How cost-effective is nutrition care delivered in primary healthcare settings? A systematic review of trial-based economic evaluations.

CONTEXT: Nutrition care is an effective lifestyle intervention for the treatment and prevention of many noncommunicable diseases. Primary care is a high-value setting in which to provide nutrition care. OBJECTIVE: The objective of this review was to evaluate the cost-effectiveness of nutrition care interventions provided in primary care settings. DATA SOURCES: Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials, EconLit, and the National Health Service Economic Evaluation Database (NHS EED) were searched from inception to May 2021. DATA EXTRACTION: Data extraction was guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines. Randomized trials of nutrition interventions in primary care settings were included in the analysis if incremental cost-effectiveness ratios were reported. The main outcome variable incremental cost-effectiveness ratios (ICERs) and reported interpretations were used to categorize interventions by the cost-effectiveness plane quadrant. RESULTS: Of 6837 articles identified, 10 were included (representing 9 studies). Eight of the 9 included studies found nutrition care in primary care settings to be more costly and more effective than usual care. High study heterogeneity limited further conclusions. CONCLUSION: Nutrition care in primary care settings is effective, though it requires investment; it should, therefore, be considered in primary care planning. Further studies are needed to evaluate the long-term cost-effectiveness of providing nutrition care in primary care settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42020201146.

Effectiveness of dietetic consultation for lowering blood lipid levels in the management of cardiovascular disease risk: A systematic review and meta-analysis of randomised controlled trials.

AIM: Evidence of the effectiveness of dietetic consultation for the management of cardiovascular disease (CVD) risk factors has not been previously synthesised. A systematic review and four meta-analyses evaluated the effectiveness of dietetic consultation for lowering blood lipid levels in high-risk individuals in primary health-care settings. METHODS: Of the 4860 records identified, 10 eligible randomised controlled trials (RCTs, n = 1530) were evaluated for reporting blood lipid outcomes following dietetic consultation (DN)-defined as at least one exclusive individual face-to-face consultation with a dietitian and comparators (C)-defined as no nutrition intervention or usual or minimal care provided by physicians and/or nurses. RESULTS: DN groups were effective for lowering blood lipid levels across nine studies reporting total cholesterol (TC) and LDL; and across five of six studies reporting triglycerides (TG). Between-group differences were not consistently assessed, with significance levels reported in four studies all in favour of DN, P < 0.05. Meta-analyses for TC and LDL (seven studies) confirmed DN and C groups were equally effective, P > 0.05; and for TG (six studies) DN groups were significantly more effective than C groups, P < 0.05). CONCLUSIONS: This review provides RCT evidence that dietetic counselling is effective for lowering TG levels and at least as effective as usual and minimal care for improving cholesterol levels in high-risk individuals in primary health care. However, more adequate reporting of methods and greater consistency in timing interventions and data collection will enhance the quality of the evidence and increase confidence in the health benefits of dietetic counselling for the management of CVD risk.

Nutrition care guidelines for men with prostate cancer undergoing androgen deprivation therapy: do we have enough evidence?

BACKGROUND: To review the evidence available to support clinical practice guidelines for dietary interventions aimed at mitigating the side effects of androgen deprivation therapy (ADT) in men with prostate cancer, and to identify future research priorities. METHODS: An analytical model was designed to select and interpret evidence for the effect of dietary interventions on ADT side effects. Key terms identified articles that investigated dietary interventions to mitigate ADT side effects among men treated for prostate cancer. Medline, Embase, Proquest, CINAHL, Cochrane databases, and PubMed were searched from inception through June, 2018. Clinical trial registries were also searched for up-to-date study protocols. Articles were not restricted on design. Methodological quality was assessed using the mixed methods appraisal tool. RESULTS: Sixteen articles met inclusion criteria, each with distinct dietary interventions. Twelve studies used interventions that combined diet with physical activity and/or medication and/or counselling. Four articles examined the effect of diet alone on ADT side effects. Of those, three articles measured changes to participants' dietary intake and influence on ADT side effects. One article showed daily caffeinated beverages improved cancer-related fatigue. Two articles showed no impact of isoflavone supplementation on hot flushes, quality of life, body mass index, or blood lipids. Dietary intake and compliance was poorly reported across all studies limiting knowledge of acceptability and feasibility for dietary interventions. Information on the nutrition care practices and views of clinicians treating men for prostate cancer is limited. No articles measured the impact of diet on long-term ADT side effects. Methodological quality of included papers ranged from weak to strong. CONCLUSIONS: Current evidence for dietary interventions to mitigate ADT side effects is limited. Further investigations are warranted to explore the impact of changes in dietary intake on ADT side effects before practice guidelines can be considered.

Questionnaires that measure the quality of relationships between patients and primary care providers: a systematic review.

BACKGROUND: International guidance on models of care stress the importance of good quality, continuous patient-provider relationships to support high quality and efficient care and hospital avoidance. However, assessing the quality of patient-provider relationships is challenging due to its experiential nature. The aim of this study was to undertake a systematic review to identify questionnaires previously developed or used to assess the quality of continuous relationships between patients and their provider in primary care. METHODS: MEDLINE, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and SCOPUS databases were searched for English language studies published between 2009 and 2017. Key terms used identified studies conducted in the primary care setting examining relationships between patients and providers. Studies that focused on the conceptualisation, development, testing or review of a questionnaire, or studies that used a questionnaire for assessing the quality of continuous relationships between patients and providers were eligible. Studies that did not assess quality via a questionnaire, only assessed single aspects of relationships, only assessed single encounters, assessed transitions between settings or assessed relationships using an index were excluded. Information on validity testing of each relevant questionnaire identified from articles was reviewed to inform recommendations for future research and evaluation. RESULTS: Twenty-seven studies met the eligibility criteria, including 14 unique questionnaires. The questionnaires were diverse in length, scope, focus and level of validity testing. Five questionnaires were considered not feasible for future use due to size and lack of development work. Three questionnaires were considered strongest candidates for use in future work based on being relevant to the topic and primary care setting, freely available in English and not needing additional pilot work prior to use. These three questionnaires were the Care Continuity Across Levels of Care Scale, the Nijmegan Continuity Questionnaire and the Patient-Doctor Depth of Relationship Tool. CONCLUSIONS: This study provides an overview of 14 unique questionnaires that have been used to assess the quality of continuous relationships between patients and primary care providers. The decision to use one of the questionnaires in future work requires careful consideration, including the scope, length, validation testing, accessibility of the questionnaires and their alignment with the initiative being evaluated.

Effectiveness of Dietetic Consultations in Primary Health Care: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: A dietetic consultation is a structured process aimed at supporting individual patients to modify their dietary behaviors to improve health outcomes. The body of evidence on the effectiveness of nutrition care provided by dietitians in primary health care settings has not previously been synthesized. This information is important to inform the role of dietitians in primary health care service delivery. OBJECTIVE: The aim of this systematic review was to evaluate the evidence of the effectiveness of individual consultations provided exclusively by dietitians in primary care to support adult patients to modify dietary intake and improve health outcomes. STUDY DESIGN: ProQuest Family Health, Scopus, PubMed Central, Medline, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for English language systematic reviews or randomized controlled trials published before October 2016. The key terms used identified the provision of nutrition care exclusively by a dietitian in a primary health care setting aimed at supporting adult patients to modify dietary behaviors and/or improve biomarkers of health. Interventions delivered to patients aged younger than 18 years, in hospital, via telephone only, in a group or lecture setting, or by a multidisciplinary team were excluded. The methodologic quality of each study was appraised using the Cochrane Risk of Bias tool and the body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual. MAIN OUTCOME MEASURES: Outcomes included the effectiveness of dietetic interventions in terms of anthropometry, clinical indicators, and dietary intake. A statistically significant between-group difference was used to indicate intervention effectiveness (P<0.05). RESULTS: Twenty-six randomized controlled studies met eligibility criteria, representing 5,500 adults receiving dietetic consultations in a primary care setting. Eighteen of 26 included studies showed statistically significant differences in dietary, anthropometric, or clinical indicators between intervention and comparator groups. When focusing specifically on each study's stated aim, significant improvements favoring the intervention compared with control were found for the following management areas: glycemic control (four out of four studies), dietary change (four out of four studies), anthropometry (four out of seven studies), cholesterol (two out of eight studies), triglycerides (one out of five), and blood pressure (zero out of three) studies. CONCLUSIONS: Dietetic consultations for adults in primary care settings appear to be effective for improvement in diet quality, diabetes outcomes (including blood glucose and glycated haemoglobin values), and weight loss outcomes (eg, changes in weight and waist circumference) and to limit gestational weight gain (Grade II: Fair evidence). Research evaluated in this review does not provide consistent support for the effectiveness of direct dietetic counseling alone in achieving outcomes relating to plasma lipid levels and blood pressure (Grade III: Limited evidence). Therefore, to more effectively control these cardiovascular disease risk factors, future research might explore novel nutrition counseling approaches as well as dietitians functioning as part of multidisciplinary teams.