Background
Nutrition disorders, such as sarcopenia, malnutrition, and cachexia are prevalent in cancer patients and correlated with negative outcomes, increased costs, and reduced quality of life (QOL). Registered dietitians (RDs) effectively diagnose and treat nutrition disorders. RD staffing guidelines in outpatient cancer centers are non-specific and unvalidated. This study explored RD staffing ratios to determine trends which may indicate best practices.
Methods
Facility-level measures including full time equivalents (FTE), referral practices, RD participation interdisciplinary round participation, and nutrition referral practices were obtained from survey data of RDs working in oncology clinics and from cancer registries across VHA between 2016-2017. A proactive score was calculated based on interdisciplinary meeting attendances, use of validated screening tools, and standardized protocols for nutrition referrals. Chart review was conducted for 681 Veterans from 13 VHA cancer centers and 207 oncology providers (OPs) to determine weight change, malnutrition, oral nutrition supplement (ONS) use, time to RD referral, and survival. Logistic regression was used for statistical analysis.
Results
Mean and median RD FTE assigned to oncology clinics was 0.5. The total RD:OP ratio ranged from 1:4 to 1:850 with an average of 1 RD to 48.5 OP. An increase in RD:OP ratio from 0:1 to 1:1 was associated with a 16-fold increased odds of weight maintenance during cancer treatment (95% CI: 2.01, 127.53). A 10% increase in the RD:OP ratio increased probability of weight maintenance by 32%. Being seen by an RD was associated with 2.87 times odds of being diagnosed with malnutrition (95% CI: 1.62, 5.08). Each unit increase in a facility’s proactive score was associated with 38% increased odds of a patient being seen by an RD (95% CI: 1.08, 1.76), and 21% reduced odds of being prescribed an ONS (95% CI: 0.63, 0.98).
Conclusions
Few cancer centers employ dedicated fulltime RDs and nutrition practices vary across cancer centers. Improved RD:OP ratios may contribute to improved nutrition outcomes for this population. When RDs are active in interdisciplinary cancer teams, nutrition treatment improves. These efforts support patient complexity, facility funding, and QOL. These data may be used to support cancer care guidelines across VHA.