Healthcare Quality Week is a good time to consider how healthcare professionals are working to improve health outcomes, as well as to address the challenges and opportunities that lie ahead. One area where further progress is needed is in cancer care and nutrition.
Quality Cancer Care Is Important for Older Adults
More than two-thirds of all new cancers are diagnosed in those ages 60 and older, and the number of cancer cases in the U.S. continues to grow as the older adult population increases. Also growing is the cost of cancer care—last year the U.S. spent more than $208 billion on cancer care. And, 63 percent of cancer patients report financial challenges following a cancer diagnosis. Quality cancer care can help to improve health outcomes for older adults and to control costs.
Many Individuals with Cancer Are at Risk for Poor Nutrition
Nutrition is a social determinant of health that can impact health and healthcare costs. There is strong evidence that poor nutrition leads to poor health outcomes in cancer, including decreased tolerance of chemotherapy and radiation treatment, increased length of hospital stay, lower quality of life and mortality. Even at the first medical oncology visit, one study found that more than 50 percent of patients with cancer have some type of nutritional impairment, and 9 percent were overtly malnourished.
Early nutrition interventions, including oral nutrition supplements, can improve health and nutrition outcomes in oncology patients. In addition, evidence-based guidelines highlight the importance of consistent malnutrition screening, rescreening and referral of at-risk patients to a registered dietitian nutritionist for medical nutrition therapy. Yet, only about half of ambulatory oncology settings—the primary site for oncology care—screen for malnutrition. What can be done to help solve this challenge?
The Oncology Care Model and Nutrition-focused Quality Improvement Programs
Integrating quality nutrition care into quality frameworks for cancer care can help address the nutrition challenges faced by many adults with cancer. The Centers for Medicare & Medicaid Services is the single largest payer for U.S. healthcare. Its Center for Medicare and Medicaid Innovation (CMMI) tests various new payment and service delivery models for Medicare, with the aim of smarter spending, achieving better care for patients and healthier communities.
Only about half of ambulatory oncology settings screen for malnutrition.
One CMMI model is the Oncology Care Model, which targets chemotherapy and related care during a six-month period, beginning with the patient’s start of a chemotherapy treatment. About 25 percent of Medicare’s fee-for-service, chemotherapy-related cancer care is covered under the OCM.
Oncology clinics participating in the OCM commit to provide enhanced services including treatment therapies consistent with nationally recognized clinical guidelines. Both the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition have developed nutrition-specific oncology care standards and guidelines that could be useful for OCM providers.
In addition, there are nutrition sections in the American College of Surgeons Commission on Cancer Accreditation Standards and Association of Community Cancer Centers Cancer Program Guidelines, several Enhanced Recovery after Surgery Society Guidelines and in the National Cancer Institute’s Physicians Data Query resources. Nutrition care recommendations are also included in the National Comprehensive Cancer Care Network Clinical Practice Guidelines for head and neck cancer and pancreatic cancer.
CMS uses specific quality measures to evaluate OCM practices on their quality of care and to help determine performance-based payments. Nutrition potentially impacts each of the following five quality measures for OCM providers (see Table below).
|Quality measure name (CMS, 2020)||OCM measure #||Potential impact of nutrition|
|Risk-adjusted proportion of patients with all-cause emergency department (ED) visits or observation stays that did not result in a hospital admission within the six-month episode||
|Many common reasons for cancer patient ED visits are nutrition-related (such as nausea, vomiting, dehydration)|
|Oncology: medical and radiation—pain intensity quantified (MIPS 133, NQF 0384)||OCM-4a||Emerging research identifies that diet may be a regulator in chronic pain via management of inflammation/oxidative stress.|
|Oncology: medical and radiation— plan of care for pain (NQF 0383)||OCM-4b||Emerging research identifies that diet may be a regulator in chronic pain via management of inflammation/oxidative stress.|
|Preventive care and screening—screening for depression and follow-up plan (CMS 2v8.1, NQF 0418)||OCM-5||There is a potential link between malnutrition and anxiety/depression, underscoring the importance of malnutrition screening and intervention.|
|Patient-reported experience of care||OCM-6||Diet and energy questions are included in patient oncology surveys.|
The OCM also encourages and measures providers’ ability to identify and implement practice redesign strategies that improve the quality and patient’s experience of oncology care. Nutrition-focused quality improvement programs (QIPs) can be useful in driving change as part of practice redesign strategies, perfecting care processes and advancing patient-centered care.
Abbott supported a nutrition-focused Quality Improvement Program (QIP) study for at-risk or malnourished patients (a large percentage of whom had cancer) receiving home healthcare after hospital or skilled nursing facility discharge, or after being seen in an outpatient clinic. Significant reductions were observed in 90-day hospitalization rates, overall healthcare resources used (e.g., hospitalization, emergency department and outpatient visits) and cost savings of $1,500 per patient treated.
Such findings illustrate how a nutrition-focused QIP can help improve health and provide economic benefits for cancer care. Resources from the Malnutrition Quality Improvement Initiative, including an online interdisciplinary toolkit and support programs may be useful in developing a nutrition-focused QIP to aid in redesigning practice activities for OCM providers.
In the next two years, CMS is working to launch a new cancer care payment model, called Oncology Care First (OCF). Providing medical nutrition therapy in the OCF model and, as an additional service factored into population-based payments, would be powerful catalysts to address gaps in nutrition care and improve outcomes.
However, there is no need for OCM providers to wait. Quality nutrition care aligns with the enhanced services and quality measures of the OCM, and nutrition-focused QIPs can benefit practice redesign strategies for delivering quality cancer care.
Beth Besecker, MD, MBA, is director of Medical Affairs Adult Nutrition–U.S. for the Abbott Nutrition Division of Abbott in Columbus, Ohio