Presentation on theme: "Charitini Orphanidou, MSc, RDN Regional Professional Practice Leader"— Presentation transcript:
1Development of Clinical Practice Guidelines (CPGs) in Oncology Nutrition Charitini Orphanidou, MSc, RDNRegional Professional Practice LeaderNutrition Services - BCCACentre for the Southern Interior
2BACKGROUNDMandate 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 SOPsA project was conducted from Jan-April 2003, to provide background for the development of National Oncology Nutrition CPGs
3CPGs National Working Group Charitini Orphanidou Co-Chair BCKaren Biggs Co-Chair ONTSatnam Sekhon Member BCAngela Martens Member MANDonna Danelon Member ONTCatherine Morley Contract Work BC
4CPGs - 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.
5CPGs - 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.
6The Practice Guidelines Development Cycle update1. Select/Frame clinical problem8. Scheduled Review7. Adopt guideline, policies2. Generate evidence-based-recommendation (EBR)6. Negotiate practice policies3. Ratify EBR4. Formulate practice guideline5. Independent review
7LEVELS OF EVIDENCE Level I Evidence Level II Evidence Review of all relevant RCTsLevel II EvidenceAt least one properly designed RCTLevel III EvidenceEvidence obtained from well-designed controlled trials without randomizationLevel IVA EvidenceEvidence from descriptive studies of provider practices, patient behaviors/knowledge/attitudesLevel IVB EvidenceOpinions of respected authorities
8CPGs for Oncology Nutrition How do we start?Where do we focus?What is important?
9PURPOSE OF PROJECTTo 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 developmentsuggest other resources required to support oncology nutrition practiceinform future CPG development research projects
10FUNDING SOURCESLynn Stevenson, BCCA Provincial Practice Leader for NursingOncology Nutrition Network of Dietitians of CanadaSupportive Care Department, Hamilton Regional Cancer Centre
11OBJECTIVESIdentify key oncology nutrition clinical issues in cancer centre and community settings requiring CPG developmentRecommend directions on study submitted to CFDRIdentify and recommend practice resource needs in oncology nutrition careRecommend approaches to enhance CPG uptake and useRecommend a CPG dissemination planIdentify and report any unanticipated findings
12DATA COLLECTION AND ANALYSIS Interviews and discussion groups with BC dietitians14 BCCA dietitians14 dietitians working in acute care hospitals and community settingsWritten survey to Ontario oncology dietitiansReview of BCCA Nutrition Services report from Partners in Cancer Care conference, Nov 2002
13DATA COLLECTION AND ANALYSIS Interviews and discussion groups focused on the assessment, intervention, monitoring/outcomes components of careUse of a modified Delphi Process (present earlier findings to subsequent respondents to more clearly articulate the issues)
15KEY CLINICAL ISSUES REQUIRING CPG DEVELOPMENT NUTRITION RISK SCREENINGoptimal approaches to screeningreview of available toolsdiagnostic vs predictive roleuse in initial assessment and in evaluation of nutrition intervention outcomes
16KEY 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
17CPG DEVELOPMENT STEPSSystematic review of the literature for each topic to be investigatedDefinition of literature inclusion/exclusion criteriaGather documents to reviewInclude published and unpublished materials (include manual searching)Determination of document relevance relative to criteriaSummary preparation of available evidence
18CHALLENGESEvidence available in oncology nutrition care not comparable in volume to that for other disciplinesThere are neither the number of researchers nor research funding sources available compared to other disciplines
19PRACTICE RESOURCE NEEDS OF CANCER CENTRE RDNs CPGs and/or evidence summariesAn oncology nutrition practice research programA Foundations of Oncology Nutrition Care Manual
20PRACTICE RESOURCE NEEDS OF RDNs IN COMMUNITY SETTINGS Primary need is for a Foundations of Oncology Nutrition Care Manualoncology nutrition care in community settings mostly involves symptom management for patients prior to cancer diagnosis, or rehabilitating following treatmentPerceived CPGs to be more relevant to cancer centre dietitians
21ONCOLOGY NUTRITION PRACTICE RESEARCH 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?
22Oncology Nutrition Research Program could be framed according to 4 outcome categories: Biochemical / physical parametersPerformance / functional parametersFinancial considerations (including cost benefit/cost effectiveness assessment)Client perceptions
23FOUNDATIONS OF ONCOLOGY NUTRITION CARE MANUAL contain evidence based information on best practicescontain information on issues / situations regarding beliefs, meaning of eating, suggestions to counselling approachesarticulate positions or evidence summaries about new and / or controversial aspects of oncology nutrition
24DISSEMINATION 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
25POTENTIAL USES OF RESOURCES BCCA RDNsinform decision making and planningpromote consistent practiceorient new staffeducate and train interns, graduate studentsprovide updates to RDNs in communityfacilitate research agendaCOMMUNITY RDNsenhance patient careenhance communication with BCCA RDNsbe kept up-to-date on developmentseducate and train interns
26UNANTICIPATED FINDINGS DIFFERING APPROACHES TO ONCOLOGY NUTRITION CARE: FOR CANCER CENTRE RDNs Centrality of knowing tumour site and stage, treatment plans, and pre-existing conditionsConsideration of three components of nutritional assessment and intervention planning:- physiologic nutritional needs- beliefs, meanings of food/eating- nutrition education/counselling approachesAssessment and planning/implementing interventions are intertwined; not discrete activities
27UNANTICIPATED FINDINGS DIFFERING APPROACHES TO ONCOLOGY NUTRITION CARE: FOR COMMUNITY RDNs Often did not know patient’s diagnosisDid not have in-depth familiarity with different types of cancer, cancer treatment, and its implicationsNutrition care for cancer pts was only one of many conditions they tried to stay up-to-dateHospital-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
28UNANTICIPATED FINDINGS RESOURCES USED TO INFORM PRACTICE Resources used by BCCA dietitians related to the three components of nutritional assessmentWith experience, practice became less dominated by textbook or manual type informationWith experience, strive to find a balance between standards for care and personalized solutionsMonitor the medical and nutrition literature, consult with patients and families, and dietetic/medical colleagues
29Where 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