Judi Porter

Not Enough Time or a Low Priority? Barriers to Evidence-Based Practice for Allied Health Clinicians

Introduction: Evidence‐based practice (EBP) is a key principle in the delivery of effective and high‐quality health care. Existing research suggests that allied health professionals are generally supportive of EBP but rarely participate in activities associated with EBP. Methods: This mixed‐method study used 8 focus groups of allied health professionals and managers and a questionnaire of all participants to explore the attitudes and barriers to EBP in a large metropolitan health service. Qualitative data were analyzed using a thematic analysis of focus group transcriptions. Questionnaire data were analyzed descriptively. Results: Fifty clinicians and 10 managers across 7 allied health disciplines participated in the study. The questionnaire identified that clinicians have a positive attitude but low participation in EBP. Qualitative data revealed that EBP was not highly valued by clinicians and managers or viewed as a core component of clinical care, with activities directly related to maintaining patient flow viewed as higher priorities. Lack of skills and resources and difficulty associated with implementing evidence into practice were further barriers. Discussion: Achieving higher uptake of EBP among allied health clinicians requires a cultural shift, placing higher value on these activities despite the challenging context of constant pressures to increase patient flow. Addressing EBP through small group projects rather than considering it to be an individual responsibility may be more acceptable to both clinicians and managers, with added benefits of peer support for both evaluating evidence and translation into practice.

The cost‐effectiveness of identifying and treating malnutrition in hospitals: a systematic review

BACKGROUND Disease-related malnutrition is known to have significant clinical and economic consequences. This systematic review of recent evidence aimed to establish the cost-effectiveness of identifying and treating malnutrition in the hospital setting. METHODS A search of four electronic databases and the Internet was conducted for relevant publications from 2003 to 2013. The search strategy considered both nutritional care and healthcare costs. Hospitalised adults with, or at risk of malnutrition, were the focus of the review. Eligibility criteria included publications of original research to identify or treat malnutrition through usual care. Studies with a focus on enteral and parenteral nutrition interventions were beyond the scope of the review. Methodological quality was assessed using the Consensus on Health Economic Criteria checklist. RESULTS Of the 1174 records identified through database searching, 19 full-text articles were assessed for eligibility. Three studies were included in the final review, highlighting the absence of recent high quality cost-effectiveness studies in this field. One economic modelling study and two prospective clinical trials were included of moderate to high methodological quality. CONCLUSIONS Definite conclusions could not be drawn regarding the cost-effectiveness of individual interventions because of the heterogeneity of treatments, controls and populations. The present review highlights an evidence gap in the care of malnourished hospitalised adults, limiting the ability of clinicians and healthcare managers to make informed, cost-effective treatment decisions. Further economic evaluations are needed and should be considered as a routine component of future research.

Dietary mobile apps and their effect on nutritional indicators in chronic renal disease: A systematic review

Dietary apps for mobile technology are becoming increasingly available and can assist in recording food and fluid intake for nutrition assessment or monitoring. Patients with chronic renal disease, particularly those on dialysis, are required to make significant dietary changes. This study systematically reviews the current literature to assess whether dietary mobile apps improve dietary intake and clinical outcomes in the renal population, specifically those with chronic kidney disease levels 3–5, including dialysis. A systematic search of Medline Complete, CINAHL, Embase, PsycINFO and the Cochrane Library was performed and supplemented by manual searches of citation and reference lists. Of the 712 studies considered, five were eligible for inclusion in this review. The quality of each included study was assessed using a Quality Criteria Checklist for Primary Research. Among five studies (two randomised controlled trials (RCTs) and three case studies/reports), none found significant changes in nutrient intake, biochemical markers or intradialytic weight gain, through the use of dietary mobile apps. The included studies show potential for clinical benefits of mobile app interventions in a renal population. However, there is a need for additional rigorous trials to demonstrate if there is a clinical benefit of mobile app interventions in this population.

Is vitamin B6 deficiency an under‐recognized risk in patients receiving haemodialysis? A systematic review: 2000–2010

Vitamin B6 is a water‐soluble vitamin, important for the normal functioning of multiple organ systems. In patients receiving haemodialysis, vitamin B6 deficiency has been reported. The impact of ongoing advances in renal medicine on vitamin B6 status has not been evaluated. The aims of this review were (i) to determine the current level of vitamin B6 deficiency in the haemodialysis population; (ii) to determine the effect of current haemodialysis prescriptions on vitamin B6 levels; and (iii) to consider the impact of recent medical advances in haemodialysis on vitamin B6 levels. Electronic databases were used to locate studies with biochemical measures of vitamin B6 between the years 2000 and 2010. Inclusion exclusion criteria were applied by two independent reviewers. Of 316 articles identified, 53 were selected for detailed review. Appropriate vitamin B6 measures and information were extracted. Eleven final studies were included. Vitamin B6 deficiency was shown to be between 24% and 56%. Dialysis reduced plasma levels by 28–48% depending on the dialyser used. Advances in renal medicine including the use of erythropoietin stimulating agents and ion exchange phosphate binding resins were shown to negatively affect vitamin B6 status. Current recommendations for supplementation range from 10–50 mg. These figures are based on older studies often with small numbers of patients. Suboptimal vitamin B6 status is common in the haemodialysis population. Advances in renal medicine and engineering of dialysis membranes may contribute to increased levels of deficiency.

Organisational benefits of a strong research culture in a health service: a systematic review

Objective The aim of the present study was to determine whether there is an association between having research culture in a health service and better organisational performance. Methods Using systematic review methods, databases were searched, inclusion criteria applied and study quality appraised. Data were extracted from selected studies and the results were synthesised descriptively. Results Eight studies were selected for review. Five studies compared health services with high versus low levels of research activity among the workforce. Three studies evaluated the effect of specific interventions focused on the health workforce. All studies reported a positive association between research activity and organisational performance. Improved organisational performance included lower patient mortality rates (two of two studies), higher levels of patient satisfaction (one of one study), reduced staff turnover (two of two studies), improved staff satisfaction (one of two studies) and improved organisational efficiency (four of five studies). Conclusions A stronger research culture appears to be associated with benefits to patients, staff and the organisation. What is known about this topic? Research investment in the health workforce can increase research productivity of the health workforce. In addition, investment in clinical research can lead to positive health outcomes. However, it is not known whether a positive research culture among the health workforce is associated with improved organisational performance. What does this paper add? The present systematic review of the literature provides evidence that a positive research culture and interventions directed at the health workforce are associated with patient, staff and organisational benefits. What are the implications for practitioners? For health service managers and policy makers, one interpretation of the results could be to provide support for initiatives directed at the health workforce to increase a research culture in health services. However, because association does not imply causation, managers need to interpret the results with caution and evaluate the effect of any initiatives to increase the research culture of the health workforce on the performance of their organisation.

A systematic review of the collaborative clinical education model to inform speech-language pathology practice

Abstract A shortage of clinical education placements for allied health students internationally has led to the need to explore innovative models of clinical education. The collaborative model where one clinical educator supervises two or more students completing a clinical placement concurrently is one model enabling expansion of student placements. The aims of this review were to investigate advantages and disadvantages of the collaborative model and to explore its implementation across allied health. A systematic search of the literature was conducted using three electronic databases (CINAHL, Medline, and Embase). Two independent reviewers evaluated studies for methodological quality. Seventeen studies met inclusion/exclusion criteria. Advantages and disadvantages identified were consistent across disciplines. A key advantage of the model was the opportunity afforded for peer learning, whilst a frequently reported disadvantage was reduced time for individual supervision of students. The methodological quality of many included studies was poor, impacting on interpretation of the evidence base. Insufficient data were provided on how the model was implemented across studies. There is a need for high quality research to guide implementation of this model across a wider range of allied health disciplines and to determine educational outcomes using reliable and validated measures.

How does nutritional state change during a subacute admission? Findings and implications for practice.

Background/Objectives:Nutritional status influences patients’ clinical and functional outcomes. The aims were to identify changes in nutritional state during subacute care and associated participant characteristics.Subjects/Methods:A longitudinal study was undertaken with consecutive patients admitted to subacute care wards during a 3-month period. Participants were recruited under a waiver of consent to reflect the usual demographic. Change in classification (malnourished, at risk of malnutrition, well nourished) of the full Mini Nutritional Assessment (full MNA) between admission and discharge was the primary outcome. Weight (kg), mid-arm and calf circumference (cm) change were secondary outcomes. Hand grip strength (kg) and fat-free mass (kg) (assessed using bioelectrical impedance analysis) were measured for a consenting subgroup.Results:Participants (n=248, 36.7% male) had a median age of 80 years and a length of stay of 17 days. On admission, 29.1% were classified as malnourished. By discharge, nutritional classification remained stable for 62.0% of participants (n=132), declined for 10.3% (n=22) and improved for 27.7% (n=59, including 52.5% malnourished on admission). Impaired cognition (odds ratio (OR)=0.169, P=0.002) and higher full MNA score at admission (OR=0.870, P=0.001) reduced odds of improvement in full MNA. There was no change in hand grip strength (n=46), but there was a decline in mean fat-free mass (−1.1 kg, 95% confidence interval: −0.1 to −2.2 kg, P=0.043, n=24).Conclusions:Multidisciplinary care supports the nutritional state of most patients admitted to subacute care. Those with cognitive impairments or at risk of malnutrition were less likely to demonstrate improvement and may benefit from more intensive or tailored nutritional care.

Food Skills of People with a Chronic Mental Illness: The Need for Intervention

This study quantified the food skills of people with a mental illness living in hospital-based care and the community using the Functional Needs Assessment — Nutritional Management Program (Dombrowski 1990). There were clear and marked food skills deficits among people living in hospital-based care. There were no significant differences between the food skills of male and female participants. The deficits that were identified may place patients at nutritional risk if they are moved into community accommodation without appropriate support mechanisms for the provision of food. Recommendations are made for intervention through the implementation of food skills training and incidental learning.

Systematic review and meta-analyses of foodservice interventions and their effect on nutritional outcomes and satisfaction of adult oncology patients

Aim An understanding of effective foodservice interventions on nutrition outcomes in adult patients with cancer is required to support clinical decision making. This systematic review aimed to determine the effect of foodservice interventions across a range of nutritional outcomes and satisfaction of hospitalised and ambulatory adult oncology patients. Methods The review protocol was registered with PROSPERO (CRD42016045772). Six databases were searched using search terms associated with the intervention and population. No date or language restrictions were applied. Authors applied the inclusion criteria to titles and abstracts and then full‐text papers. The final library was assessed for risk of bias. Outcome data were combined narratively and, where possible, by meta‐analysis. Results From the title and abstract review of 4414 studies, 12 studies testing the effect of foodservice interventions were included in this review. Meta‐analyses demonstrated significantly greater energy (mean difference 1.54 MJ/day; 95% CI 0.85–2.23 MJ/day) and protein (mean difference 18.98 g/day; 95% CI 11.58–26.39 g/day) intake through the addition of oral nutrition supplements. Other positive effects on anthropometric outcomes were also recorded. Patient satisfaction was enhanced through other foodservice interventions. Conclusions Limited original research was found exploring the effect of foodservice interventions in oncology patients. Significant findings were found in favour of the intervention across a range of nutritional outcomes, suggesting that foodservice interventions may improve clinical outcomes and satisfaction in this population. Effective foodservice interventions for oncology patients remain under‐researched, so we encourage dietitians and foodservice staff to implement rigorous study designs to evaluate and publish interventions in this clinical group.

The Effect of Low Carbohydrate Diets on Fertility Hormones and Outcomes in Overweight and Obese Women: A Systematic Review

(1) Background: Medical interventions including assisted reproductive technologies have improved fertility outcomes for many sub-fertile couples. Increasing research interest has investigated the effect of low carbohydrate diets, with or without energy restriction. We aimed to systematically review the published literature to determine the extent to which low carbohydrate diets can affect fertility outcomes; (2) Methods: The review protocol was registered prospectively with Prospective Register for Systematic Reviews (registration number CRD42016042669) and followed Preferred Reporting Items For Systematic Reviews and Meta-Analyses guidelines. Infertile women were the population of interest, the intervention was low carbohydrate diets (less than 45% total energy from carbohydrates), compared to usual diet (with or without co-treatments). Four databases were searched from date of commencement until April 2016; a supplementary Google scholar search was also undertaken. Title and abstract, then full text review, were undertaken independently and in duplicate. Reference lists of included studies and relevant systematic reviews were checked to ensure that all relevant studies were identified for inclusion. Quality assessment was undertaken independently by both authors using the Quality Criteria Checklist for Primary Research. Outcome measures were improved fertility outcomes defined by an improvement in reproductive hormones, ovulation rates and/or pregnancy rates; (3) Results: Seven studies fulfilled the inclusion criteria and were included in the evidence synthesis. Interventions were diverse and included a combination of low carbohydrate diets with energy deficit or other co-treatments. Study quality was rated as positive for six studies, suggesting a low risk of bias, with one study rated as neutral. Of the six studies which reported changes in reproductive hormones, five reported significant improvements post intervention; (4) Conclusion: The findings of these studies suggest that low carbohydrate diets warrant further research to determine their effect. These randomised controlled trials should consider the effect of carbohydrates (with or without energy deficit) on hormonal and fertility outcomes.