oncology nutrition standards of practice and clinical practice guideline development : a canadian...
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Oncology Nutrition Standards of Practice and Clinical Practice Guideline Development : A Canadian Experience
• Charitini Orphanidou, MSc, RDN Clinical Practice Leader - Nutrition, BCCA, Kelowna BC
• Catherine Morley, PhD, RDN, FDC Consultant - Nutrition and Dietetics, West Vancouver BC
• Karen Biggs, MHSc, RD Team Leader Clinical Nutrition, HRCC, Hamilton ON
HAMILTON REGIONAL CANCER CENTRE
BC Cancer Agency Centre for the Southern Interior
AgendaAgenda
Standards of Practice
• Defined
• National Working Group
• Review of the Standards
• National Review
• Dissemination
Clinical Practice Guidelines
• Defined
• Quality of Evidence
• National Working Group
• Work to date
• Future work
Key Stakeholders
• Canadian Association of Provincial Cancer Agencies (CAPCA)
• Canadian Strategy for Cancer Control (CSCC)
CAPCA
• A national board consisting of chief executive officers of each of the provincial cancer agencies plus trustees drawn from provincial cancer agency boards and a representative from the Canadian Cancer Society/National Cancer Institute mission
• CAPCA is an interprovincial organization engaged in cancer control
CAPCA: Key Policy Advisory Committees
• Clinical Practice Guideline Initiative
• Psychosocial Oncology Policy Advisory Committee
• Supportive Care Policy Advisory Committee (Joint effort of CAPCA and CSCC).
Canadian Strategy for Cancer Control (CSCC)
“Cancer control is too complex and broad a challenge for any single jurisdiction or organization to achieve by acting alone. This strategy presents an unprecedented opportunity for coordinated and collaborative action on a number of fronts that promises to change the cancer control landscape in Canada”.
CSCC: Priority Areas
1. Establish a Council
2. Standards and Guidelines
3. Primary Prevention
4. Rebalance Focus
5. Human Resources
6. Research
CSCC Priority Areas: Standards and Guidelines
Standards of Practice
Leader
Dr. Brent Schacter, CEO Cancer Care Manitoba
Mandate: Develop national Standards of Practice
Clinical Practice Guidelines
Leader Dr.George Browman CEO
Hamilton Regional Cancer Centre
Mandate: Facilitate a national coordinated approach to CPGs
R E C A P…...
• Two National Groups citing Standards of Practice and Clinical Practice Guidelines as key priority areas
• Supportive Care Advisory Group Working encouraging these priority areas
• Members of these groups encouraging dietitians to begin work in these areas
Standards of Practice: Defined
A Standard:• a measure, criterion or specific behavior against
which something or someone is measured• are norms that express an agreed upon level of
practice that has been developed to characterize, measure and provide guidance for achieving excellence
• provides a guide to the knowledge, skills, judgments and attitudes that are needed to practice safely
Standards: Common Components
DESCRIBE:• what dietitians do• what dietitians are
accountable for• acceptable level of
performance in a given situation
1. Patient population is defined
2. Statement of objectives and rationale
3. Process of care
4. Identifies personnel to deliver care
5. Defined initiation and monitoring of care
6. Documentation of care
Standards of Practice
• IMPERATIVE that they are established
• Outline roles and competencies that guide practice
• Links are proposed within the standards regarding basic and graduate education, clinical practice, continuing education and research
Standards are the Foundation...
Decisions are made for:• Defining appropriate levels of staffing
• Establishing nutrition roles and responsibilities within an agency or organization
• Determining core curriculum for dietetic education
• Determining outcome of care influenced by nutrition intervention
• Defining public policy on the role on nutrition in patient care
National Working Group: Oncology Nutrition Standards of Practice
• Working group consisted of interested members of DC Oncology Network in collaboration with the BCCA
• Dietitians working in oncology
• Teleconferencing efficient/effective in accomplishing work nationally
National Working GroupMEMBERS
• Karen Biggs MHSc, RD ON• Sandra Gentleman RDN BC• Angela Martens RD MB• Catherine Morley PhD, RDN, FDC BC• Charitini Orphanidou MSc, RDN BC• Satnam Sekhon RDN BC
Canadian Oncology Nutrition Standards of Practice…...
SECTIONS
• Introduction
• Overview of Nutritional Care in Oncology
• Nutrition Issues for Persons Living with Cancer
• Foundations
• Programs and Services
• References
• Glossary
Standards of Practice
Introduction
• Population defined
• How to use the Standards
• What is included in the document
Standards of Practice
Nutritional Care in Oncology
• Significance of nutritional care
• Proactive vs. reactive
• Well referenced
Standards of Practice
Nutrition Issues in Persons Living with Cancer
• Potential effects of malnutrition
• Continuum of care
• Cancer survivorship
Standards of Practice
Foundations
Section 1: Organization and Structure
Section 2: Professional Attributes
Standards of Practice
Section 1: Organization and StructureStandard 1: Organizations will provide
Nutrition Care
Standard 2: Position Profile
Standard 3: Representation in the Administrative Structure
Standard 4: Membership in Interdisciplinary Teams
Section 1: Organization and Structure
Standard 5: Program Resources
Standard 6: Supportive Research Environment
Standard 7: Integrated Documentation
Standard 8: Program Workload Data
Section 1:: Organization and Structure
Standard 9: Oncology Nutrition Leadership
Standard 10: Performance Reviews
Standards of Practice
Section II: Professional Attributes
Standard 11: Qualifications
Standard 12: Ethics
Standard 13: Unique Body of Knowledge
Standard 14: Competent Application of Knowledge
Section II: Professional Attributes
Standard 15: Continued Competence
Standard 16: Evidence Based Practice
Standards of Practice
Programs and ServicesSection III: Oncology Nutrition Services
Section IV: Research
Section V: Education and Training
Section VI: Evaluation of Programs and Services
Standards of Practice: Programs and Services
Section III: Oncology Nutrition Services
A) Nutritional Care of Individuals
B) Nutrition Education for Groups
C) Management of Practice
Standards of Practice: Oncology Nutrition Services
A) Nutritional Care for Individuals
Standard 17: Access to Services
Standard 18: Nutrition Screening
Standard 19: Nutrition Consultation
Standard 20: Nutrition Counseling and/or Education
Standard 21: Continuity of Care
Standards of Practice: Oncology Nutrition Services
B) Nutrition Education for Groups
Standard 22: Group Nutrition Education
Standards of Practice: Oncology Nutrition Services
C) Management of Practice
Standard 23: Administrative Responsibilities
Standard 24: Health Care Team Members
Standard 25: Community Liaison
Standards of Practice: Programs and Services
Section IV: Research
Standard 26: Supportive Research Environment
Standard 27: Promotion of and Participation in Research
Standards of Practice: Programs and Services
Section V: Education and Training
Standard 28: Participation in Education and Training
Standards of Practice: Programs and Services
Section VI: Evaluation of Programs and Services
Standard 29: Evaluation of Programs and Services
Standards of Practice: Review
Critical Review
1. Provincial Supportive Care Leaders– CAPCA & CSCC
– Administrators at BCCA and HRCC
2. Medical Oncologist (Director of Supportive Care)
3. Provincial Groups of Dietitians– Ontario and British Columbia
4. Dietitians of Canada Oncology Network Members
Standards of Practice: Review
• Printed copy provided to every reviewer or member; comments requested
Standards of Practice:Reviewers’ Feedback
• Provincial Leaders in Supportive Care, Provincial RD Groups, Medical Oncologist provided useful comments and guidance
• Limited feedback from DC Oncology Network members
Standards of Practice: Update
• Revisions complete
• Submitted to CSCC/ CAPCA Standards of Practice Leaders
Well Deserved BREAK!
Clinical Practice Guidelines in Oncology Nutrition
CPGs: CPGs: Agenda
Clinical Practice Guidelines• Defined
• The Practice Guideline Development Cycle
• National Working Group
• Work done to date
• Future work
CPGs…….. Defined
Defined: • Systematically developed statements to
assist practitioner and patient decisions about appropriate health care for specific clinical circumstances
• Evidence based
WHY… Do We Need CPGs
• Evidence of unexplained and inappropriate variations in clinical practice patterns
• Concern that further limitations in resources will effect the delivery of high quality health care
• To assist clinicians in assimilating rapidly evolving scientific evidence into practice
CPGs…… continued
What We Know:• Attributes
• Methodologic Rigour
• Barriers to development/ implementation
Practice Guideline Development Cycle
• Facilitates a uniform approach to guideline development
• Consists of eight well-defined steps
• Expert panel required for relevant areas
Practice Guidelines Development Cycle
8. Schedule Review
7. Adopt guideline, policies
6. Negotiate practice policies
5. Independent review
1. Select/frame clinical problem
2. Generate evidence-based recommendation
(EBR)
3. Ratify EBR
4. Formulate practice guideline
update
Browman et al, 1995, JCO, 13(2), 502-512.
Practice Guideline Development Cycle
1. Select/Frame Clinical Problem
• Priorize/select topic• Select outcomes• Frame the problem
2. Generate EBR
• Search, gather and synthesize evidence
• Grade the strength of evidence
• Generate preliminary EBR
Levels of Scientific Evidence
Level I EvidenceRCT that are big enough to detect benefit
Meta-analysis
Level II EvidenceRCT that are too small therefore showing trends
Level III EvidenceFormal comparison with nonrandomized controls
Level IV EvidenceFormal comparisons of historical controls
Practice Guideline Development Cycle
3. Ratify the Final EBR
• Reconcile differences in interpretation of evidence
• Document important opinions and reasons for them
4. Formulate Practice Guidelines
• Foster clinical flexibility and credibility through consensus building
Practice Guideline Development Cycle
5. Independent Review of EBR and Guideline
• Independent review• Discipline specific
experts• Modify if warranted
6. Negotiate Practice Policies
• Implement guideline• Problem solve
systematic constraints
Practice Guideline Development Cycle
7. Adoption of Guideline and Policies
• Adopted formally and given official status
8. Guideline Review and Update
• Regularly scheduled reviews and updates imperative
CPGs….. Oncology Nutrition
• Initially confused– How to get started?– Where to focus? – What is important?
CPGs National Working Group
• Charitini Orphanidou Co-Chair BC• Karen Biggs Co-Chair ON• Catherine Morley Contractor BC• Satnam Sekhon BC• Angela Martens MB• Donna Danelon ON• Patricia Campbell NS
CPG National Working Group:Work to date……..
INITIALLY:
Where to begin and how to get started?Ensure national perspective and needs identification
What were the key clinical practice issues?
CPG National Working Group:Work to date……..
• Reviewed CPGs in other areas of nutrition practice and non-nutrition areas
• Realized this project was/is HUGE and not to be done independently of oncology nutrition clinicians
• Wanted to formulate a plan of action within a research context
CPG National Working Group:Work to date……..
• CFDR grant application process discussed
• Broad national perspective required
• Smaller working group prepared a letter of intent
TITLE:
Basing Oncology Clinical Practice Guidelines on the Collective Experience of Dietitians Working with People Living with Cancer
CPG National Working Group:Work to date……..
Preliminary project: BCCA and Hamilton oncology dietitians
• Funding from BCCA, HRCC, DC-ONN
• To identify key clinical practice issues
• Piloted data gathering approaches (to assess potential use should study receive funding)
CPGs… Project Findings
Key Clinical Issues Identified as:
1. Nutrition Risk Screening
2. Enteral Feeding: Indications and Approaches
Other Findings:
1. Need for a Foundations of Oncology Nutrition Care Manual
2. Oncology Nutrition Research Agenda (with staffing/ resourcing issues)
3. Enhanced cancer centre-community setting networking/ communication
CPGs… Project Findings
CPGs… Currently…
• Plan to move ahead with Evidence Summaries using Systematic Literature Reviews on the two key clinical issues identified in the project
To Conclude…To Conclude…
• Tremendous strides
• A lot of hard work
• Wonderful growing and colleague building experience
• A lot to learn
• Proud of where we are at
• Thank you for your attention
• Questions/discussion welcome!