Friday, 19 July 2013

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 

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) 
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Tuesday, 16 July 2013

Small health changes are good!


In the early theoretical analysis for my thesis, I came across two key papers: the first is an economic analysis of lifestyle interventions by general practitioners for people with diabetes by Rob Carter and colleagues back in 1997 (Dalton 1997). The second is also an economic analysis, investigating treatment and prevention strategies for obesity commissioned and published by the OECD (Sassi 2009; 2010).

When I say "economic analysis" it means [loosely/broadly] a series of rational hypotheticals to understand what is happening, why, and with what consequences. How it works is you create an evidence-based hypothetical model of a service, or intervention, from the literature, and then you put into the model what you know for sure (from the evidence), then make evidence-informed rationalised assumptions to fill in the gaps to work out stuff like cost-effectiveness. Think of it as a mathematical sequence of events drawn from the literature: if I do this to x, what happens to y?

Or just take this message: economics is a science of decision-making; and health economics is a science of decision-making about health.

This kind of health economic modelling (econometrics) forms one part of the decision-making about health services. You can imagine if you were making decisions about funding one health service over another, the cost effectiveness of a service would be an important part of making that decision. Not the only part of course, and not always the most heavily weighted part of making decisions.

Imagine what happened if we only ever funded the most cost-effective services? What do you think such decision-making would do to equity and justice? This does not mean we blindly fund all health services, or that there should be a blanket fund to anything health. We are all accountable for our use of the scarce resources available, and to do our best to make informed judgements about what we do.

A special note for my dietitian colleagues: my work is about capturing what we do so we can report efficiency and effectiveness. If you feel anxious about this kind of reporting….read related blogs 1 and 2….and know I am here to hold hands as we get on top of this data stuff. Promise. Data will in fact raise and support our professional autonomy and credibility.

Right. Back to the “evidence small changes are good thing”. Carter’s work (Dalton 1997), and more recent, his teaming up with Boyd Swinburn, and Marg Moodie in the ACE series of economic modelling for obesity, consistently supports the early findings:

“…lifestyle changes that can be sustained over the longer period are better than dramatic changes that cannot be sustained”

Of course the body of work on the econometrics of prevention and treatment strategies for overweight and obesity are more detailed than this sweeping one-liner I have pulled out of the results. But having read across the literature, I can tell you there is something in the “small changes”. And in fact, Sassi’s work reports:

“The dietitian-GP partnership is potentially the most cost-effective long term strategy to halt and reverse obesity”

I hypothesised the dietitian-GP partnership came out on top is because of the intricacy of making
decisions about food: changing the know what to know how.  Dietitians are trained specifically to support behaviour change that is so completely individual driven, public health campaigns for prevention are not sufficient in the day to day challenges of “sticking to the two and five”.

Wait. Before you start tweeting “see small sustainable changes are better” remember how we practice to evidence, and we translate this evidence as suited to the person in front of us? What that means in this scenario is, the evidence suggests, “overall, small changes are good, and are likely cost-effective”. But we know as practitioners some people really do respond better to a dramatic change first, and then need the dietetic support to keep to it – what is best for this person at this time in this clinic with this dietitian? What is the client in front of me really telling me? Of all the options I know of to support this person to achieve their health goals, which ones will I pitch to this person as the MOST SUITABLE option at this time?

Epilogue
Evidence-based practice means the health professional brings all they know about all the evidence, and translates this to present the best option/s for what works for this person at this time. Data from that decision-making provides evidence of what works why/why not to inform clinical decision-making.

Tips du jour:
1. Small changes make a positive contribution to Australia’s health
2. Health economics is one part of the information needed to make decisions about health services
3. Dietitians can make a measurable impact on Australia's health statistics



References
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

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

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Monday, 15 July 2013

Dietitians: as effective as clinical trials

Yesterday I started writing this article here (the one you are reading now) but ended up writing about some other stuff as a prelude: Confessions of a dietitian.  Today I am going to add to the discussion on the effectiveness of dietitians. 

Put the trolleys in your mind (from yesterdays post, or here).  One trolley illustrates what the evidence says should be in our trolley to be healthy (proportions of fruit, veg, lean meat, dairy, extras etc), the other trolley is what Australians actually put in their trolley.  There is clearly a gap (and a rather big one) between what the evidence says to eat - ADG trolley, and what we do eat - Real-life trolley.  The evidence-based (ADG) healthy trolley is what dietitians are trained to support people to achieve.  But when you look at the real-life trolley, where would you start in trying to get people to achieve the healthy trolley? 

Here is an excerpt from an early version of my thesis' abstract:

A problem for dietitians is that there is an expectation their service will achieve the evidence-based health benchmarks of a healthy body weight (BMI<25kg/m2), meet fruit and vegetable intake targets, as well as exercise recommendations.  The expectation of a dietetic service exists despite the scientific evidence that few or no interventions achieve such health targets (Franz 2007; Cochrane 2010).

The central tenet of this thesis is that it is likely dietitians do facilitate significant and measurable improvements to an individual’s health, even where the improvements achieved fall well short of the health benchmarks.  There is evidence the small health gains that are achieved may be clinically significant, and even cost-effective (Dalton 1997; Sassi 2009).

And then I go on in the abstract and introduction to talk about the problem my thesis is investigating which is about data: collecting and reporting data from practice.  Sure, I’ve simplified “the problem” for this blog, and also, so there is some material left to put in the final thesis *ahem*.  But whenever I have presented this work to dietitians, there is a real sense of anxiety about reporting data from practice.  This anxiety is because dietitians know when it comes to achieving health improvements, especially weight – it is HARD, and outcomes may not present as “effective” because the improvements are small, if any. 

The first point to make is: if we continue to not collect and report data, we continue to keep doing what we are doing (and hope no one asks what we are doing or notices our existence).  If we collect, report and understand that data, we can start to build a practice-generated evidence-base about what we do with this patient at this time in this clinic with this dietitian.  And we can then do better (see hypothesis).  To me, this IS evidence based practice AND translational research.  BAM.  Winning. 

I’ve tweeted this catch phrase previously: “no data = no problems.  but no solutions”

Not sure who first said it, but I took it from Chris Bain’s presentation we did together on a Vic State job (back in 2009).  Thanks Chris, I've changed your quote a bit, Voevodin-style….where are you by the way?

The second point is: halting further weight gain is an important outcome, and a contribution to Australia's health statistics.  Before doing this research, I was unconvinced "halting is good too" - but now, I am convinced it really is good.  Evidence coming.  I know, I am promising a lot.  

In the first few months of my thesis, I was exploring effectiveness of dietitians.  Published studies from practice was sparse as expected (given we aren’t routinely collecting data yet), sure there were some RCTs looking at dietetic services versus other health professional’s services, while other studies compared one diet over another, but none stood out as THE intervention for weight management.  No real surprise there either because the diet that works is the one you can stick to (Thomas 2008). 

My work was not intended to find THE weight loss strategy and then implement that system across dietetic services.  My work is to be a step toward developing a system to record and report whatever it is that dietitian does with that patient at that time, and have that data reported back to the dietitian in a way that automatically generates useful data to make clinical decisions: what works, why, and when to change/add/adjust. 

There are many strategies to support people to achieve their health goals.  Dietitians are trained to know all approaches, to critically assimilate the information, and then translate that information for the person in front of them. We simply want an efficient system to capture what is done in the iterative exchange of information during a consultation.


A system that generates the evidence from practice is also a [critical] reflective practice tool.  The “evidence” presented to the dietitian supports a “putting aside” of their own personal philosophical approach that may be lurking and inadvertently influencing practice (sure, I’m guilty).  But also allows a bravery to step outside our own attitudes, beliefs, and behaviour, because dietitians will now have in front of them accurate, reliable, meaningful data on which to make the next critical decision. 

Epilogue
There is more to say about effectiveness of dietitians - in particular to highlight points from Dalton 1997 and Sassi 2009, and explain some economic modelling of health services. That to come (probably next week).

PS. The data that went to build the trolleys was an analysis I did in 2010 using a previous paper we'd published (Kettings 2009) and then data from the ABS (2008) on household spending. Just so you know it's not made up....details will be in thesis or a later publication.

Tips du jour:
1. Embrace data, lets use it to our advantage
2. Practice-generated evidence is the new black lets be the first to do it

References

Australian Bureau of Statistics (ABS). All data sourced from the ABS was sourced online from www.abs.gov.au The data used in the trolley analysis is from 2008: household spending. This data was also reported in Australia's Food & Nutrition by the AIHW 2012. 

Cochrane Collaboration. Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese adults (Review) The Cochrane Library Issue 12, 2010 (see also Cochrane Collaboration. Long term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus The Cochrane Library Issue 1, 2009; or any other review of weight loss interventions on Cochrane).
Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led behavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University Working Paper 65.  

Franz MJ, JJ VanWormer, AL Crain, JL Boucher, T Histon, W Caplan, JD Bowman and NP Pronk. Weight-loss outcomes: systematic review and meta-analysis of weight loss clinical trials with a minimum of 1-year follow-up. JADA 2007 107:1755-1767 

Kettings CM, AJ Sinclair and M Voevodin. A healthy diet consistent with Australian health recommendations is too expensive for welfare-dependent families Australian and New Zealand Journal of Public Health 2009; 33(6): 566-572

Sassi, F. et al. (2009), “Improving Lifestyles, Tackling Obesity: The Health and Economic Impact of Prevention Strategies”, OECD Health Working Papers, No. 48, OECD Publishing.
http://dx.doi.org/10.1787/220087432153

Thomas S, Hyde J, Karunaratne A, Kausman R, Komesaroff PA.  "They all work...when you stick to them" A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals.  Nutrition Journal 2008; 7:34
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