Attitudes of Australian Patients Undergoing Treatment for Upper Gastrointestinal Cancers to Different Models of Nutrition Care Delivery: Qualitative Investigation

Systematic Review of Patient Preferences and Experiences Regarding Dietetic Outpatient Care

INTRODUCTION

Dietitians play a crucial role in delivering medical nutrition therapy in outpatient settings where overnight admission of patients is not required. Despite the increasing focus on value-based healthcare and patient-reported measures (PRMs), there have been no recent reports synthesising patient experiences of dietetic outpatient care. This study aims to synthesise existing literature on patient preferences and experiences of outpatient dietetic care and to provide updated guidance for dietitians to improve patient-centred care.

METHODS

A qualitative systematic review with meta-ethnography was conducted. The review included studies that reported patient experiences of dietetic care provided at outpatient settings detailed through focus groups, interviews, surveys or questionnaires, regardless of language, year or nationality. Participants' quotes and second-order concepts were extracted verbatim and synthesised. Main themes and sub-themes were then developed.

RESULTS

Five database searches yielded 5786 articles. After title and abstract screening and full-text review, 72 articles were included. Three overarching themes were identified: (1) the process of accessing and receiving dietetic care was problematic; (2) the delivery and content of dietetic advice were suboptimal at times and (3) personal attributes of the dietitian and a desire for speciality expertise influenced perceptions of the quality of dietetic care.

CONCLUSION

The findings from this study provide actionable insights for dietitians to tailor their outpatient services by improving accessibility, refining the delivery of care and enhancing specialised expertise to meet individual patient needs and expectations effectively.

Assessing the impact of an intensive dietitian-led telehealth intervention focusing on nutritional adequacy, symptom control and optional supplemental jejunal feeding, on quality of life in patients with pancreatic cancer: a randomised controlled trial protocol

BACKGROUND

Pancreatic cancer is the third leading cause of cancer-related death in Australia, with a persistently poor 5-year survival rate of around 13%. Symptoms arising from the disease and chemotherapy such as epigastric pain, anorexia, bloating and fat-malabsorptive diarrhoea cause poor oral intake and weight loss, and reduce an individual's quality of life and ability to tolerate anti-cancer treatment. The primary aim of this study is to determine if an early, intensive telehealth nutrition intervention can improve quality of life compared to usual care for people undergoing treatment for pancreatic cancer.

METHODS

This multicentre randomised controlled trial will recruit adults newly diagnosed with borderline resectable, locally advanced or metastatic pancreatic cancer from multiple health services across Victoria (metropolitan and regional). The control group will receive usual nutrition care, which is site-dependent. The intervention group will receive weekly telehealth dietetic consultations for six months, targeting nutritional adequacy through dietary education and counselling, oral nutrition supplement drinks and dietetics-led symptom management advocacy, including appropriate dosing of pancreatic enzymes. Escalation to supplemental jejunal tube feeding may occur if clinically required in the intervention arm. The primary outcome is quality of life (EORTC-QLQ C30 summary score); secondary outcomes include survival, chemotherapy dosing changes, and nutrition status markers including body composition. Outcomes will be measured at baseline, and three- and six-months.

DISCUSSION

The findings of this study will provide evidence of the impact that intensive nutrition therapy, including counselling, provision of oral nutrition supplement drinks and the option for jejunal feeding, has on quality of life and health outcomes in pancreatic cancer. The consistent dietetic approach with the use of telehealth consultations to reduce malnutrition and aid symptom management challenges the current model of care.

TRIAL REGISTRATION

31st January 2024, Australian and New Zealand Clinical Trial Registry (Trial ID/No. ACTRN12624000084583).

Supplemental tube feeding: qualitative study of patient perspectives in advanced pancreatic cancer

OBJECTIVES

Malnutrition is associated with poor quality of life and survival outcomes for patients with cancer, but is challenging to prevent or treat in pancreatic cancer due to the multifactorial drivers of nutritional decline. A novel application of percutaneous endoscopic gastrostomy with a jejunal extension tube to deliver supplementary nutrition may improve outcomes, and will be tested in a randomised controlled trial. This study explored the perspectives of people living with pancreatic cancer regarding the acceptability of this proposed intensive nutrition intervention, to elucidate appropriateness and anticipated barriers, and facilitate informed design of the planned trial.

METHODS

Participants were patients with pancreatic cancer previously enrolled in a Pancreaticobiliary Cancer Biobank. Qualitative semi-structured interviews were conducted by telephone and transcribed verbatim for deductive thematic analysis. The Framework Model was used, with the Theoretical Framework of Acceptability as the analytical framework.

RESULTS

10 participants were recruited. Four overarching themes were developed from interviews: (1) deterioration in physical and mental well-being are consequences of debilitating nutrition impact symptoms; (2) willingness to participate depends on an individual threshold for nutritional deterioration; (3) predicted perceived effectiveness outweighed anticipated burdens and (4) adequate dietetic support is needed for maintaining a percutaneous endoscopic gastrostomy with jejunal extension feeding tube at home with confidence.

CONCLUSIONS

Most participants believed that the intervention would benefit people with advanced pancreatic cancer to maintain their nutrition throughout chemotherapy. Regular and ad hoc support was considered essential, and the degree of individual nutritional deterioration was identified as an important indicator for trial participation.

Effect of Communication Mode on Disclosure of Nutrition Impact Symptoms During Nutrition Intervention Delivered to People With Upper Gastrointestinal Cancer

Individuals diagnosed with upper gastrointestinal cancers experience a myriad of nutrition impact symptoms (NIS) compromise a person's ability to adequately meet their nutritional requirements leading to malnutrition, reduced quality of life and poorer survival. Electronic health (eHealth) is a potential strategy for improving the delivery of nutrition interventions by improving early and sustained access to dietitians to address both NIS and malnutrition. This study aimed to explore whether the mode of delivery affected participant disclosure of NIS during a nutrition intervention. Participants in the intervention groups received a nutrition intervention for 18 weeks from a dietitian via telephone or mobile application (app) using behaviour change techniques to assist in goal achievement. Poisson regression determined the proportion of individuals who reported NIS compared between groups. Univariate and multiple regression analyses of demographic variables explored the relationship between demographics and reporting of NIS. The incidence of reporting of NIS was more than 1.8 times higher in the telephone group (n = 38) compared to the mobile group (n = 36). Telephone predicted a higher likelihood of disclosure of self-reported symptoms of fatigue, nausea, and anorexia throughout the intervention period. A trusting therapeutic relationship built on human connection is fundamental and may not be achieved with current models of mobile health technologies.

Asynchronous Telemedicine: A Systematic Literature Review

Background

Asynchronous telemedicine (ATM), which describes telemedical interaction between a patient and provider where neither party communicates simultaneously, is an important telemedicine modality that is seeing increased use. In this article, we summarize the published peer-reviewed literature specifically related to ATM to (1) identify terms or phrases that are used to describe ATM, (2) ascertain how this research has thus far addressed the various aspects of the quadruple aim of medicine, and (3) assess the methodological rigor of research on ATM. We also divided the literature into pre- and post-COVID-19 onset periods to identify potential variations in the literature between these two periods.

Methods

This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search, utilizing multiple databases and applying inclusion and exclusion criteria, initially produced 2624 abstracts for review. De-duplication and screening ultimately yielded 104 articles for data extraction.

Results

"Store-and-forward" and variations of "e-visit" were the most frequently used alternative terms for ATM. Care quality was the most frequently addressed aspect of the Quadruple Aim of Medicine-more than double any other category-followed by patient satisfaction. We separated cost of care into two categories: patients' cost of care and providers' cost to provide care. Patient cost of care was the third most addressed aspect of the Quadruple Aim of Medicine followed by provider well-being and provider's cost to provide care. Methodological rigor of the studies was also addressed, with only 2 quantitative studies ranked "Strong," 5 ranked "Moderate," and 97 ranked "Weak." Qualitative studies were generally acceptable but struggled methodologically with accounting for all participants and articulation of results.

Conclusions

Although "store-and-forward" is somewhat more frequently used in the studies included in this review, variants of "e-visit," are growing in recent usage. Given the relative newness of modality, it is not surprising that quality of care is the most researched aspect of the Quadruple Aim of Medicine in ATM research. We anticipate more balance between these areas as research in this field matures. Primary areas of research need currently relate to practitioners-specifically their costs of providing care and well-being. Finally, future ATM research needs to address research challenges of selection bias and blinding in quantitative studies and improved participant tracking and articulation of both study design and results in qualitative studies.

The roles of the dietitian in an 18-week telephone and mobile application nutrition intervention for upper gastrointestinal cancer: a qualitative analysis

PURPOSE

This study aimed to explore the patient-dietitian experience during an 18-week nutrition counselling intervention delivered using the telephone and a mobile application to people newly diagnosed with upper gastrointestinal (UGI) cancer to (1) elucidate the roles of the dietitian during intervention delivery and (2) explore unmet needs impacting nutritional intake.

METHODS

Qualitative case study methodology was followed, whereby the case was the 18-week nutrition counselling intervention. Dietary counselling conversations and post-intervention interviews were inductively coded from six case participants which included fifty-one telephone conversations (17 h), 244 written messages, and four interviews. Data were coded inductively, and themes constructed. The coding framework was subsequently applied to all post-study interviews (n = 20) to explore unmet needs.

RESULTS

Themes describing the roles of the dietitian were as follows: regular collaborative problem-solving to encourage empowerment, a reassuring care navigator including anticipatory guidance, and rapport building via psychosocial support. Psychosocial support included provision of empathy, reliable care provision, and delivery of positive perspective. Despite intensive counselling from the dietitian, nutrition impact symptom management was a core unmet need as it required intervention beyond the scope of practice for the dietitian.

CONCLUSION

Delivery of nutrition care via the telephone or an asynchronous mobile application to people with newly diagnosed UGI cancer required the dietitian to adopt a range of roles to influence nutritional intake: they empower people, act as care navigators, and provide psychosocial support. Limitations in dietitians' scope of practice identified unmet patient's needs in nutrition impact symptom management, which requires medication management.

TRIAL REGISTRATION

27th January 2017 Australian and New Zealand Clinical Trial Registry (ACTRN12617000152325).

Telemedicine and Pancreatic Cancer: A Systematic Review

Introduction: Pancreatic cancer requires a multidisciplinary approach in a high-volume center for all the steps of the diagnostic-therapeutic course. However, the most experienced centers are not evenly distributed throughout the country causing a real "health migration" that involves patients and families with relevant economic, time, and energy costs to bear. The COVID-19 pandemic had a deep impact on surgical and oncological care and the travel limits due to COVID-related restrictions, have delayed the care of cancer patient living far from the referral centers. In this scenario, several telemedicine approaches have been proposed to reduce the distance between clinicians and patients and to allow a fast and effective access to care even for patients distant from referral centers. The aim of the study is to analyze the evidence and describe the current utility of telemedicine tool for patients with pancreatic cancer. Methods: We systematically searched the literature in the following databases: Web of Science, PubMed, Scopus, and MEDLINE. The inclusion criteria were article describing a telemedicine intervention (virtual visits, telephone follow-up/counseling, mobile or online apps, telemonitoring) and focusing on adult patients with pancreatic cancer at any stage of the disease. Results: In total, 846 titles/abstracts were identified. Following quality assessment, the review included 40 studies. Telemedicine has been proposed in multiple clinical settings, demonstrating high levels of patient and health professional satisfaction. Conclusion: Successful telemedicine applications in patients with pancreatic cancer are telerehabilitation and nutritional assessment, remote symptom control, teledischarge after pancreatic surgery, tele-education and medical mentoring regarding pancreatic disease as well as telepathology.

Effect of Early and Intensive Telephone or Electronic Nutrition Counselling Delivered to People with Upper Gastrointestinal Cancer on Quality of Life: A Three-Arm Randomised Controlled Trial

BACKGROUND

Delay in dietetic service provision for upper gastrointestinal cancer exacerbates disease-related malnutrition and consequently increases morbidity and mortality. Dietetic services are usually referral-based and provided face-to-face in inpatient or outpatient settings, which can delay the commencement of nutrition care. The aim of this study was to provide intensive dietetic intervention close to the time of diagnosis for upper gastrointestinal cancer and assess the effect on quality-adjusted life years.

METHODS

A three-arm randomised controlled trial of adults newly diagnosed with upper gastrointestinal cancer was performed. A behavioural-based, individually tailored, symptom-directed nutrition intervention was provided in addition to usual care, delivered by a dietitian using a telephone (synchronously) or a mobile application (asynchronously) for 18 weeks, compared with a usual care control group. Data were collected at baseline, three, six, and twelve months post-randomisation. The primary outcome was quality-adjusted life years (EQ-5D-5L quality of life assessment tool). Data were analysed using linear mixed models.

RESULTS

One hundred and eleven participants were randomised. Quality-adjusted life years were not different in the intervention groups compared with control (telephone: mean (95% CI) 0.04 (0.43, 2.3), p = 0.998; App: -0.08 (-0.18, 0.02), p = 0.135) after adjustment for baseline, nutrition risk status, age, and gender. Survival was similar between groups over 12 months. The asynchronous mobile app group had a greater number of withdrawals compared with the telephone group.

CONCLUSION

Early and intensive nutrition counselling, delivered at home, during anticancer treatment did not change quality-adjusted life years or survival over 12 months compared with usual care. Behavioural counselling alone was unable to achieve nutritional adequacy. Dietetic services delivered asynchronously using a mobile app had low acceptance for patients undergoing anticancer treatment.

TRIAL REGISTRATION

27 January 2017 Australian and New Zealand Clinical Trial Registry, ACTRN12617000152325.

Evaluation of the implementation of a best practice gestational diabetes model of care in two Australian metropolitan services

INTRODUCTION AND AIMS

Dissemination and local adaptation of best practice models of care are often poorly achieved in knowledge translation processes. Understanding and documenting the iterative cycles of improvement can elucidate barriers, enablers and benefits of the process for future adoption and service integration improvements. This project examined the process of local adaptation for a third stage translation of a gestational diabetes dietetic model of care through collaboration with two Queensland (Australia) hospitals.

METHODS

Using a hub (research team)-spoke (sites) model, two Queensland Hospital and Health Service Districts were supported to assess and address evidence-practice dietetic model of care gaps in their gestational diabetes mellitus (GDM) services. Sites selected demonstrated strong GDM team cohesiveness and project commitment. The project phases were: Consultation; Baseline; Transition; Implementation; and Evaluation.

RESULTS

Despite strong site buy-in and use of a previously successful model of care dissemination and adoption strategy, unexpected global, organisational, team and individual barriers prevented successful implementation of the model of care at both sites. Barriers included challenges with ethics and governance requirements for health service research, capacity to influence and engage multidisciplinary teams, staff turnover and coronavirus disease 2019's (COVID-19's) disruption to service delivery.

CONCLUSION

This third iteration of the dissemination of a best practice model of nutrition care for GDM in two Queensland Hospital and Health Service Districts did not achieve successful clinical or process outcomes. However, valuable learnings and recommendations regarding future clinical and research health service redesign aligned with best practice are suggested.