What Practice Issues Over 25 Years Most Interest Registered Dietitians? Survey and Interview Results.

Dietetics has changed substantially; a mixed-methods project was undertaken to: (i) gauge interest in the profession history since 1993, (ii) identify preferred format(s), (iii) identify possible topics, and (iv) identify possible key informants. An online bilingual survey was conducted in 2018, with follow-up phone interviews among interested respondents. Survey content was organised as 12 major topics. Respondents were invited via a Dietitians of Canada (DC) newsletter, Facebook groups, and at the DC national conference. Survey data, including respondent-generated topics of interest and interview content, were descriptively analyzed. The online survey garnered 360 responses; 332 (92%) completed more than 10% of the survey and were interested in history. Detailed responses were analyzed (296 English; 36 French); 51 were interviewed. An online timeline was the most preferred format (79%). Review of the rise in technology and obesity, aging, supermarket registered dietitians (RDs), the local/organic movement, Practice-based Evidence in Nutrition (PEN), the changes in training models and scope of practice, public awareness of the profession, and advocacy and unique career paths were of most interest (≥ 50% of respondents). These results confirm interest in the recent history of the profession among RDs and provide guidance on preferred format and topics for further work.

Patient reports of lifestyle advice in primary care.

PURPOSE: Patients' perceptions of preventive lifestyle in primary care practice were examined. METHODS: Practice was assessed with a modified version of the Primary Care Assessment Survey (PCAS). This was mailed to random samples of patients twice, using practice mailing lists from three Ontario Family Health Networks (FHNs). Family Health Networks are physician-based group practices, with additional nurse-led telephone advisory services to provide care 24 hours a day, seven days a week. The PCAS questionnaire consisted of nine scales (ranging from 0 to 100). For preventive counselling, additional questions on diet and exercise counselling were included to determine how the physician delivered the intervention. RESULTS: Of the 2184 survey questionnaires mailed to patients, 22% were undeliverable. The response rate was 62% at valid addresses (49% of all mailed questionnaires). Of the nine scales, scores (± standard deviation) for preventive counselling were lowest at 33 ± 25. In particular, rates of diet (37%) and exercise (24%) counselling were low in the FHNs. For most other aspects of primary care services, patients generally rated FHNs highly. The majority of patients advised about diet and exercise were given verbal advice or pamphlets. CONCLUSIONS: In these primary health care organizations, considerable room exists for increased preventive counselling, especially about diet and exercise.

Creating case scenarios or vignettes using factorial study design methods.

AIM: This paper is a report of a study conducted to develop clinical case vignettes using an adaptation of an incomplete factorial study design methodology. BACKGROUND: In health care, vignettes or cases scenarios are core to problem-based learning, common in practice guideline development processes, and increasingly being used in patient or care-giver studies of chronic or life-threatening illnesses. A large number of behavioural, psycho-social and clinical factors can be relevant in such decision problems. Unbiased methods for choosing what factors to include are needed, when it is not possible to include all relevant combinations of factors in the vignettes. METHOD: The factors to be considered, number of levels or categories for each factor, and desired number of scenarios were decided in advance. An algorithm was used first to create the full factorial data set, and then a random subset of combinations was generated, according to predefined criteria, based on maximizing determinants. The subset of combinations was incorporated into written vignettes. The study was conducted in 2004-2005. FINDINGS: Application of the method yielded diverse and balanced scenarios that covered the full range of factors to be considered for a project to elicit health providers' processes in diet counselling for dyslipidemia. CONCLUSION: The approach is flexible, decreases possible researcher bias in the creation of vignettes, and can improve statistical power in survey research. This novel application of study design methodology merits consideration when vignettes are being developed to elicit opinions or decisions in studies of complex health issues.

Development of a nutrition counselling care map for dyslipidemia.

PURPOSE: Care maps or clinical pathways for nutrition therapy of dyslipidemia could add to current practice guidelines, by providing templates for feasible and recommended diet counselling processes. A care map was therefore developed by engaging expert and generalist dietitians and external experts from across Canada in a multi-stage consensus process. METHODS: First, a qualitative study was undertaken with a convenience sample of 12 practitioners to identify possible diet care options, using hypothetical client scenarios and cognitive analysis. Second, these care options were rated for five case scenarios considered typical (overweight clients, with or without clinical cardiovascular disease and other comorbidities, potentially motivated to change, consuming high-fat diets, and facing various major barriers to eating behaviour change). The rating was conducted through a survey of participants. Highly appropriate, recommended, and feasible options for counselling were ranked through a two-round modified Delphi process, with teleconference discussions between rounds. RESULTS: Forty-nine professionals started the consensus process; 39 (80%) completed all aspects. Numerous care processes were appropriate for all clients, with additional focus on barriers for low-income clients, sodium intake for clients with hypertension, and smoking cessation in smokers. CONCLUSIONS: The resulting care map, "Dietitians' Quick Reference Guide for Clinical Nutrition Therapy for Overweight Clients with Dyslipidemia," provides a basis for current practice and new effectiveness studies.

Common ground: the canadian collaborative mental health initiative.

BACKGROUND: As one of 12 participating national health associations, Dietitians of Canada (DC) endorsed the Charter Principles and Commitments created by the Canadian Collaborative Mental Health Initiative (CCMHI). The Chair of the DC Board of Directors signed the Charter, committing DC to work collaboratively to uphold the Principles and actively endorse the Commitments. ACHIEVEMENTS: The Initiative's vision, making mental health care work--new places, new partners, new hope, provided the Steering Committee with a clear direction. The CCMHI Charter Principles cover promotion and prevention, a holistic approach, collaboration, partnership, respect, information exchange, and resources. In addition to the Charter, the CCMHI has produced a series of 12 toolkits and research papers. The toolkits are practical pieces that also contain ideas and other information. Dietitians of Canada has developed a toolkit that examines the dietitian's role in primary health care mental health programs. A set of reviews of the practice of collaborative mental health care in Canada covers a wide range of issues, from the attributes of effective collaborative care to a discussion of the barriers to collaboration. CONCLUSION: Communications between the 12 member organizations are ongoing, and the organizations await the establishment of the Canadian Mental Health Commission, which is expected to be up and running in fall 2006.

Nutrition in primary health care: using a Delphi process to design new interdisciplinary services.

PURPOSE: A modified Delphi process was used to identify key features of interdisciplinary nutrition services, including provider roles and responsibilities for Ontario Family Health Networks (FHNs), a family physician-based type of primary care. METHODS: Twenty-three representatives from interested professional organizations, including three FHN demonstration sites, completed a modified Delphi process. Participants reviewed evidence from a systematic literature review, a patient survey, a costing analysis, and key informant interview results before undertaking the Delphi process. Statements describing various options for services were developed at an in-person meeting, which was followed by two rounds of e-mail questionnaires. Teleconference discussions were held between rounds. RESULTS: An interdisciplinary model with differing and complementary roles for health care providers emerged from the process. Additional key features addressing screening for nutrition problems, health promotion and disease prevention, team collaboration, planning and evaluation, administrative support, access to care, and medical directives/delegated acts were identified. Under the proposed model, the registered dietitian is the team member responsible for managing all aspects of nutrition services, from needs assessment to program delivery, as well as for supporting all providers' nutrition services. CONCLUSIONS: The proposed interdisciplinary nutrition services model merits evaluation of cost, effectiveness, applicability, and sustainability in team-based primary care service settings.

Estimation of human resource needs and cost of adding registered dietitians to primary care networks.

PURPOSE: Information on human resources and costs is needed to plan for the addition of registered dietitian (RD) services to new models of primary health care (PHC). Estimates were developed, based on an analysis of an enhanced RD model of counselling and health promotion services in three Ontario Family Health Networks (FHNs). METHODS: Both direct and indirect costs were averaged over the three FHNs. Costs and RD activities were tracked throughout 2005. The FHN staff completed two questionnaires addressing communication, case management, and satisfaction with RD services. RESULTS: Actual and reported case management indicated that an estimated 1.3% to 2.4% of the 60,000 enrolled patients may require individual nutrition counselling in a year. If one full-time equivalent (FTE) RD can manage 380 new referrals, then one FTE RD is needed per 15,800 to 29,000 patients. The estimated direct costs of adding one FTE RD (including expenses and fixed costs) is US dollars 78,169 to US dollars 80,169, when the RD is an independent contractor. CONCLUSIONS: Additional studies are needed to develop better estimates of human resource needs and costs of interdisciplinary nutrition services in all PHC settings. These estimates should be based on population characteristics and direct and indirect costs for all models of nutrition services in PHC settings.

Promoting healthy lifestyles in Ontario Family Health Networks.

PURPOSE: Primary health care reform presents new opportunities for registered dietitians (RDs) to contribute to health promotion and disease prevention in family practices. Since this is an emerging area of RD practice, a health promotion specialist was contracted to conduct a needs assessment and develop a plan for implementing nutrition-focused healthy lifestyle activities. METHODS: The needs assessment was conducted as part of an Ontario-based demonstration project in three Family Health Networks (FHNs). RESULTS: The needs assessment revealed a lack of agreement about what types of activities should be undertaken, a lack of information on the population's needs, a lack of coordination with other agencies in the community, and barriers of time and resources. The health promotion specialist recommended that health care team members in each FHN develop a shared understanding of their goals, and undertake the entire planning and evaluation cycle. Specific strategies were suggested to increase awareness, to provide health education, and to improve environmental support. CONCLUSIONS: A significant need exists for conceptual development, planning, testing, and evaluation of disease prevention and health promotion in family physician-based primary health care organizations. The findings may be useful to others interested in increasing the focus on health promotion and disease prevention in such practices.

Leveraging systems thinking to design patient-centered clinical documentation systems.

A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reflect and reinforce inefficiency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication.