Student: Dru Norriss
Supervisors: Ben Hudson, Pip Mason, Michael O'Dea, Jane Cartwright [Dept Public Health & General Practice, Pegasus Health, Partnership Health Canterbury]
Sponsor: Partnership Health Canterbury, hosted by Pegasus Health
Introduction
In December 2008, Partnership Health Canterbury introduced a scheme whereby General Practitioners (family doctors) were able to refer patients registered on CDM Options for Care (a programme to help patients with significant chronic disease) to dietitians for up to 5 fully-paid consultations. A further 5 consultations were available if recommended by the dietitian and approved by the GP. Initially, patients could be referred for a variety of chronic conditions. After July 1 2009, the criteria changed such that patients had to be enrolled in Care Plus (generally meaning that they have 2 or more chronic conditions with significant burden to the patient and high cost to the health system) and BMI (body mass index) measure of >30 kg/m2. The scheme was introduced in response to a perceived need for a community dietitian service, with funded dietitian services in Canterbury previously very difficult to access from within primary care.
Aims
This project aims to investigate the reach and performance of the community dietitian service. The aims can be summarised as follows:
- To assess the demography (ethnicity and NZdep06 quintile showing socioeconomic deprivation) of those utilizing the service as compared with the eligible Canterbury (Partnership Health Canterbury) PHO population.
- To assess the reasons for individual patients being referred to the service.
- To assess perceived strengths and weaknesses and barriers to use of the service from the perspectives of patients, doctors and the dietitians providing the service.
- To consider the individual dietitian consultation model compared with other lifestyle interventions for weight loss and chronic disease.
Methods
Demography and reason for referral data were obtained from Pegasus Health. Referrals up to 7/12/2009 were analysed.
Expected referral proportions were generated from information held by Partnership Health Canterbury. This data was combined with obesity prevalence data from "A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey" to calculate adjusted figures.
The third and fourth aims were achieved with the use of postal questionnaires. 1031 questionnaires were sent to patients. 175 questionnaires were sent to individual General Practitioners. 12 questionnaires were sent to private dietitians, representing all those currently providing the service to the PHO.
Results
1079 referrals were analysed. Breakdown by ethnicity (percents show proportion among the 1002 referrals with known ethnicity data): Asian 14 (1%); Eurpoean/Other 891 (89%); Maori 80 (8%); Pacific 17 (2%). No ethnicity data was available for 77 referrals. The expected referrals based on the adjusted PHO data were: Asian 3%; European 75%; Maori 11%; Pacific 6%.
The breakdown of referrals by NZdep06 quintile is as follows (percents show proportion among the 983 referrals with known quintile data): Quintile 1 222 (23%); quintile 2 210 (21%); quintile 3 225 (23%); quintile 4 166 (17%), quintile 5 160 (16%). No quintile data was available for 96 referrals. The expected referrals based on the adjusted PHO data were: Quintile 1 25%; quintile 2 19%, quintile 3 20%, quintile 4 17%, quintile 5 19%. (Quintile 5 denotes highest socioeconomic deprivation, quintile 1 the lowest).
The top 5 reasons for referral were: Obesity 700; Hyperlipidaemia 209; Type 2 Diabetes 172; Other 141; and Cardiovascular Disease 137.
A summary of important findings from the questionnaires follows. 207 were returned from patients, 89 from GPs, and 7 from dietitians.
86% of patients rated "somewhat easy" or "very easy" for travelling to the dietitian's office.
89% of patients selected "usually" or "always" for getting suitable appointment times. 80% of patients selected "usually" or "always" for feeling heard and understood by the dietitian.
80% of patients selected "usually" or "always" for finding the advice they received practical, affordable and easy to put into practice.
71% of patients were referred for weight-loss, of which 17 (12%) has accessed the Green Prescription programme in the past year.
50 (57%) of GPs indicated they thought their patients would benefit if their nurses were upskilled in nutrition and lifestyle interventions.
Conclusion
Comparison of referrals made with expected referrals yields no indication that the dietitian service is being utilised grossly inequitably, although there is some suggestion of over referral of European/other and NZdep06 quintiles 2-4. Caution must be taken in interpreting the results however as there have been only 1079 referrals to date. If the small percentage differences between expected and actual referrals remained over time as numbers utilising the service increased, this would begin to suggest inequity with higher confidence.
The responses to patient questionnaires indicated a moderately high level of satisfaction with the service. There is some suggestion that there are issues around the actual delivery of dietitian intervention and advice, and the relationship between the dietitians and clients, with a slightly lower percentage (80%, 80% vs. 86%, 89%) of patients indicating positive responses to the relevant questions above.
Considering the obesity focus of the referral criteria, it may useful to establish systems to encourage patients to seek other interventions first (eg Green Prescription, Appetite for Life) aimed at general lifestyle-based chronic disease management and prevention and to then later escalate to dietitian services if deemed necessary.