Heads up GPs, we can save $billions if we work together!

I write this post in response to an article published in the GP-subscribed Endocrinology Update with headline Dietitian referrals have limited benefit to patients (10-07-13).  

My post here is a shout-out to all GPs, nurse practitioners, and dietitians: we can be more effective together!  In this post, I’ll walk you through what I know, and the evidence I am aware of to argue dietitians ARE effective.  And are a strong adjunct service in the Australian community.

Michael Woodhead (author of the dietitians are ineffective article) my post is no reflection on your professional capabilities. You have a job to do, spunky headlines get the hits, I know that, we all know that.  The end. 

Wellllll, the end, except, that headline you’ve selected and the opening statement are accidentally powerful.  Don’t worry Michael, you are not in trouble, I know you didn’t mean it.

Like all health professionals, including GPs, we (dietitians) are in part restricted by the system within which we work.  Decoded: we are doing our best with what we have.  That is not a disclaimer.  It is a fact. 

First up, disclosure of interest: I am a dietitian.  I am doing a PhD about effectiveness of dietetic services in primary care.  I know we can do better.  My hypothesis is we can do better if we have accurate, reliable, and useful data available to us during our consult. 

You’d think it a minimum standard, to have accurate and reliable data, but it is not.  Dietitians often rely on patient-reported biochemistry measures, current drug type and dose, ability to exercise etc.  Having the right information at the right time creates an efficiency, which is a first step to report effectiveness.  This stuff will be in my thesis, but is an important point to make here so you know we know this is a problem. 

Right, enough about me…..  Alright then, one more thing.  Do you eat two fruit and five vegetables every day?  What is your body mass index?  Exercise for 60 minutes today?  Me neither.  But you’d know about my form.  It’s hard.  Lets keep perspective on our expectations.

My interpretation of the study by Spencer is slightly more positive than Michael’s.  The study is supportive evidence dietitians ARE effective.  If a dietitian can achieve a significant change in body weight and waist circumference, in an average of two sessions per client, well, that sounds pretty amazing to me!  Sure, it may not be clinically relevant at face value, or the matched metabolic improvements.  But consider this: if that person had not seen the dietitian, it is likely they would continue down the trajectory of gradual weight gain over years with associated burden of disease.  

Most important: The outcome a dietitian achieves is almost completely dependent on the client. The client, after being given their “food prescription” is to then exit the consultation room, pop down to the shop to buy the food prescribed, and when they are at the shop, ignore the cheaper, more satiating, desirable options.  The point: A food prescription is hard to fill.

  

Sorry Michael, your article content is important, albeit trumped up, so lets get back to it.  

Michael’s article reports on a study published this month in the Australian Journal of Primary health by Spencer and colleagues in Queensland.  The Queensland study reports on the interventions and outcomes of three dietitians providing a service in the community to clients on an EPC with type 2 diabetes.  Michael summarises the findings in his article titled “dietitian referrals have limited benefits for diabetes patients” and the opening statement of his article is:

"Millions of dollars are being wasted in Medicare-subsidised dietetic services for type 2 diabetes patients because of poor attendance and modest results in weight loss, research from Queensland suggests."

I say: dietitians cannot support people to achieve their health goals if that person doesn’t rock up to the appointment.  Right, that’s cleared that up then. 

Oh, wait.  Except I’d add, this opening statement tells me there is a problem with the system.  In particular, it is likely there is a problem with how we are selecting clients onto EPC.  Why are we waiting till they have “one or more” comorbidities?  What happened to prevention?  So dietitians are meant to help people who don’t rock up, and who have years and years of poor food habits formed, have little money, and are working with average culinary knowledge, skills, and, [often] limited capacity to get these pro-health food skills. 

It is no surprise to any health professional if I describe the clients eligible for the EPC appointments as “more complex” than full-fee paying clients.  EPC clients tend to have a number of health issues, and usually have gotten to this [unhealthy] point after many years of less nutritious culinary behaviours.  That is a generalisation of course.  There are many reasons individuals struggle with their health, food is one, but is most likely the biggest influence over time.  And then, EPC clients also have a less flexible food budget, as well as substandard food preparation, storage and cooking facilities, let alone a nice sun-filled room with a table to eat the lovingly prepared nutritious delights. 

Now, that challenge of navigating to only the foods prescribed goes for all of us, including me.  But for EPC clients, consistently prioritising the healthy options is possibly an even greater challenge.  In fact, part of my thesis hypothesises “low-income” is in itself a culture when it comes to choosing food.  What I mean is, low-income has it’s own set of “what is normal” – and what you see most often becomes YOUR normal.  A problem is the marketing strategies of nutrient poor food and drinks are targeted at the “low-income culture”.  What, you knew that already?  Ok, well, that is the sort of colourful, exciting, fun, propaganda a dietitians food prescription is up against.

I am not saying it is hopeless.  It is not. Ever. But we must recognise behaviour change is CHALLENGING.  It takes time.  Effort.  Strategic effort.  Together.  Whatever it takes.  Yeah.  Lets do it.  C’mon.

Stopping a trajectory is a good outcome too.  Small changes are good.  Very good. [Check out Carter, Moodie, and Swinburn’s ACE work].

Spencer (2013) is not the first paper to report data indicating dietitians are effective.  An economic analysis by the OECD reports the dietitian-GP partnership is potentially the most cost-effective long-term strategy to halt and reverse obesity (OECD 2009; 2010).  I have suggested the dietitian-GP cost-effectiveness found in the OECD analysis is BECAUSE the small changes in behaviour from one-on-one consultations with a dietitian make a measurable difference in health outcomes. Dietitians can make a measurable contribution to Australia’s health statistics - It is this hypothesis that will be a next phase in our research in an RCT.   

But wait, there is more.  Check this out:  A New Zealand study by Coppell and colleagues published in 2010 in the BMJ reports on an RCT (n=94) in people with type 2 diabetes.  All participants were on maximum OHGs.  The test group received intensive nutrition intervention with a dietitian (n=45).  Compared with the control group, the test group measured a 0.4% improvement in HbA1c (p<0.007)!  Again, on eyeballing that result, 0.4% feels clinically insignificant but the authors give the comparative analysis to you (like all good writers should):

"..the magnitude of the reduction in HbA1c is comparable with that seen in clinical trials when a new drug has been added to conventional agents"

I could conclude “dietitians to replace drugs”.  Would that be cost-effective….you bet! What say you Michael?  You want to use that heading?

@MDPStudy


Epilogue
To our medical colleagues: we see this as an opportunity to make improvements to work toward our shared health goals for individuals, communities and populations.  You coming with?

Tips du jour
1. There is good evidence dietitian-GP partnerships is a cost-effective option for Australia
2. Small changes in behaviour can achieve measurable changes in health
3. Supporting each other to create an efficient health service is the way to effectiveness 

Other blogs by me

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

References
Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann J.  Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment- Lifestyle Over and Above Drugs in Diabetes Study (LOADD): randomised controlled trial.  BMJ 2010, 341

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led beahavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University.  Working Paper No. 65 1997

Organisation for Economic Co-operation and Development (OECD) Publications available at www.oecd.org 

Sassi F, Cecchini M, Lauer J, Chisholm D.  Improving lifestyles tackling obesity: the health and economic impact of prevention strategies.  OECD Health Working Papers No. 48

and

Sassi F.  Obesity and the economics of prevention: Fit not fat.  OECD 2010

Spencer L, O'Shea M-C, Ball L, Desbrow B, Leveritt M.  Attendance, weight, waist circumference outcomes of patients with type 2 diabetes receiving Medicare-subsidised dietetic services.  Australian Journal of Primary Health (2013)