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Group Clinics for Coeliac Disease better for the patients and better for the NHS

We’re pleased to highlight this highly commended submission for the CSSC Service Development Prize 2020 from David Sanders and colleagues on behalf of Sheffield Teaching Hospitals for improving patient access to dietitians via group clinics for coeliac disease, creating a better patient experience and cost savings for the NHS.

D Sanders Team

Group Clinics for Coeliac Disease better for the patients and better for the NHS

David Sanders on behalf of Sheffield Teaching Hospitals.

Dieticians are difficult to access by coeliac patients, partly due to an underfunded NHS, meaning patients aren’t seen or are given a minimum of 6 weeks to wait after diagnosis confirmation. The group aimed to improve access in order to enhance patient experience and adherence by giving all patients the same first appointment for a broad educational diet overview.

The group demonstrated that a group clinic was equivalent to a one-to-one appointment and the service delivery innovation successfully penetrated the NHS with associated significant cost savings and increased patient satisfaction.

Authors

GI Specialist Dietitians

Nick Trott, Rachel Buckle, and Christian Shaw

GI Fellow

Anupam Rej

Consultants

David Sanders and Marios Hadjivassiliou


Size of the Service Delivery Problem (Ref 1)

Coeliac Disease affects 1% of all adults in the UK (although currently ¾ of cases are undiagnosed). The cornerstone for treatment is the GFD which is delivered by dietitians across the UK through one-to-one appointments (dietitian with patient). Approximately 12,000 newly diagnosed patients with coeliac disease are diagnosed annually. The gastroenterology NHS dietetic services in the UK are underfunded and as a result patients are either not seen or given a minimum of 6 weeks to wait after their diagnosis has been confirmed (see our current abstract National Provision of Dietetic Service submitted to the BSG 2020).

We hypothesised that improving immediate access to dietitians would greatly improve the patient experience and enhance adherence. All patients receive the same first appointment where they are in effect given a broad educational overview of the diet. It is only afterwards (second appointment) that the individual patient’s complexities of the diet become apparent.

Intervention

Patients with a new diagnosis of CD, confirmed histologically, were prospectively recruited over 18 months. Patients received either a group clinic or traditional one-to-one appointment, led by a dietitian. Quality of life questionnaires were completed at baseline (Short-Form 36 [SF-36] survey and Hospital Anxiety and Depression Score [HADS]), as well as biochemical parameters (haemoglobin, adjusted calcium, vitamin D, hematinics) being recorded. Patients were followed up at 3 months, where adherence scores were assessed (Biagi questionnaire), as well as biochemical parameters and quality of life questionnaires being completed.

Results

60 patients with CD were prospectively recruited and received either an individual (n=30) or group clinic (n=30). A statistically significant reduction in tissue transglutaminase (TTG) was noted following group clinics (mean 58.5, standard deviation [SD] 43.4 U/ml vs mean 13.2, SD 5.7 U/ml, p<0.01), as well as an increase in folate levels (mean 7.9, SD 3.7 ug/l vs mean 11.6, SD 4.8 ug/l, p=0.01) and vitamin D levels (mean 52.7, SD 28.5 nmol/l vs mean 73.9, SD 29.8 nmol/l, p<0.01). No significant differences in baseline and follow-up biochemical parameters between one-to-one and group clinics were noted. At follow-up, there was no statistically significant difference between mean GFD adherence scores (mean 3.1, SD 0.4 vs mean 3.1, SD 0.7, p=0.66) between one-to-one and group clinics.

Buy in from Patients

The unforeseen consequence of the study was ‘peer-to-peer support’. By meeting in this fashion, patients were then able to help each other by sharing experiences and knowledge. Free text: ‘It was great for covering all the areas I was not sure about and practical tips like how to eat out. The group clinic allowed me to meet others with my problem and I felt much more confident afterwards.’

NHS Penetration

We provided two free National GI Dietetic study days (2017 & 2019) with an attendance on both occasions of >250 GI dietitians. The ‘How I do it’ group clinic was delivered at these meetings and as well as direct advice and implementation support for any dietitians wishing to pursue this innovation. Having been the only unit in the UK undertaking coeliac disease group clinics, now > 30% of Trusts have adopted our approach. We also demonstrated >50% dietician time saving for the group clinic which extrapolates to ~ £750K annual saving to the NHS

Conclusion

We are the first group internationally to demonstrate that a group clinic is equivalent to a one-to-one appointment and this service delivery innovation has penetrated the NHS with associated significant cost savings as well as increased patient satisfaction.

References

1. Rej A, Trott N, Sanders DS. Is Peer Support in Group Clinics as Effective as Traditional Individual Appointments? The First Study in Patients with Celiac Disease. Clin Transl Gastroenterol 2020 Jan 24.

Contact details for more information

Academic Unit of Gastroenterology, Room P39, P Floor, Royal Hallamshire Hospital, Glossop Road, S10 2JF, Sheffield.