Promoting High Value Care by De-adopting The Neutropenic Diet

From the 2018 HVPAA National Conference

Ahana Sen (University of Texas Southwestern Medical Center, Dallas, TX;), Arjun Gupta (University of Texas Southwestern Medical Center, Dallas, TX;), Deepak Agrawal (University of Texas Southwestern Medical Center, Dallas, TX;), Hsiao C. Li (University of Texas Southwestern Medical Center, Dallas, TX;), David Johnson (University of Texas Southwestern Medical Center, Dallas, TX;), Navid Sadeghi (University of Texas Southwestern Medical Center, Dallas, TX;)

Background

Patients with cancer associated neutropenia are commonly prescribed ‘neutropenic  diets’ despite multiple randomized controlled trials demonstrating that restrictive ‘neutropenic diets’ do not reduce infection rates compared to more liberal diets. Neutropenic diets are associated with lower quality-of-life and malnutrition.

Objectives

To determine ordering patterns of the neutropenic diet at our institution to guide high-value care efforts with the eventual goal of eliminating it. We also wanted to determine if they were ordered reliably and consistently. Finally, we sought to educate individuals on the lack of evidence and efficacy of the neutropenic diets and to remove this entity from our institution

Methods

We studied the inpatient utilization of neutropenic diets at Parkland Health & Hospital System, Dallas,Texas from September 2016-September 2017. We analyzed the contents and duration of the neutropenic diet, and its  prescription patterns. We used the Culture, Oversight, Systems Change,Training (COST) framework to guide the delivery of high value care by ultimately abandoning the use of the neutropenic diet.

Results

In the  1-year study period, there were 4,781 admissions in which patients were neutropenic (absolute neutrophil count, < 1,000 /µL) at any given time during the admission. Of these, 163 unique patients with 229 admissions (4.7%) had a neutropenic diet ordered. In 20/229 admission (8.7%), the patient was not neutropenic. The most common ordering providers were internal medicine (53%), and oncology (29%). Internal medicine and oncology physicians were educated  regarding the lack of efficacy of a neutropenic diet (Training) and ordering patterns were monitored (Oversight) using the information technology department. Involved trainees recruited multi-departmental leaders, from the administration, infection control, nutrition services, oncology, and internal medicine  to champion this initiative (Culture). The neutropenic diet order was then removed from the system through an electronic medical record modification (Systems change).

Conclusion

Inpatients with neutropenia at our institution received the neutropenic diet inconsistently, and with inconsistent contents. Guided by a standardized value  framework, we abandoned the use of a low-value practice, neutropenic diet, at our institution, resulting in high-value care change with minimal resource utilization.

Implications for the Patient

The neutropenic diet was prescribed inconsistently at our institution, and we were able to abandon its use to promote high value care. Other institutions should encourage de-adoption of the neutropenic diet.

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