Keywords

Dietitian-led, general practice, primary care

 

Authors

  1. Hickson, Mary

ABSTRACT

Objective: This scoping review aims to examine and map the existing evidence exploring and/or evaluating the implementation, cost and/or effectiveness of dietitian-led clinics in primary care.

 

Introduction: Dietitians may be able to offer new models of care within the primary care setting for relevant diagnosed patients, providing cheaper, more efficient and effective service in comparison to the traditional approach of general practitioner support and referral for specialist treatment. There is some evidence for the efficacy of dietetic care in primary care, but there is a lack of information concerning the broader contribution dietitians may make, including cost effectiveness and the range of conditions that dietitians may successfully manage.

 

Inclusion criteria: Eligible studies will explore dietitian- or nutritionist-led clinics treating patients with any condition, and will be based in primary care or general practice settings in developed countries. Studies may include experimental, quasi-experimental, observational and qualitative studies.

 

Methods: The searches will be limited to the past 10 years to ensure retrieved information will be relevant to today's healthcare setting. There will be no limit for language. The following databases will be searched: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), AMED (EBSCO), British Nursing Index (ProQuest), and Cochrane Database of Systematic Reviews (Wiley). Retrieved papers will be screened for inclusion by at least two reviewers. Where a decision is not possible, full text will be retrieved and reviewed. Data will be extracted from the included papers and a narrative summary will accompany the charted results and will describe how the results relate to the review's objective.

 

Article Content

Introduction

The World Health Organization (WHO) describes primary care as "first-contact, accessible, continued, comprehensive and coordinated care. First-contact care is accessible at the time of need; ongoing care focuses on the long-term health of a person rather than the short duration of the disease; comprehensive care is a range of services appropriate to the common problems in the respective population and coordination is the role by which primary care acts to coordinate other specialists that the patient may need".1(para.3) The terms "general practice" and "family medicine" are both synonymous with primary care and may be used interchangeably in the literature. How primary care is organized varies between countries and may be centered on the general practitioner (GP), or primary care physician, or take a more team-oriented approach recognizing the primary care team (or family medicine team). The WHO describes the primary care team as "a group of fellow professionals with complementary contributions to make in patient care",1 (para.5) of which a dietitian may be one member.

 

Dietitians have a skill set that enables them to lead on the therapeutic support provided to patients with certain conditions that are amenable to treatment with dietary manipulation. Examples of such conditions include diabetes mellitus, cardiovascular disease, over- and underweight, food allergies, chronic obstructive pulmonary disease, gastrointestinal conditions, and renal and liver conditions. Dietitians have historically worked largely in acute hospital settings2; however, there is little information on dietitians who work in primary care. This may be a service commissioned by the general practice to private dietitians or contracted from dietetic services based in the acute or community sectors.

 

Throughout the developed world, health care is changing. Some of the contributing factors include demographic shifts such as: the aging population, increase of long-term conditions, increase of dementia, changes in the diversity of society, health inequalities and limited funding.2 This has led to an increased demand within the primary healthcare sector while simultaneously, GP numbers in many countries are declining, including the UK,3 USA4 and Australia.5

 

Given the skill set of dietitians, it may be that new models of care within the primary care setting could see dietitians taking a lead in delivering primary care for relevant diagnosed patients and providing cheaper, more efficient and effective service in comparison to the traditional approach of GP support and referral for specialist treatment. Indeed, this has been promoted by the UK government as a way to tackle work pressures within primary care and general practice.6,7

 

A dietitian-led clinic is any clinic run and managed by a registered dietitian and, in this scoping review, is limited to the primary care setting where the clinic is likely to support the work of GPs. This would mean that patients with relevant diagnoses (as described earlier) could be referred by another healthcare professional, self-refer or be invited to the clinic for diet and lifestyle advice and support.

 

There are several systematic reviews that indicate how advice provided by a dietitian can improve outcomes in specific conditions, such as hypertension,8 diabetes, weight loss and diet quality.9 The evidence for gestational weight gain9 and prevention of gestation diabetes10 is weaker primarily due to lower-quality study design. Other systematic reviews have explored interventions on weight management in children11 and adults,12 type 2 diabetes,13 diabetes prevention,14 and Mediterranean diet and healthy eating,15 but these studies were not specific to dietetic interventions, although they included studies examining dietetic care. They all showed that dietary interventions could improve outcomes, and some showed that care provided by dietitians achieved superior outcomes, but the quality of the study designs were often weak. Other original studies also support the view that dietitians and/or dietary counseling (which dietitians are uniquely trained to deliver) are effective in improving clinical outcomes in a number of health conditions.16-20 Therefore, it would seem that greater utilization of dietetic interventions in the primary care setting could be an effective way to manage many common chronic diseases; however, it is important to demonstrate that interventions are effective in the setting in which they will be delivered.

 

A review by Mitchell et al.9 is the only one available looking specifically at dietitians in primary care, and this included only randomized controlled trials. The reviewers did not search for any particular disease category, but looked at any patient receiving dietetic consultations. The conditions treated included HIV, cardiovascular disease, obesity, hypertension, diabetes, impaired fasting glucose, gestational diabetes and colorectal cancer. The results show fair (Grade 2) evidence for dietetic consultations for adults in primary care settings for improvement in diet quality, diabetes outcomes (including blood glucose and glycated hemoglobin values), and weight loss outcomes (e.g. changes in weight and waist circumference) and to limit gestational weight gain. The evidence for controlling lipid levels and blood pressure is limited (Grade 3), but this review included only studies where the provision of nutritional care was exclusively by a dietitian. Many of the studies testing interventions for cardiovascular diseases have multi-disciplinary team interventions and these, with the dietetic contribution, would not have been included in this review.

 

Thus, there is some evidence for the efficacy of dietetic care in primary care. Nevertheless, there is a lack of information concerning the broader contribution dietitians may make within the primary care setting, including cost effectiveness and the range of conditions that dietitians may successfully manage. There may also be useful qualitative information as well as quantitative work. A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, PubMed and CINAHL databases found no scoping reviews exploring dietetic care with the primary care setting. A search of the PROSPERO database found no similar systematic review protocol registered or ongoing. The objective of this scoping review is to examine and map the existing evidence exploring or evaluating the implementation, cost and/or effectiveness of dietitian-led clinics in primary care.

 

Review questions

The review questions for this scoping review are:

 

i. Does a dietitian-led clinic in general practice and/or primary care improve patient satisfaction and clinical outcomes?

 

ii. Does a dietitian-led clinic in general practice and/or primary care reduce costs?

 

iii. Is it feasible to implement dietitian-led clinics in general practice and/or primary care?

 

 

Inclusion criteria

Participants

This review will consider studies that include dietitian- or nutritionist-led clinics in primary care settings treating patients with any conditions. Both terms will be considered because the professions are linked and the name varies between countries. However, to be comparable, any dietitian- or nutritionist-led studies would need to require the dietitian or nutritionist to have have a nationally recognized credential or formal certification.

 

Concept

The proposed review is designed to explore the feasibility, organization and effectiveness of dietitian-led clinics within a primary care setting. Therefore, all studies with a focus on any aspect of dietitian- or nutritionist-led healthcare services for any disease group will be considered. Of particular interest will be any evidence of cost effectiveness in comparison to the usual organization of services.

 

Context

The context for this review will be primary care or general practice. General practice is part of primary care, but both terms will be of interest because services provided as part of primary care will be of interest even if not based in general practice. Both terms may be used interchangeably in papers and therefore it is important to identify all sources of evidence. Dietitian- or nutritionist-led clinics in hospitals, regional healthcare facilities or specialist centers will not be included. Where studies have been conducted in the community, they will be relevant if recruitment has included GPs.

 

This review will also only consider evidence from developed countries, since the settings are more likely to be comparable. It is recognized that health care is delivered and organized differently even among developed countries, but findings from developing countries will have less applicability. The World Bank country classifications includes a list of countries that are deemed to be developing.21 Studies conducted in a country listed as developing will be excluded.

 

Types of studies

This scoping review will consider all available publications that have a focus on dietitian- or nutritionist-led clinical care in a primary care setting. These may include experimental, quasi-experimental, observational and qualitative studies. Systematic reviews will be considered, as well as text and opinion papers, case studies, and relevant academic presentations, in both peer-reviewed and gray literature. Dietetic networks will be used to identify relevant gray literature from other countries.

 

Methods

The proposed systematic review will be conducted in accordance with JBI methodology for scoping reviews.22

 

Search strategy

The search strategy aims to find both published and unpublished studies. The systematic search will be developed and run by an experienced information specialist (AW). The initial strategy was iteratively designed by testing search terms against a pre-defined list of relevant articles and tested in several different databases. The final strategy will be translated for use in each of the databases (an example of the Ovid MEDLINE search is in Appendix I). The searches will be limited to the past 10 years, excluding studies prior to 2008. Limiting the search to the past 10 years ensures that the information retrieved will be as relevant as possible to today's healthcare setting. There will be no limit on language applied to the searches.

 

Information sources

The following databases will be searched: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), AMED (EBSCO), British Nursing Index (ProQuest), and Cochrane Database of Systematic Reviews (Wiley). Next, unpublished studies will be sought through requests to experts and professional bodies using existing dietetic networks, and through searching OpenGrey, ProQuest Dissertations and Theses, ClinicalTrials.gov and EU Clinical Trials Register. Finally, the reference list of each of the included papers will be hand searched to identify any further studies.

 

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA) and duplicates removed. The set will then be uploaded to Rayyan QCRI (Copenhagen: The Nordic Cochrane Centre, Cochrane) and titles and abstracts screened by two independent reviewers for assessment against the inclusion criteria for the review. Any disagreements will be solved by consensus or by the decision of a third reviewer. The full text of studies that may meet the inclusion criteria will be retrieved and re-screened to confirm inclusion. Full-text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. The final full-text papers will be imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia).

 

Papers will be included if the study is based in primary care and general practice; explores health service delivery in a developed country; involves dietitian-or nutritionist-led clinics, consultations, advice or counseling; and was published in or after 2008. Studies testing the efficacy of a nutrient, food or dietary pattern that involves a dietitian to deliver information will be excluded.

 

Data extraction

Data will be extracted from the included papers by two independent reviewers using an adapted version of the JBI results extraction instrument.23 The data extracted will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. This information will be tabulated including the following: author/s, year of publication, country, setting, purpose of the study, study design, intervention (where relevant), participants, relevant outcomes such as cost efficacy or relevant clinical outcome data, and key findings that related to the review question. The draft tool is included in Appendix II. The draft results extraction instrument will be tested on the first five papers and modified as necessary, and further revisions may be made during the process of extracting data from the remaining studies. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

 

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review's objective and question/s.

 

Funding

This review is funded by a project grant award to the University of Plymouth by the British Dietetic Association (BDA) General Education Trust (a charitable body specifically convened to support dietetic research and development projects). Officers of the BDA and trustees of the General Education Trust had no role in the development of the protocol, design of the study, data collection and collation, or interpretation and discussion of the data. Officers of the BDA did assist with identification of gray literature through their own knowledge and use of professional networks.

 

This research was also supported in part by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

 

Appendix I: Search strategy for MEDLINE (Ovid)

Appendix II: Data extraction tool

References

 

1. World Health Organization. Primary Health Care: Main Terminology [internet]. Geneva: World Health Organization; 2019 [cited 21 January 2019] Available from: http://www.euro.who.int/en/health-topics/Health-systems/primary-health-care/main. [Context Link]

 

2. Hickson M, Child J, Collinson A. Future Dietitian 2025: informing the development of a workforce strategy for dietetics. J Hum Nutr Diet 2018; 31 (1):23-32. [Context Link]

 

3. NHS Digital. General and Personal Medical Services, England As at 30 September 2017, Provisional Experimental statistics [internet]. NHS Digital; 2017 [cited 21 January 2019] Available from: https://digital.nhs.uk/data-and-information/publications/statistical/general-and. [Context Link]

 

4. Dall T, West T, Chakrabarti R, Reynolds R, Lacobucci W. The Complexities of Physician Supply and Demand: Projections from 2016 to 2030. Washington, DC: Association of American Medical Colleges; 2018. [Context Link]

 

5. Government of Western Australia. General practice workforce supply and training in Western Australia: optimising Western Australia's prevocational training to support general practice workforce development. Department of Health; 2018. [Context Link]

 

6. NHS England. General practice forward view. London (UK): NHS; 2016. [Context Link]

 

7. NHS. The NHS Long Term Plan - a summary. London (UK): NHS; 2019. [Context Link]

 

8. Riegel GR, Ribeiro PAB, Rodrigues MP, Zuchinali P, Moreira LB. Efficacy of nutritional recommendations given by registered dietitians compared to other healthcare providers in reducing arterial blood pressure: systematic review and meta-analysis. Clin Nutr 2018; 37 (2):522-531. [Context Link]

 

9. Mitchell LJ, Ball LE, Ross LJ, Barnes KA, Williams LT. Effectiveness of dietetic consultations in primary health care: a systematic review of randomized controlled trials. J Acad Nutr Diet 2017; 117 (12):1941-1962. [Context Link]

 

10. Oostdam N, van Poppel MN, Wouters MG, van Mechelen W. Interventions for preventing gestational diabetes mellitus: a systematic review and meta-analysis. J Womens Health (Larchmt) 2011; 20 (10):1551-1563. [Context Link]

 

11. Ho M, Jensen ME, Burrows T, Neve M, Garnett SP, Baur L, et al. Best practice dietetic management of overweight and obese children and adolescents: a 2010 update of a systematic review. JBI Database System Rev Implement Rep 2013; 11 (10):190-293. [Context Link]

 

12. Flodgren G, Deane K, Dickinson HO, Kirk S, Alberti H, Beyer FR, et al. Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people. Cochrane Database Syst Rev 2010. [Context Link]

 

13. Moller G, Andersen HK, Snorgaard O. A systematic review and meta-analysis of nutrition therapy compared with dietary advice in patients with type 2 diabetes. Am J Clin Nutr 2017; 106 (6):1394-1400. [Context Link]

 

14. Sun Y, You W, Almeida F, Estabrooks P, Davy B. The effectiveness and cost of lifestyle interventions including nutrition education for diabetes prevention: a systematic review and meta-analysis. J Acad Nutr Diet 2017; 117 (3):404-421. e436. [Context Link]

 

15. Maderuelo-Fernandez JA, Recio-Rodriguez JI, Patino-Alonso MC, Perez-Arechaederra D, Rodriguez-Sanchez E, Gomez-Marcos MA, et al. Effectiveness of interventions applicable to primary health care settings to promote Mediterranean diet or healthy eating adherence in adults: a systematic review. Prev Med 2015; 76: (Suppl): S39-S55. [Context Link]

 

16. Canani RB, Leone L, D'Auria E, Riva E, Nocerino R, Ruotolo S, et al. The effects of dietary counseling on children with food allergy: a prospective, multicenter intervention study. J Acad Nutr Diet 2014; 114 (9):1432-1439. [Context Link]

 

17. Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann JI. Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment--Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial. BMJ 2010; 341:c3337. [Context Link]

 

18. Lin JS, O'Connor E, Whitlock EP, Beil TL, Zuber SP, Perdue LA, et al. Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults: Update of the Evidence for the U.S. Preventive Services Task Force. 2010. [Context Link]

 

19. Sialvera TE, Papadopoulou A, Efstathiou SP, Trautwein EA, Ras RT, Kollia N, et al. Structured advice provided by a dietitian increases adherence of consumers to diet and lifestyle changes and lowers blood low-density lipoprotein (LDL)-cholesterol: the Increasing Adherence of Consumers to Diet & Lifestyle Changes to Lower (LDL) Cholesterol (ACT) randomised controlled trial. J Hum Nutr Diet 2018; 31 (2):197-208. [Context Link]

 

20. Sugawara N, Sagae T, Yasui-Furukori N, Yamazaki M, Shimoda K, Mori T, et al. Effects of nutritional education on weight change and metabolic abnormalities among patients with schizophrenia in Japan: a randomized controlled trial. J Psychiatr Res 2018; 97:77-83. [Context Link]

 

21. World Bank. Developing Countries [internet]. The Hague: International Statistical Institute; 2018 [cited 21 January 2019] Available from: https://www.isi-web.org/index.php/resources/developing-countries. [Context Link]

 

22. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci 2010; 5:69-169. [Context Link]

 

23. Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Aromataris E, Munn Z. Chapter 11: Scoping Reviews. Joanna Briggs Institute, Joanna Briggs Institute Reviewer's Manual [internet]. Adelaide: 2017. [Context Link]