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Transcript of Thesis defense revised2
Melissa Olfert, DrPH, MS, RD (Chair)Pamela J. Murray, MD, MHPMelanie Clemmer, PhD
1
Role of the Dietitian in Multidisciplinary Treatment of Polycystic Ovary Syndrome
Wendy Thompson
Outline
• Introduction/Background• Study Objectives• Study Design• Methodology• Results• Conclusions• Future Research • Questions
2
The Significance of the PCOS
3
National Institutes of Health Office of Disease Prevention, 2012
4 Billion Dollars!
Does NOT includeco-morbidities
Pathophysiology of PCOS
4
Alex Rotstein, Raginin Srinivasan, Erin WongMcMaster Pathophysiology Review (MPR), 2013
How is PCOS Diagnosed?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. 2012 2
~ 50-75% will visit multiple clinicians before it is identified2
Health Implications of PCOS• 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
PCOS Treatment• Lifestyle intervention =
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
DietSmoking Cessation
Stress
Benefits of Weight Loss in PCOS• Potential Benefits
Include1-3:• insulin levels
• testosterone
• risk for CVD and diabetes
• Improved dermatological symptoms
• Improved fertility8
• 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
Nutritional InterventionsCurrent diet recommendations:• 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
Current Utilization and Knowledge of 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
Proposed Benefits of Dietitians
11
Geier et al, 2012
Ped. E
ndo.
Dietitian
Gynec
ologist
Psychologis
t
100%76% 71% 61%
% of Patients Seen by Providers
Only study that has assessed potential benefits of dietitians
Study Objectives
• Objective 1: 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
Study Design
Phase 2: Focus Group Series (N=9)
Phase 1: Survey (N=261)
13
Timeline of Project
14
PHASE 1:Survey Tool
DevelopmentFebruary - April 2013
WVU's IRB Approval
March 2013
Survey RecruitmentMarch - June
2013
Survey OpenMay 15th - July 15th,
2013
Survey Data AnalysisAugust -
November 2013
PHASE 2:Focus Group
PlanningNovember -
January
WVU's IRBAddendum Approval
Early January 2014
Focus Group RecruitmentJanuary 2014
Focus Groups Conducted
Late January2014
Focus Group Data Analysis
February 2014
Survey Recruitment
Survey Participants
N=261
LISTSERVs:• SAHM• NASPAG• SART-ASRM• EmbryoMail
LinkedIn Groups
Direct Emails
15Inclusion Criteria:• Health Care Provider• Currently Treat PCOS
Phase 1
Focus Group Recruitment
16
Focus Group 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
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
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
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
Focus Group Data Analysis• 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 data2. Generate initial codes – assign participant ID numbers &
categories3. Search for themes – create code-list4. Review themes – rearrange as needed5. Define and name themes – code and sort data6. Producing the report – synthesize data
20
Phase 2
Boyatzis, 19981; Braun & Clark, 20062
Survey Results
21
Phase 1
Survey Sample
22
59%
20%
5%
3%3%
3%7%
Provider Type
PhysiciansDietitiansFertility SpecialistResearchersMidlevel ProvidersEducator/CounselorsOther
N=210
64%
36%
Location
USAOther
N=184
Geographical Demographics
West
Mid-W
estSo
uth
Northeast
05
10152025303540
15%
36%
22%27%
USA Regions
% o
f par
ticip
ants
Australi
a
North Americ
a*
Central A
merica
South
America
Europe
Middle East Asia
05
101520253035
5%10%
5%10%
34%
24%
12%
World Regions
% o
f par
ticip
ants
23N=74N=41
Participant Settings
24Hospita
l/Clin
ic
Private
Office
Researc
h Facil
ityOth
er0
10203040506070 66%
45%
8% 4%
Setting for Care
71%
23%
6%
Population Setting
Urban
Suburban
Rural
N=205
N=141
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
Strengths and Weaknesses of the Current System
05
10152025303540
34%30%
10%
Needs Improvement
% o
f Pro
vide
rs
26More Multidisc
iplinary
Involve
ment
Expand Nutriti
on & Exercise
Programs Elim
inate Access
Barriers*
* Wait-Time, Cost, InsuranceN=88
0
5
10
15
20
2521% 21% 20%
17%
Current Strengths
% o
f Pro
vide
rs
Management of S
ymptoms
Lifesty
le Changes
N=87Patient E
ducation & Counseling
Multidisciplin
ary Collaboration
Potential Barriers for Future Multidisciplinary Clinics
27
Money and resources (30%)
Insurance/reimbursement (26%)
Difference of opinions (16%)
Time
(12%)
N=76
Potential Advantages for Multidisciplinary Clinics
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
Ideal Involvement of Providers
Specialty NHighly
InvolvedInvolved 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
Survey Conclusions• Multidisciplinary clinics 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
Focus Group Results
31
Phase 2
Focus Group Demographics• Dietitians• PCOS (4)
• Physicians• Adolescent/Internal
Medicine• Pediatric
Endocrinologist (2)
• Other• LN/CNS • Health Psychologist
32
67%33%
Multidisciplinary Clinic
YesNo
71%
29%
Gender
Female
Male
Focus Group Questions
Participants’ Treatment Facilit
y
• “Describe any nutritional interventions that you provide to your patients”• “How are dietary interventions and patient care communicated between
providers?”
Utilization of
Nutritional Interventio
ns
• 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
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
Nutrition Interventions
Tasks of the 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
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.”
When is Dietary Intervention Warranted
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
Challenges for Dietitians
Insurance
Lack of PCOS knowledge
Lack of physician referrals
Patient follow-through
38
Lack of Referrals from 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”
Lack of Patient Follow-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.“
Importance of Involving RDs• 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
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.”
42The better the clinician understands PCOS, the better they are able to treat it!
Discussion• Supports the findings:• 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
Limitations
• Small sample size
• Completion rate
• Missing equal representation of disciplines
• Self-reported experience
• Not generalizable to the entire population of healthcare professionals
44
Conclusions• PCOS patients require 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.”
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
Acknowledgments
Committee MembersDr. Melissa Olfert
Dr. Pamela MurrayDr. Melanie Clemmer
ORL Research TeamJade White
Mackenzie BarrFellow Interns
Family and Friends
Study Participants 47
Questions
48