Thesis defense revised2

Thesis defense revised2

• 1.
  Melissa Olfert, DrPH,MS, RD (Chair) Pamela J. Murray, MD, MHP Melanie Clemmer, PhD 1 Role of the Dietitian in Multidisciplinary Treatment of Polycystic Ovary Syndrome Wendy Thompson
• 2.
  Outline • Introduction/Background • StudyObjectives • Study Design • Methodology • Results • Conclusions • Future Research • Questions 2
• 3.
  The Significance ofthe PCOS 3 National Institutes of Health Office of Disease Prevention, 2012 4 Billion Dollars! Does NOT include co-morbidities
• 4.
  PathophysiologyofPCOS 4 Alex Rotstein, RagininSrinivasan, Erin Wong McMaster Pathophysiology Review (MPR), 2013
• 5.
  How is PCOSDiagnosed? NIH 1990 Rotterdam 2003 AE-PCOS Society 2006 • Hyperandrogenism • Chronic Anovulation ---Both criteria needed • Hyperandrogenism • Oligo-and/or anovulation • Polycystic ovaries ---2 of 3 criteria needed • Hyperandrogenism • Ovarian dysfunction ---Both criteria needed First developed and most commonly used criteria today Formulated to expand on NIH diagnostic definition Formulated to provide an evidence-based definition 5 *All possible related disorders must be ruled out NIH Evidenced Based Methodology Workshop on PCOS, 2012; Shannon et al. 20122 ~ 50-75% will visit multiple clinicians before it is identified2
• 6.
  Health Implications ofPCOS • Obesity • Type 2 Diabetes • CVD • Infertility • Depression/Anxiety • Dermatological Symptoms • Metabolic Syndrome • Hypothyroidism • Eating Disorders • Obstructive Sleep Apnea • Endometrial/Ovarian Cancer 6 Sirmans & Pate, 2014; Daniilidis A. & Dinas K., 2009
• 7.
  PCOS Treatment • Lifestyleintervention = first line treatment1-3 • Support medical management • Weight loss is best achieved though multidisciplinary lifestyle management4 • Requires ongoing support for long-term success5-6 7 Teede et al, 20111; Humphreys & Costarellil, 20082; Jeanes et al, 20093; Moran et al, 20094; Himelein, 20065; Stankiewicz, 20066 Physical Activity Diet Smoking Cessation Stress
• 8.
  Benefits of WeightLoss in PCOS • Potential Benefits Include1-3: •  insulin levels •  testosterone •  risk for CVD and diabetes • Improved dermatological symptoms • Improved fertility 8 • Weight loss of 5% to 10% can improve metabolic and reproductive aspects of PCOS1-2 • Does not reverse PCOS, but helps control associated co- morbidities3 Teede et al, 20111; Farhat et al, 20112; Barthelmess & Naz, 20143
• 9.
  Nutritional Interventions Current dietrecommendations: • Energy for weight maintenance or loss1-2 • Moderate to low glycemic index1-3 •  Carbohydrates2 (35-40%)3 • Evenly distribute energy intake1,3 • 4-5 meals/snacks per day • General healthy guidelines 9 Moran et al, 20131; Academy of Nutrition and Dietetics, Nutrition Care Manual, 20142, Grassi, The Dietitian’s Guide to PCOS, 20073 No optimum dietary composition1
• 10.
  Current Utilization and Knowledgeof Dietitians • Interview-Guided Questionnaire (N=53)1 • 26% of overweight were referred to RD • Patients reported diet advice from endocrinologist to be useful, but inadequate • Survey Report (N=206)2 • 15% saw a dietitian • 3% over 2 visits with RD • Knowledge of Dietitians • Survey (N=105)2 • Only 34% felt well informed • 64% believed there was an insufficient evidence base for the dietary management of PCOS 10 Humphreys & Costarellil, 20081; Jeanes et al, 20092 There has been no published research on the current utilization or knowledge of dietitians and PCOS in the USA
• 11.
  Proposed Benefits ofDietitians 11 Geier et al, 2012 100% 76% 71% 61% % of Patients Seen by Providers Only study that has assessed potential benefits of dietitians
• 12.
  Study Objectives • Objective1: To investigate the current trends and future implications for multidisciplinary treatment of PCOS across different providers • Objective 2: To explore the role, importance and challenges for RDs in multidisciplinary PCOS treatment 12
• 13.
  Study Design Phase 2:Focus Group Series (N=9) Phase 1: Survey (N=261) 13
• 14.
  Timeline of Project 14 PHASE1: Survey Tool Development February - April 2013 WVU's IRB Approval March 2013 Survey Recruitment March - June 2013 Survey Open May 15th - July 15th, 2013 Survey Data Analysis August - November 2013 PHASE 2: Focus Group Planning November - January WVU's IRB Addendum Approval Early January 2014 Focus Group Recruitment January 2014 Focus Groups Conducted Late January 2014 Focus Group Data Analysis February 2014
• 15.
  Survey Recruitment Survey Participants N=261 LISTSERVs: •SAHM •NASPAG •SART-ASRM •EmbryoMail LinkedIn Groups DirectEmails 15Inclusion Criteria: • Health Care Provider • Currently Treat PCOS Phase 1
• 16.
  Focus Group Recruitment 16 FocusGroup Participants N=9 US Survey Participants (n=22) Additional PCOS Experts (n=12) Referrals (n=4) Inclusion Criteria: • Health Care Provider • Currently Treat PCOS Phase 2
• 17.
  Survey Design • Development: •30 Questions • Basic Demographics • Current Facility • Future Implications • Developed based on reviewing existing literature and clinics • Expert reviewed • Implementation: • Qualtrics • Open for 2 months 17 Phase 1
• 18.
  Focus Group Methodology •Development: • 7 Major questions1 • Expert review • Implementation: • Held via teleconference1 • 2-3 note takers and facilitator • Audio recorded • Similar providers were placed together to promote group cohesiveness2-3 and compatibility4-5 18 Phase 2 Stewart & Shamdasani, 19901; Cartwright et al, 19682; Terborg et al, 19763; Haythorn et al, 19564; Sapolsky, 19605
• 19.
  Survey Data Analysis •Quantitative • Numerical Data • Mean, Median, Mode, Standard Deviation • Qualitative • Assessed for themes and categorized accordingly using Excel (clustering) • Frequencies 19 Phase 1
• 20.
  Focus Group DataAnalysis • Braun & Clarke’s Thematic Analysis1-2 • Identify, analyze and report patterns (themes) within data • Guide to Thematic Analysis2 1. Become familiar with the data – transcribe, clean, & compile data 2. Generate initial codes – assign participant ID numbers & categories 3. Search for themes – create code-list 4. Review themes – rearrange as needed 5. Define and name themes – code and sort data 6. Producing the report – synthesize data 20 Phase 2 Boyatzis, 19981; Braun & Clark, 20062
• 21.
  Survey Results 21 Phase 1
• 22.
  Survey Sample 22 59% 20% 5% 3% 3% 3% 7% Provider Type Physicians Dietitians FertilitySpecialist Researchers Midlevel Providers Educator/Counselors Other N=210 64% 36% Location USA Other N=184
• 23.
  Geographical Demographics 0 10 20 30 40 15% 36% 22% 27% %ofparticipants USA Regions 0 5 10 15 20 25 30 35 5% 10% 5% 10% 34% 24% 12% %ofparticipants WorldRegions 23 N=74 N=41
• 24.
  Participant Settings 24 0 10 20 30 40 50 60 70 66% 45% 8% 4% Setting forCare 71% 23% 6% Population Setting Urban Suburban Rural N=205 N=141
• 25.
  Multidisciplinary Specialties Involved 59% 41% Multidisciplinary Status Yes No 25 Specialty #Involved % Involved Dietitian/Nutritionist 94 71% Physician 89 67% Nurse 63 48% Fertility Specialist 46 35% Mid-Level Providers 37 28% Social Worker 37 28% Psychologist 34 26% N=132
• 26.
  Strengths and Weaknessesof the Current System 34% 30% 10% 0 10 20 30 40 %ofProviders Needs Improvement 26 * Wait-Time, Cost, InsuranceN=88 21% 21% 20% 17% 0 5 10 15 20 25 %ofProviders Current Strengths N=87
• 27.
  Potential Barriers forFuture Multidisciplinary Clinics 27 Money and resources (30%) Insurance/reimbursement (26%) Difference of opinions (16%) Time (12%) N=76
• 28.
  Potential Advantages for MultidisciplinaryClinics 28 Increased access to more disciplines (10%) Better communication between providers (15%) Better results & long-term outcomes (18%) Convenience & efficiency (30%) Comprehensive and integrated care (32%) N=82
• 29.
  Ideal Involvement ofProviders Specialty N Highly Involved Involved Neutral Occasionally Involved Never Involved Dietitian 110 59% 30% 6% 3% 2% Endocrinologist 109 48% 36% 6% 7% 3% Gynecologist 110 45% 43% 5% 5% 2% Fertility Specialist 97 30% 33% 14% 13% 9% Exercise Physiologist 95 18% 40% 18% 9% 15% Health Psychologist 105 11% 45% 21% 15% 8% 29
• 30.
  Survey Conclusions • Multidisciplinaryclinics could provider greater convenience, access to care, and ultimately lead to a better prognosis for patients with PCOS • The most common barriers identified included money/resources, insurance, and difference of opinions • 90% of responders believed that dietitians should be either highly involved or involved 30 Phase 1
• 31.
  Focus Group Results 31 Phase2
• 32.
  Focus Group Demographics •Dietitians • PCOS (4) • Physicians • Adolescent/Internal Medicine • Pediatric Endocrinologist (2) • Other • LN/CNS • Health Psychologist 32 67% 33% Multidisciplinary Clinic Yes No 71% 29% Gender Female Male
• 33.
  Focus Group Questions Participants’ Treatment Facility •“Describe any nutritional interventions that you provide to your patients” • “How are dietary interventions and patient care communicated between providers?” Utilization of Nutritional Interventions • When is dietary intervention warranted for a patient with PCOS? • How accessible are nutritional interventions for the majority of PCOS patients? Challenges and Changes • “What are some of the challenges for getting dietitians more involved with PCOS?” • “Do you feel like providers know and understand the value of nutritional interventions for PCOS patients?” • In your career, have you seen any shift in the awareness or interest of PCOS? 33 Phase 2
• 34.
  Nutritional Interventions Provided Physicians •Basic diet history • Brief nutrition education Psychologist • Motivational interviews to facilitate changes • Explore emotional/mindless eating • Clarify information --“Dietitian provides the education but the psychologist gets the change.” 34
• 35.
  Nutrition Interventions Tasks ofthe RD • Individualized treatment • Assess food coping mechanisms • Explore emotional or disordered eating habits • Help understand condition Specific Interventions • Managing insulin resistance • General healthy eating guidelines • Sensible dietary supplementation • Correct nutrient deficiencies • Assist in treatment 35
• 36.
  Communication Differences Solo Providers •Limited opportunity • No face to face communication • Only email and progress notes • Confidentiality barriers • Not ideal, but still effective Multidisciplinary • More verbal communication • More integration of care • Little formal case management • Varies by setting 36“In an ideal world, there would be PCOS treatment clinics all around the world and all the providers would have the opportunity to converse about each patient.”
• 37.
  When is Dietary InterventionWarranted For PCOS? • Always important to discuss and provide nutrition counseling • Equally important regardless of BMI • Immediately upon on diagnosis patients should meet with RD • First line treatment How Accessible are Dietary Interventions for PCOS? • Not very accessible! 37
• 38.
  Challenges for Dietitians Insurance Lackof PCOS knowledge Lack of physician referrals Patient follow-through 38
• 39.
  Lack of Referralsfrom Physicians • Lack of insurance coverage • Limited access • Quick to write off as uninterested or noncompliant • Little confidence • Value pharmacological treatment • Feel they have treatment covered • Not educated on the value 39 “Physicians are the gatekeepers”
• 40.
  Lack of PatientFollow-Through • Lack of insurance coverage • Not ready for change • Practicality • Stigma or punishment • Overwhelmed • Already know what the dietitian is going to tell them 40“It is just food – you are just going to tell me to eat asparagus rather than a snickers bar and I already know that.“
• 41.
  Importance of InvolvingRDs • Access to adequate lifestyle interventions • Physicians should not be fully responsible: • Little to no training • “They can only be the experts on so many things” • Takes time • “More than just handing the patient a 1,200 kcal diet plan” 41 CDC – NCHS, Ambulatory Health Care Data, 20101 Average length of visit = 18.7 minutes
• 42.
  Shift in Awareness •More information in the lay press • Patient-driven diagnosis • Support groups • Websites • More awareness in medical community • Providers still do not understand it • “It’s starting to get mentioned but it doesn’t get the attention it deserves.” 42 The better the clinician understands PCOS, the better they are able to treat it!
• 43.
  Discussion • Supports thefindings: • Multidisciplinary clinics provide access to more disciplines1,2 • Patients need dietitians for adequate lifestyle management3 • Strengthens the need for evidence on the benefits of dietitians1 • Uncovered the potential under-utilization of health psychologist in addition to the RD3,4 for PCOS despite potential benefits1 • First study to gain insight from a mix of PCOS providers on potential implications of multidisciplinary clinics and the challenges of involving dietitians in the care of PCOS 43 Geier, 20121; Bekx, 20102; Humphreys, 20083; Jeanes, 20094
• 44.
  Limitations • Small samplesize • Completion rate • Missing equal representation of disciplines • Self-reported experience • Not generalizable to the entire population of healthcare professionals 44
• 45.
  Conclusions • PCOS patientsrequire special attention with individualized, focused, multidisciplinary care – ideally in one facility • The most common challenges for dietitians include insurance, lack of knowledge, and lack of physician referrals • Dietitians and health psychologist are highly overlooked when it comes to the care of PCOS • Education for PCOS and lifestyle interventions need to be increased across providers 45 “Often times, with PCOS, nutrition counseling is treated like dermatology and it needs to be treated more like psychology.”
• 46.
  Future Research Aims •Assess factors influencing weight loss/maintenance • Delivery methods • Frequencies • Long-term success • Determine how to effectively educate: • Dietitians on PCOS • Physicians on the importance lifestyle interventions • Development of a screening tool 46
• 47.
  Acknowledgments Committee Members Dr. MelissaOlfert Dr. Pamela Murray Dr. Melanie Clemmer ORL Research Team Jade White Mackenzie Barr Fellow Interns Family and Friends Study Participants 47
• 48.
  Questions 48