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While the contributions of dietitians to cancer care are increasingly being acknowledged in much of the oncology provider community, so too is the recognition that adequate nutritional care is absent from the treatment of most cancer patients. Although the anecdotal evidence supporting this impression is overwhelming, until now there has been little effort to gather numbers to validate the need for dietitian services in routine cancer care. The authors of an article published late last year in the Journal of Oncology attempt to remedy this oversite.
The article—written by members of the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics (AND)—set out to determine the staffing patterns of registered dietitian nutritionists (RDNs) as well as the state of nutrition services, malnutrition screening, and referral and reimbursement practices in outpatient cancer centers nationwide. The ON DPG distributed an online survey of 18 quantitative and qualitative questions to its members, and the replies represent 215 cancer centers.
Survey results indicate that the average ratio of RDNs to patients in outpatient cancer care programs and practices is 1:2,308. Approximately half (53 percent) of the cancer centers surveyed say they screen for malnutrition, and 65 percent of centers say they use a validated malnutrition screening tool. The majority (77 percent) of centers say they do not bill for their dietitian services. This is the first national study to evaluate the patterns of dietitian services in outpatient cancer centers. The results indicate a significant gap in RDN access for oncology patients in need of nutritional care.
The consequences of this lack of services are clear. Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Registered dietitian nutritionists—healthcare professionals specifically trained to assess for malnutrition and to treat it—are not routinely employed in outpatient cancer centers, in which more than 90 percent of cancer patients are treated.
Suzanne Dixon, MPH, MS, RDN—a registered dietitian and epidemiologist—is a past chair of the Oncology Nutrition Dietetic Practice Group and former Director of the Outpatient Oncology Nutrition Program at the University of Michigan Comprehensive Cancer Center. Dixon is one of the authors of Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey, published November 2019 in the Journal of Oncology.
ACCCBuzz: Why was this survey necessary?
Suzanne Dixon: There is a significant connection between cancer patients’ nutritional status and their treatment outcomes. Malnourished patients have more drug toxicities, more dose reductions, more treatment breaks, more unplanned hospitalizations, more infection risks, and require costlier care compared to adequately nourished patients. We pay for patients’ lack of nutritional care down the line.
But it is very difficult to obtain reimbursement for nutrition services. One significant barrier to getting more RDNs into outpatient oncology settings is that many cancer centers see these services as red ink on their bottom lines—a cost center that will not bring in ROI. We wanted to begin the process of disproving that. Currently, we don’t even have benchmarks for what appropriate staffing for RDNs looks like. But we do know that oncology dietitians are generally overworked and stressed. We wanted more data on staff ratios to illustrate how this is happening.
ACCCBuzz: Why is malnutrition a particular issue for patients undergoing cancer therapies?
Suzanne Dixon: Patients with cancer who are malnourished do poorly. If they feel uncomfortable side effects, they tend to stop eating and then lose weight. Many begin treatment having already lost weight unintentionally. A 2017 study demonstrated this by using a validated screening tool to assess the nutritional status of 1,952 treatment-naïve patients. More than half (51 percent) of those patients were diagnosed with nutritional impairment, 9 percent were overtly malnourished, and 43 percent were at risk for malnutrition. In addition, more than 40 percent had already experienced anorexia. This was a real wakeup call: Even before treatment begins, many patients are nutritionally compromised. Unfortunately, many healthcare providers believe that weight loss and poor nutrition are inevitable with cancer treatment. But in many cases, they are not.
ACCCBuzz: What services does a registered dietitian nutritionist provide in cancer centers?
Suzanne Dixon: Dietitians provide a number of services. Even if patients are not malnourished, they may be struggling to eat well while undergoing treatment. They may be experiencing taste aversions, have chewing difficulties, or experience mouth sores and digestive issues that make eating unpleasant. Dietitians have ongoing dialogues with these patients to come up with tailored solutions to meet individual needs.
If a dietitian is not available, nurses often give patients in treatment a checklist of foods to eat and foods to avoid. While this is a good place to start, it cannot take the place of individual dietary coaching that may need to involve caregivers or even entire families.
Patients with head and neck cancers can require extensive services from dietitians. Patients may be on feeding tubes and unable to get enough to eat orally. Feeding tubes can’t be placed and then ignored. This leads to poor outcomes as well. A patient may not tolerate a particular formula, so dietitians need to work with insurers to get new formulas covered. Dietitians monitor feeding tubes for infection, ensure they are being used properly, and aren’t clogged or compromised. Oncology-trained dietitians are required to do this safely.
ACCCBuzz: What are the main takeaways from your survey?
Suzanne Dixon: Given that our survey results indicate that the average ratio of RDNs to patients in outpatient cancer care programs and practices is 1:2,308, it was unsurprising to learn that dietitians spend a majority of their time seeing very ill patients. In general, other providers are tasked with the other jobs dietitians are trained to do. The literature has demonstrated that nutrition services are at times delivered by nurses or physician assistants who often don’t have training or a background in nutrition.
The fact that many cancer practices do not have the administrative support necessary to have a referral process to RDNs in place contributes to the problem. Time is another limiting factor. Just being able to see all scheduled patients in a given day is difficult, much less input patient malnutrition information into an EHR.
Because patients are not screened or triaged appropriately, many times, when nutritionists see them, they cannot be as effective. Dietitians talk about getting only “train wreck referrals,” that is, referrals that read, for example, “Patient has lost 33 pounds; please evaluate.” By that time, the amount we can do to help that patient is limited. You cannot build up nutrition status during treatment after a substantial loss. And that reinforces the idea that nutritionists cannot help people.
ACCCBuzz: What are the most effective ways to increase cancer patients’ access to registered dietitian nutritionists?
Suzanne Dixon: You need to get nurses and doctors interested. Sell your services to them, tell them how what you do can affect patient outcomes. Show them the literature that supports your claims. Economic analyses illustrate how much it costs each time a patient misses a chemotherapy dose or is hospitalized due to malnutrition. Tell them that your services, when used proactively, can help prevent these things from happening.
Publishing the results of this survey is one step toward collecting the data necessary to illustrate the need for RDN services. I am confident reimbursement is coming for these services. Our next project is to compile a malnutrition consensus paper with representatives from several professional cancer organizations, including ACCC. The group will lay the foundation toward building a case and roadmap for RDN reimbursement.
Read more about approaches to integrating dietitian services into cancer care from ACCC-member programs. ACCC members can access Making the Business Case for Hiring a Registered Dietitian, a guide produced this year as part of the ACCC President's Theme.