Veterans Health Administration cancer centers are lacking registered dieticians (RDs), and patients are more likely to be diagnosed with malnutrition when they are on staff, according to a new study .
The average number of full-time RDs across 13 cancer centers was just 1 per 1,065 patients, advanced practice oncology dietitian Katherine Petersen, MS, RDN, CSO, of the Phoenix VA Health Care System, reported at the AVAHO annual meeting.
However, patients treated by RDs were more likely to be diagnosed with malnutrition (odds ratio [OR], 2.9, 95% CI, 1.6-5.1). And patients were more likely to maintain weight if their clinic had a higher ratio of RDs to oncologists (OR, 1.6 for each 10% increase in ratio, 95% CI, 2.0-127.5).
Petersen told Federal Practitioner that dieticians came up with the idea for the study after attending AVAHO meetings. “A lot of the questions we were getting from physicians and other providers were: How do we get dietitians in our clinic?”
There is currently no standard staffing model for dieticians in oncology centers, Petersen said, and they are not reimbursed through Medicare or Medicaid. “We thought, ‘What do we add to the cancer center by having adequate staffing levels and seeing cancer patients?’ We designed a study to try and get to the heart of that.”
Petersen and her team focused on malnutrition. Nutrition impairment impacts an estimated 40% to 80% of patients with gastrointestinal, head and neck, pancreas, and colorectal cancer at diagnosis, she said.
Petersen discussed the published evidence that outlines how physicians recognize malnutrition at a lower rate than RDs. Dietary counseling from an RD is linked to better nutritional outcomes, physical function, and quality of life.
The study authors examined 2016 and 2017 VA registry data and reviewed charts of 681 veterans treated by 207 oncologists. Oncology clinics had a mean of 0.5 full-time equivalent (FTE) RD. The mean ratio of full-time RDs to oncologists was 1 per 48.5 and ranged from 1 per 4 to 1 per 850.
“It's almost like somebody randomly assigned [RDs] to cancer centers, and it has nothing to do with how many patients are seen in that particular center,” Petersen said. “Some clinics only have .1 or .2 FTEs assigned, and that may be a larger cancer center where they have maybe 85 cancer oncology providers, which includes surgical, medical, and radiation oncology and trainees.”
Why would a clinic have a .1 FTE RD, which suggests someone may be working 4 hours a week? In this kind of situation, an RD may cover a variety of areas and only work in cancer care when they receive a referral, Petersen said.
“That is just vastly underserving veterans,” she said. “You're missing so many veterans whom you could help with preventative care if you're only getting patients referred based on consults.”
As for the findings regarding higher RD staffing and higher detection of malnutrition, the study text notes “there was not a ‘high enough’ level of RD staffing at which we stopped seeing this trend. This is probably because – at least at the time of this study – no VA cancer center was adequately staffed for nutrition.”