The Human Nutrition EHAP Impacts of the outcomes of collaborative PhD projects in society

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1 The Human Nutrition EHAP Impacts of the outcomes of collaborative PhD projects in society Ms. Sharon Kennelly, Doctoral candidate, Dublin Institute of Technology (Since 2005) A/Senior Community Dietitian Health Service Executive (HSE)

2 Introduction The Oral Nutritional Supplements (ONS) Project Project concept - Corina Glennon-Slattery Community Dietitian Manager supported by HSE Senior Staff, Dr. Pat Doorley and Pat O Dowd in Needs Assessment within HSE 2002 early collaboration with DIT -undergraduate research project. (Loane et al 2004, JHND) Funding for a value for money project secured Action Research Post Advertised 2004/2005 Decision to partner with DIT was to improve expertise and ensure high quality and scientific rigour. Registered as MPhil candidate April 2005

3 Collaborative project support structure PhD Candidate HSE Community Nutrition & Dietetic Service Dublin Institute of Technology HSE Primary Care Reimbursement Service HSE National Contracts Office HSE National Multidisciplinary Working Group established 2009

4 The problem of disease related malnutrition in the community Low rates of malnutrition in general population Who is at risk in the community? The elderly and those with chronic disease. Consequences of malnutrition to the individual Delayed recovery, decreased immunity, increased mortality Consequences of malnutrition to the health service Longer hospital stays, higher healthcare costs in the community e.g. increased prescriptions

5 European Parliament April 8, 2010 Members of the European Parliament s Environment, Health and Food Safety committee this week voted for the third time for the European Commission to fund research and guidelines for nutritional support to tackle Europe s silent killer, malnutrition. (European Society for Enteral and Parental Nutrition (ESPEN), 2010)

6 What are oral nutritional supplements (ONS) Oral Nutritional Supplements (ONS) commercially manufactured food products with various nutritional content include : Liquid sip feeds Protein/fat/CHO sources Disease related malnutrition main prescribing indication Growing evidence ONS improve clinical outcomes for patients who are malnourished in the community (Stratton et al 2003) Widely prescribed in the community setting by general practitioners (GPs) in Ireland & the UK GPs and nurses are mainly responsible for the management of patients prescribed these products (Gall et al, 2001)

7 Why focus on ONS in the community? High costs to HSE - 27 million per year approx (2008) (Barry, 2009) Reports of 30-70% inappropriate prescribing in the UK. Patient not malnourished or at risk of malnutrition. No nutritional assessment carried out prior t o prescribing [Fourth Valley Primary Care Trust, 2001; Causeway HSS Trust, 1999; Gall et al, 2001; Hood & Welch, 2000; Mc Combie, 1999; Panico, 2002) Telephone survey in 2002 revealed poor knowledge, lack of evidence-based practice, little training and resources (Loane et al, 2004)

8 Study Design/Flowchart Phase 1 Baseline cross-sectional study-patient Interviews (n=10 GPs) (n = 79/90 eligible patients recruited prospectively) Development of Community Dietetic Intervention Programme Phase 2 Phase 3 Roll out-of Educational Intervention & Dietetic Referral Service. Evaluation of changes in knowledge & reported practice immediately, and at 6 months post Intervention (n = 96 health professionals) Investigation of changes in health professional practice 150 patient records reviewed Changes in prescribing practices (using data from PCRS)

9 Key elements of the ONS project The provision of training and education to healthcare professionals. Best practice management of malnutrition and use of ONS Audit and feedback regarding ONS usage and expenditure to GP practices Development of a new structured community dietetic service for patients that are malnourished or at risk of malnutrition

10 The majority of patients prescribed ONS are older females with multiple chronic diseases. (Gale et al, 2001; Murdock et al, 2002) ONS were found to be unnecessary in approx 1/3 of cases where they were prescribed.-novel criteria (Steigh et al, 2002; Gall et al, 2001; Hood & Welch, 2000) Little or no evidence based practices such as nutritional assessment prior to ONS prescribing ( Loane et al, 2004) In 80% of cases no weight recorded in medical chart No structured nutrition screening by GPs and nurses 70% patients did not receive any dietary advice

11 . Acceptability was good High satisfaction with format and content of sessions MUST was reported easy to use by 62% (34/55). 80% (44/55) of heath professionals reported that MUST was an acceptable nutrition screening tool. Knowledge improved Significant positive increase in knowledge seen, which was retained 6 months after the intervention (P<0.001). Improvement in reported practices 69% (38/55) reported to weigh patients more frequently 78% (43/55) gave basic dietary advice to patients at risk of malnutrition

12 Results of 2 year evaluationpeer review paper provisionally accepted JHND September 2010 More appropriate prescribing The number of patients prescribed ONS who could be categorised as at risk of malnutrition increased Improved health professional practice Appropriate nutritional screening Reduction in numbers of patients prescribed ONS There was a reduction in the total number of patients prescribed ONS Reduction in expenditure on ONS A reduction in expenditure of on ONS by the group of GPs who participated in the nutrition education programme compared to an increase in those who did not.

13 Impacts of outcomes -Local Improved identification of patients at risk of malnutrition Introduction of a standard nutrition screening tool Development of structured referral pathways for patients at risk Development of local policies e.g. with general practitioners, community nurses Spin Off Projects Eating Well Into the Future Health promotion peer learning project for well older people

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15 Impacts of Outcomes- National Increased credibility and trust among peers in the project Model developed has been shared and disseminated nationally. National training days Network of Lead Dietitians established Train the trainer model used Professional body (INDI) supports project Dissemination of results to HSE senior management influence national decision making recommendations under review by CEO could change the role of dietitians in the future PhD opened doors and gave credibility Cost Savings Value for money

16 116 GPs at 36 sites involved in project (May, 2010)

17 June, 2010 Received letter from Brian Murphy HSE National Primary care Services Manager Express sincere appreciation for all your work The role out of the learning and outcomes from this programme throughout this country will be extremely beneficial..

18 Benefits and Challenges for the PhD student Challenges Juggling work/clinical and research responsibilities Meeting expectations and goals of work based managers and PhD supervisors. Away from college campus, less opportunity to learn from fellow students. Benefits Increased job satisfaction and sense of achievement. New skills and new way of thinking No loss of clinical skills during research time. Remain fully integrated in workplace Improved standing and credibility among profession Can see the fruits of your labour!

19 Thank You Academic Supervisors Dr. Clare Corish Department of Biological Sciences DIT Sheila Sugrue Department of Biological Sciences DIT Dr. Nick P. Kennedy Department of Clinical Medicine (Trinity College Dublin ) Supervisory Supervisor Workplace -HSE Managers Grainne Flanagan Clinical Specialist for Older Persons- HSE Dublin Mid-Leinster Corina Glennon Community Dietitian Manager -HSE Dublin Mid-Leinster