The demand for medical specialist outpatient appointments exceeds what can be met within current resource constraints. In many countries, government-set targets for patient waiting times exist based on clinical need. Whilst referrals are prioritised many patients wait longer than the waiting time targets. Models of care, which facilitate allied health care professionals as primary clinical contact, have resulted in high patient and clinician satisfaction levels, cost-effectiveness and more efficient use of healthcare resources. Dietitians are ideally placed to operate under extended scope models of care within gastroenterology outpatient services as a significant proportion of patients referred have functional gut disorders, which may be best managed with diet and lifestyle advice.
The aim of this Australian study was to develop a model for a dietitian-first gastroenterology clinic (DFGC) in an outpatient department of a large tertiary hospital. A mixed-methods approach was used to evaluate the impact of the service over a 21 month period including the impact on gastroenterology wait times, patient journeys and patient satisfaction levels.
The DFGC proposal was allocated funding for a 0.4 full-time equivalent (FTE) senior gastroenterology dietitian and a 0.2 FTE administration officer to support three half-day outpatient clinics per week. The dietitian was the primary contact for gastroenterology patients who were eligible for the model of care. Eligibility and referral pathways were used and a clinical decision support tool was developed to assist with appropriate triaging of referrals to ensure access in a safe, consistent and equitable manner. A gastroenterology consultant triaged all referrals from GPs. DFGC criteria included patients <50 years old, referred with altered bowel motions, abdominal pain, constipation, diarrhoea, dyspepsia/heartburn/reflux and/or non- Clinical Prioritisation Criteria (CPC) (nausea or abdominal bloating). Patients with ‘red-flag’ symptoms were excluded. Dietitians were trained to screen for organic disease using a structured process and were able to appropriately request pathology as part of extended scope practice. Those requiring medical review were referred as necessary. Dietitians provided diet and lifestyle-related management strategies with patients discharged back to the care of their GP on satisfactory resolution of symptoms.
Between June 2016 and March 2018, 658 patients met the eligibility criteria and were triaged to the DFGC by a gastroenterology consultant. This represented 5.4% of all gastroenterology referrals received during the study period. In addition, a 20% increase in referrals to the gastroenterology outpatient services occurred during this time. Of the 399 DFGC-eligible patients seen in the clinic, almost 70% had been discharged without requiring specialist medical gastroenterology input. Approximately 10% were triaged back to the gastroenterology consultant for further review. The patient satisfaction survey response rate was 83%.
This study shows that the inclusion of a DFGC within a gastroenterology outpatient service can assist in timely patient assessment and care. It also contributes to the growing body of evidence for extended scope roles of allied health professionals and models of care involving them. Future research should focus on health-related patient outcomes and a robust economic analysis is important to provide evidence for the cost-effectiveness of alternative models of care.