EAL

MNT: Gastrointestinal Disorders (2015

Citation:

Nelson M, Mendoza N, McGough N. A survey of provision of dietetic services for coeliac disease in the UK. J Hum Nutr Diet. 2007; 20: 403-411.

PubMed ID: 17845374

Study Design:

Descriptive Study

Class:

D - Click here for explanation of classification scheme.

Quality Rating:

NEUTRAL: See Quality Criteria Checklist below.

Research Purpose:

To assess the level of dietetic services provided for the management of celiac disease in hospital and community settings and to clarify the levels of services for adults and children.

?Specific areas of interest included:

Factors associated with the level and range of dietetic input to celiac patients
The grade of the dietitian providing services to celiac patients
The training of the dietitian providing services
Identification of guidelines used for management of celiac patients
Modes of teaching used
Impact of membership to British Dietetic Association and Coeliac UK
Assessment of engagement of Coeliac UK with dietitians.

Inclusion Criteria:

Members of the Regional Dietetic Managers Group within the British Dietetic Association were provided questionnaires to send to all managers of dietetic departments within their regions. The 14 regions included:

Birmingham and Black Country
East Midlands
Eastern
London
North East
North Staffordshire
North West
South East
South West
West Midlands South
Yorkshire
Scotland
Wales
Northern Ireland.

Exclusion Criteria:

No exclusions were specified.

Description of Study Protocol:

Recruitment

Existing members of the specialty practice group within a professional organization were contacted to distribute questionnaires to providers in their regions
Questionnaires were sent via email with at least three e-mail reminders and telephone or e-mail follow-up as needed
Additionally, a reminder was published in Dietetics Today professional magazine.

Design

?The survey was conducted at a one-time-per-participant assessment but with two components: Part One of the survey was completed by the manager; Part Two was completed by the dietitian providing direct services, when applicable.

Statistical Analysis

?Statistical Analysis for the Social Sciences (SPSS version 11.0; Chicago, IL, USA)

Chi square
Analysis of variance
Multiple regression.

Data Collection Summary:

Timing of Measurements

One-time questionnaire.

Dependent Variables

Level of service (number of dietitian hours dedicated to celiac patients per month)
Level of responsibility (grade or training level of dietitian providing services to celiac patients)
Number of times patients were seen (new diagnosis, three-month, six-month, annual).

Independent Variables

Age of patients (adult, child)
Setting for care provision
Presence of multi-disciplinary team
Membership in a professional organization or practice group
Presence of policy for care management
Participation in Coeliac UK.

Control Variables

No controls.

Description of Actual Data Sample:

Initial N: 328 questionnaires sent
Attrition (final N): 123 (38%) questionnaires returned
Age: Not applicable
Ethnicity: Not applicable
Other relevant demographics: Response rate ranged greatly (5% in South West to 71% in Northern Ireland and 75% in West Midlands)
Location: 14 regions of the United Kingdom.

Summary of Results:

Key Findings

There was positive significant correlation (R=0.54, P<0.001) between number of full-time equivalent dietitians working in a department and the number of hours allocated to provision of service for celiac patients, independent of population size
Having a specialist dietitian in gastroenterology was significantly associated with more hours per 100,000 in population being allocated to celiac patients (P=0.002)
A total of 12 departments had specific funding for celiac patients and the number of hours available was double that in others without specific funding (P=0.012)
A total of 21 departments where a dietitian was part of a multi-disciplinary team allocated 4.1 hours per 100,000 in population, compared to 2.6 hours in the other 61 departments (P=0.012)
Departments with a multi-disciplinary team (P=0.001) or a designated celiac dietitian (P=0.002) were more likely to have involvement with the Gastroenterology Interest Group and ongoing training
The number of hours devoted to celiac patients per 100,000 in population in nine departments that attended British Dietetic Association (BDA) training was more than the number of hours in the 70 departments that did not attend BDA training (P<0.001).

Other Findings

13% of departments allocated no specific time to celiac patients
67 departments had a staff member designated for treatment of celiac patients; 50 of these departments were a Senior II grade or higher. Most patients were seen in outpatient clinics (87.9%) or as inpatients (72.7%). Less than 10% were seen in specialist celiac clinics, however more time was allocated in this setting.
A total of 37 (30%) departments reported that the dietitian worked as part of a multi-disciplinary team in treatment of celiac patients
A total of 73 (59%) departments reported having a policy for the management of celiac disease. Of these, 62 (85%) used the British Society of Gastroenterology (BSG) guidelines.
Newly diagnosed patient were seen in under two weeks, by 43% of departments and two to four weeks in 41%. Follow-up timing varied greatly without significant trends to report.

Author Conclusion:

Based on the current, yet probably under-diagnosed, prevalence of celiac disease in the United Kingdom and the minimal provision of one half hour per celiac patient per year, there would be a minimum requirement of eight hours of dietetic services provided per month per 100,000 in population. This is almost three times the average current level of services provided as reported in this survey.
The current level of dietetic services provided is well below what is needed to allow dietitians to give celiac patients across the United Kingdom basic dietetic support as recommended by the British Society of Gastroenterology.

Funding Source:

University/Hospital:

Kings College London, London England

Not-for-profit

Coeliac UK

Other non-profit:

Reviewer Comments:

The response rates to the survey process were low and recognized by the authors
Possible bias due to questionnaires provided through specialty group of professional organization, no blinding and sponsorship of Coeliac UK organization.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	N/A
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	Yes
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	No
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	No
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	No
	6.6.	Were extra or unplanned treatments described?	No
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	N/A
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	Yes
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes