate and train interns

UNANTICIPATED FINDINGSDIFFERING APPROACHES TO ONCOLOGY

NUTRITION CARE: FOR CANCER CENTRE RDNs

1. Centrality of knowing tumour site and stage, treatment plans, and pre-existing conditions

2. Consideration of three components of nutritional assessment and intervention planning:

- physiologic nutritional needs- beliefs, meanings of food/eating- nutrition education/counselling approaches

3. Assessment and planning/implementing interventions are intertwined; not discrete activities

UNANTICIPATED FINDINGS DIFFERING APPROACHES TO ONCOLOGY NUTRITION CARE: FOR COMMUNITY RDNs

1. Often did not know patient’s diagnosis

2. Did not have in-depth familiarity with different types of cancer, cancer treatment, and its implications

3. Nutrition care for cancer pts was only one of many conditions they tried to stay up-to-date

4. Hospital-based practice offers little/no opportunity for follow-up. Often arrange for BCCA RDNs to follow pts as there is little/no Home Care RDN support in BC

UNANTICIPATED FINDINGSRESOURCES USED TO INFORM PRACTICE

Resources used by BCCA dietitians related to the three components of nutritional assessment

With experience, practice became less dominated by textbook or manual type information

With experience, strive to find a balance between standards for care and personalized solutions

Monitor the medical and nutrition literature, consult

with patients and families, and dietetic/medical colleagues

Where Are We Now?

Seeking input from other Nutrition specialty areas that have developed CPGs (eg. ICU Nutrition Support)

Forming partnerships with organizations that have the infrastructure to develop CPGs (eg. Cancer Care Ontario program in evidence based care)

Pursuing alternative funding sources