Aim Shifting to models of care that incorporate delegation of nutrition care process actions to dietitian assistants could facilitate effective and efficient nutrition care delivery. This review aimed to determine if delegation of malnutrition care activities to dietitian assistants, when compared with routine nutrition care practices influences patient, healthcare and/or workforce outcomes for adult hospital inpatients with or at risk of malnutrition. Methods This review was undertaken in accordance with PRISMA guidelines, with five databases (CINAHL, Medline, PsycINFO, Embase and Scopus) searched systematically for studies published up to and including February 2020. Exclusion criteria included review articles and studies conducted in community settings. Results The search yielded 3431 results, with 11 studies eligible for inclusion. Across all domains of the nutrition care process, there is emerging evidence dietitian assistants may improve the delivery of nutrition care practices, patient, healthcare and workforce outcomes. Findings demonstrated various roles and scope of dietitian assistants' practice throughout the studies. Positive patient outcomes were found when dietitian assistants were part of a multi‐disciplinary model of care. Conclusions Implementing delegation of components of the nutrition care process to dietitian assistants is vital in the current health climate and should be considered in a future multidisciplinary model of nutrition care. Exploration of dietitian assistant roles and opportunities are required to expand and strengthen the evidence.
Evidence-based guideline translation to practice can improve outcomes but is often impaired by poor implementation. This project aimed to evaluate the implementation of the Evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians providing clinical care to this population.Methods: A questionnaire was developed, with face and content validity confirmed by an expert panel (n = 13), to gauge participant perceptions of the guidelines against an implementation evaluation framework. Dietitians were identified through Dietitians Australia and by contacting experts in the field. Eligibility was determined by questionnaire completion and prior guideline awareness. Responses were provided using a 5-point Likert scale. Results were analysed using descriptive statistics; with inferential analysis to determine if demographic information could reveal trends in guideline use and perception.Results: Of the 43 initial respondents, n = 28 completed the questionnaire, with n = 24/28 (86%) meeting full eligibility criteria for analysis. Median (range) scores for all four domains were high: awareness (4.0 [3.2-4.8]), agreement (4.4 [4.1-4.7]), adoption (3.5 [3.1-3.9]), and adherence (4.3 [4.1-4.9]).However, perception of guideline awareness and use among multidisciplinary team colleagues was low (mean 3.2/5.0 and 3.1/5.0, respectively). Dietitians with <10 years' experience had significantly higher perceptions of the guidelines' ability to positively influence practice; support evidence-based practice; and enhance dietitian credibility (P = 0.04) vs dietitians with ≥10 years' experience.Conclusion: Dietitians demonstrated high rates of guideline implementation and positive perceptions for its use in clinical practice. Future implementation strategies and evaluation should expand to engage the wider multidisciplinary team and more experienced clinicians.
Aim Oral mucositis is a debilitating side‐effect of conventional cancer treatment, particularly of the head and neck region. This review aimed to evaluate existing evidence to identify optimal nutritional interventions for oral mucositis management in adult populations receiving treatment for cancer. Methods CINAHL, PubMed, Embase and Scopus were searched from database inception to July 2019, with each eligible article critically appraised for risk of bias and assigned a quality rating. Certainty of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation system. Results Twenty‐three articles were identified (total unique study participants n = 7605). Nine intervention areas were identified. Certainty of evidence was moderate for oral cryotherapy in patients with solid or haematological cancers receiving 5‐Fluorouracil or high‐dose Melphalan chemotherapy prior to haematopoietic stem cell transplantation; and low for zinc supplementation for patients with oral cancer undergoing radiotherapy or chemoradiotherapy. Moderate certainty of evidence exists to recommend against glutamine supplementation in all cancer patients. Conclusion Research must determine the safety and efficacy of identified interventions to guide clinical practice. Addressing limitations requires larger, higher‐quality trials to increase evidence certainty.
Weight loss and malnutrition occur frequently in patients with head and neck cancer and are associated with reduced survival. This pragmatic study aimed to determine the effect of a novel pre-treatment model of nutrition care on nutrition outcomes for patients with head and neck cancer receiving chemoradiotherapy. Methods: This health service evaluation consisted of an evaluation of the new model of care implementation (Phase 1) and an evaluation of patient outcomes (Phase 2) in pre-and post-implementation cohorts (n = 64 and n = 47, respectively). All Phase 2 patients received a prophylactic gastrostomy. The new model of care consisted of dietary counselling and commencement of proactive supplementary enteral nutrition via a prophylactic gastrostomy, in addition to normal oral intake, prior to treatment commencement. Nutrition outcomes were collected at baseline (pre-treatment) and 3 months post-radiotherapy completion.Results: The new model of care was successfully incorporated into practice with high referral (96.5%) and attendance (91.5%) rates to the counselling session, and high adherence rates to proactive tube feeding (80.9%). Patients in the postimplementation cohort had less weight-loss (1.2%; p = 0.338) and saw less of a decline in nutritional status compared to patients in the pre-implementation cohort (23% vs. 30%, respectively; p = 0.572), deemed clinically important. However, patients still experienced critical weight loss overall (mean 9.9%). Conclusion: Pre-treatment nutrition care was feasible in standard clinical practice and demonstrated clinically relevant outcome improvements for patients. Future high-quality research is warranted to investigate further multidisciplinary strategies to attenuate weight-loss further, inclusive of patient-reported barriers and enablers to nutrition interventions.
Sarcopenia is a known independent prognostic factor for decreased survival in patients with head and neck cancer, yet its importance for the growing number of younger patients diagnosed with human papillomavirus (HPV) positive oropharyngeal carcinoma (OPC+) has not been established. This systematic literature review aimed to determine the prevalence and impact of computed tomography (CT)-defined sarcopenia on survival outcomes for adult patients (>18 years) with OPC+ undergoing any treatment modality. Prospective studies were searched for using PubMed, Embase, CENTRAL, CINAHL and Web of Science up until and including February 2022. Bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In total, nine studies (total pooled patients with OPC+ n=744) were identified and included in this review; two at low, six at moderate, and one at high risk of bias. All studies varied in sarcopenia assessment methods and skeletal muscle index threshold cut-off values. These studies demonstrated the cumulative prevalence of sarcopenia for patients with OPC+ to be 42.9% (95%CI: 37.8-47.9). While overall survival (three studies, n=253) and progression-free survival (one study, n=117) was lower in sarcopenic patients with OPC+, this was not statistically significant. GRADE certainty of evidence for impact of pre-treatment sarcopenia on overall survival was low and progression-free survival very low. Although these studies showed there to be a high prevalence of pre-treatment sarcopenia in patients with OPC+, which may decrease survival, the impact on progression-free survival is very uncertain. Further, high quality research utilizing consistent sarcopenia definitions and assessment methods that are conducted specifically in OPC+ is required to strengthen evidence certainty and determine if sarcopenia is an independent prognostic factor for this population.
Purpose Human papillomavirus (HPV) is now the primary cause of oropharyngeal head and neck cancer (OPC) worldwide; yet limited research has examined the effect of HPV-positive status (OPC+) on nutrition outcomes. This study aims to determine the impact of HPV status on nutritional outcomes for adult patients with OPC undergoing any treatment modality. Methods A systematic literature review was conducted up to and including July 2021 of PubMed, Embase, CENTRAL, CINAHL, and Web of Science to identify studies conducted in adults (>18 years) with known OPC reporting on any outcome(s) related to nutrition, according to HPV status (OPC+ versus OPC−). Bias was assessed using QUIPS tool, with certainty of evidence assessed using GRADE system. Results Six studies (total n = 635) all at moderate-high risk of bias were included. Three studies reported on weight change (n = 255), three feeding tube dependency (n = 380), three feeding tube timing of placement (prophylactic or reactive) and/or utilisation (n = 255), two nutritional (energy and/or protein) intake (n = 230), and one nutritional status (n = 83). Patients with OPC+ may experience greater weight loss, may have higher utilisation of reactive feeding tubes (both GRADE low certainty, downgraded due to serious bias and imprecision), and may have lower feeding tube dependency rates (GRADE low certainty, downgraded due to serious bias and inconsistency) versus OPC− . It is uncertain whether nutritional intake and nutritional status differed between populations (GRADE very low certainty, downgraded due to serious bias and very serious imprecision). Conclusion Further, high-quality research is needed to understand optimal nutritional care practices for patients with OPC + to achieve positive health outcomes into survivorship.
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