Use of Low FODMAP diet in Scotland. Presented by Mairéad Keegan Dietetic Team Lead, Hairmyres Hospital, NHS Lanarkshire

Transcription

1 Use of Low FODMAP diet in Scotland Presented by Mairéad Keegan Dietetic Team Lead, Hairmyres Hospital, NHS Lanarkshire

2 Overview of presentation Brief introduction to IBS/Low FODMAP diet Examine current service provision in Scotland The future?? Where are we going Somerset Model Conclusion & Questions

3 Introduction IBS affects 7-21% of population (1) Attributable cost of IBS to the NHS approx. 12 million per annum Pts. following initial NICE dietary recommendations were not achieving significant symptom improvement (2) Symptom response rate 68 75% whilst following low FODMAP diet Low FODMAP diet has revolutionised dietetic practice & raised our profile significantly as clinicians The updated NICE Clinical Guideline 61 (3) states that, where required, single food avoidance and exclusion diets (for example, a low FODMAP diet) should only be given by a healthcare professional with expertise in dietary management. However, increasing pressure and demands on our dietetic services

4 Symptom response (Staudacher et al 2011)

5 Where are we in Scotland?

6 Scotland s Position Survey completed by Scottish Dietitians Leadership Network (SDLN) in September 2015, scoped out where dietetic services are in relation to the service they offer pts. with IBS Variable dietetic service provision across Scotland Results varied in relation to the following: Checking of investigations completed before referral received Criteria used for diagnosis Resources provided to pts for 1 st line advice If low FODMAP dietary advice offered Training of dietitians Services who received additional funding

7 Positive Diagnosis When an IBS pt. is referred to your service, do you check that the pt. has been positively diagnosed (has had all appropriate tests e.g. coeliac screen to confirm diagnosis?) N=17/17 100% 90% 80% 82.4% 70% Percent 60% 50% 40% 30% 20% 10% 0% 5.9% 11.8% Yes No Not sure

8 Provision of low FODMAP service? Does your service currently provide advice on the Low FOMDAP Diet to IBS patients? N=17/17 100% 90% Percent 80% 70% 60% 50% 40% 30% 20% 10% 0% 70.6% Yes 29.4% No

9 Training of Dietitians What training did dietitians receive to deliver low FOMDAP advice? N =12/12 100% 90% 80% 83.3% Percent 70% 60% 50% 40% 30% 20% 50.0% 16.7% 10% 0% Accredited external course In-house' course / training No training Other 0.0%

10 Additional Funding Did you develop the low FODMAP element of your service from additional investment or existing resources? N=12/12 100% 90% 80% 83.3% 70% Percent 60% 50% 40% 30% 20% 10% 0% 8.3% 8.3% Additional investment Existing resource Other

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12 The Future Results from national survey were used to inform DOIT Gastroenterology collaboration IBS work stream This working group is designing a national pathway for the management of pts. with IBS, similar to Somerset model With an effective pathway we can achieve the following: - Improve pts. QOL - recurrent appointments for GPs & consultants - Ultimately be cost saving to the NHS - Equitable & quality assured service is provided Now as dietitians we have the ideal opportunity to raise our profile and demonstrate our clinical effectiveness and value

13 Patient comments re effectiveness After completing the low FODMAP diet I have the best variety I've had in my diet for years. I can go out and enjoy spending time with my friends and family without feeling awkward in restaurants or needing the toilet all the time. (Male 26) At first I thought the diet would be a nightmare to follow but once I started to feel the benefits of it, it was no longer a chore. My wife even benefited from me completing the diet. I was no longer passing foul smelling wind or having to use the toilet constantly. What a difference it made to both of us. (Male 50)

14 Patient comments re effectiveness My job involves travelling all over the world and this becomes problematic when you've got a crazy bowel without any control. Prior to going on the low FODMAP diet I would take immodium all the time and avoid eating if I had to go to a conference or travel. Now I'm like a new woman, I no longer take immodium and eat regularly throughout the day. Life is so much better and a little less stressful. (Female 32) I find the service that you offer to our so called difficult IBS patients incredibly valuable. Gastro specialist doctor, NHS Lanarkshire

15 Somerset Model (4) Pts diagnosed by GP with IBS using Rome III criteria, aged 16-45, no alarm symptoms, TTG ve, faecal calprotectin <50µg/g Pts. given 1 st line advice by either general community dietitians or GPs If no improvement in symptoms, pts. referred to dietetic led gastroenterology clinic for advice, x2 appts 63% of pts. had satisfactory control of their IBS symptoms after dietetic intervention 74% reported QOL If no improvement after dietary +/- pharmaceutical interventions, GPs refer pts on to secondary care as appropriate

16 Cost savings associated with pathway Costs of FC* testing at 31 per test on a cost per case basis based on funding 10,850 for up to 350 tests Cost of dietetics service with 15% on costs, band six specialist dietitian and 48, WTE administrator support Total cost of new pathway 58,853 Present annual secondary care costs for patients with likely IBS aged , years with no alarm symptoms when seen in secondary care Savings comparison 102,345 *FC = faecal calprotectin Also noted reduction from 14.3% to 8.7% in new pt. secondary care slots Overall costs 25% for pts. with no alarm symptoms aged (Williams et al. 2016)

17 The Future To further reduce costs & waiting lists, group sessions can be used, as appropriate, to deliver the low FODMAP dietary intervention (5) Whigham et al (2015), demonstrated that group education is clinically effective; 54% satisfaction in group education vs. 60% one-to-one education For groups need to consider Group size/age/language barriers Clinical condition Atypical symptoms Online apps, commercially available products

18 One-to-one education Group education Details of cost Requirements Cost per patient ( ) Requirements for 12 patients Cost per patient ( ) 1. a Clinical activity time includes clinic room preparation, review of clinical investigations (e.g. coeliac screen, hydrogen/methane breath test results), report and letter writing and face-to-face patient contact. 2. b Calculated using cost of Band 7 Dietitian = h 1, based on data from Personal Social Services Research Unit Unit Costs of Health and Social Care and assuming 80% clinical activity. The cost for a Band 7 Dietitian used Band 7 Nurse data where gross annual salary with on-costs, qualifications and overheads were accounted for. Annual leave, sick leave and study leave were taken into account when calculating hours worked (40 weeks year 1 ) [38]. The costs provided do not include additional patient time with other health professionals (e.g. general practitioner, gastroenterologist, nurse or pharmacist), administration time or additional time spent with a dietitian (e.g. treatment failures). At the time of calculating cost-effectiveness, the exchange rate was 1 = $ = Telephone screening clinic 0.25 ha 17.91b 3 ha 17.91b One initial appointment 1.15 ha 82.40b 3.75 ha 22.39b One follow-up appointment 0.48 ha 34.39b 3.75 ha 22.39b Appointment costs b a Patient information booklets One set of booklets sets of booklets 4.50 Total costs (Whigham et al 2015)

19 Conclusion Nationally recognised evidence based dietary intervention available to offer pts which is effective Variance in dietetic service provision at present However. The future ahead is BRIGHT for dietetics. With pathway implementations, service redesigns we can demonstrate our evolution as a profession to meet the ever-changing demands and challenges on our services

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21 References 1. Lovell RM & Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10: Staudacher HM, Whelan K, Irving PM & Lomer MCE. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011;24: National Institute of Clinical Excellence (2015) Clinical Guidelines 61 Irritable Bowel Syndrome in Adults: Diagnosis and management of irritable bowel syndrome in primary care. (accessed August 2016).

22 References 4. Williams M, Barclay Y, Benneyworth R, Gore S, Hamilton Z, Matull R, Phillips I, Seamark L, Staveley K, Thole S, Greig E. Using best practice to create a pathway to improve management of irritable bowel syndrome: aiming for timely diagnosis, effective treatment and equitable care. Frontline Gastroenterol. 2016;0: Whigham L, Joyce T, Harper G, Irving PM, Staudacher HM, Whelan K & Lomer MCE. Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. 2015;28: