Dietitians' perceptions of employment models used in Australian residential aged care facilities.

OBJECTIVES: The qualitative study aimed to explore dietitians' perceptions of employment status and engagement models with residential aged care facilities (RACF) and the impact on work activities and resident care. METHODS: Dietitians currently working in RACF were recruited through convenience and snowball sampling, including contacting a list of dietitians who had previously consented to be contacted for research. A semi-structured interview guide was developed by the research team, pilot-tested and then used in each individual interview. Data were analysed using constant comparison and reflexive thematic analysis. RESULTS: Thirty-one dietitians (n = 29 female; median age, 39 years) with a range of experience working in different employment status and engagement models in RACF participated in an interview. Five themes were identified: (1) Being an employee allows for better integration and utilisation in the RACF, (2) Contract work creates a scarcity of time, (3) Ad hoc work does not meaningfully address nutrition challenges and may not be good for resident care, (4) Regularly scheduled visits support positive outcomes for residents and (5) Acknowledging many different employment models. CONCLUSION: Characteristics of engagement models likely affect dietitian work job satisfaction, individual resident care and food service in RACF. Regular dietetic engagement in RACFs is required to support resident-centred evidence-based dietetic practice and to improve residents' nutrition care. There is an opportunity for policy mandates to assist RACFs in regularly engaging a dietitian to ensure all residents have access to timely, high-quality nutrition care.

Patients' experiences of and roles in interprofessional collaborative practice in primary care: a constructivist grounded theory study.

AIM: This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates. BACKGROUND: High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown. METHODS: A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim. FINDINGS: Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.

'Through education, we can make change': A design thinking approach to entry-level dietetics education regarding eating disorders.

AIMS: To co-create strategies and identify opportunities to integrate eating disorder content within dietetics curricula at one Australian university with stakeholders using a design thinking approach. METHODS: A pragmatic mixed-methods, participatory design approach was used. An online survey explored the learning needs of dietetic students and recent graduates regarding eating disorders. Following the survey, a one-day design thinking retreat was held with stakeholders who were identified from the research team's professional networks. Eating disorder dietitians, learning experts, dietetic students, graduates, and those with lived experience were asked to identify strategies to enhance students' confidence and competence to provide care for people living with eating disorders. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using inductive coding and reflexive thematic analysis. RESULTS: Sixty-four students (n = 55, 86%) and recent graduates (n = 9, 14%) completed the online survey (26% response). Seventeen stakeholders attended the retreat. Four themes were identified: (1) changing perceptions of eating disorder care from specialist to 'core business'; (2) desiring and advocating for a national change to dietetics curricula; (3) importance of lived experience at the centre of curriculum design and delivery; and (4) collaborating to co-design and deliver eating disorder content at university. CONCLUSION: Raising awareness, upskilling students and educators, enhanced collaboration between universities and stakeholders, and the inclusion of lived experience were key to preparing students to provide care to people seeking support for eating disorders. Further research is needed to assess the impact these strategies have on dietetic students' confidence and competence.

Effectiveness of dietetic care for cancer survivors in the primary care setting: A systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Nutrition plays an important role in cancer survivorship. This systematic review and meta-analysis aim to critically assess and quantify the effectiveness of nutrition care interventions provided by dietitians to survivors who have completed treatment for cancer. METHODS: A systematic review of randomized controlled trials (RCTs) published from January 2004 to November 2023 reporting the effectiveness of primary care dietetic interventions with adult cancer survivors was conducted. PubMed, Scopus, CINAHL, Embase, ProQuest and PsycINFO databases were searched for key terms. Meta-analyses were conducted where there were sufficient studies of the same cancer type and outcomes. RESULTS: Twelve RCTs representing 1138 cancer survivors (519 breast cancer; 75 prostate cancer; 544 colorectal cancer) were included. Primary outcome measures included weight loss (n = 6), quality of life (n = 2), reducing lymphedema-related arm volume (n = 2), nutritional status (n = 1) and increasing fruit and vegetable intake (n = 1). Weight loss was observed in studies where this was the primary outcome. Results for quality of life varied. Meta-analyses of RCTs with breast cancer survivors showed that dietitian intervention achieved a mean of 3.7 kg greater intentional weight loss and 2.3% greater body fat decrease than control (p < 0.0001). CONCLUSIONS: This study provides evidence for the effectiveness of primary care dietetic interventions by dietitians with cancer survivors, particularly with respect to intentional weight and fat loss in breast cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Dietitians can play a key role in managing weight and improving long term health outcomes and prognosis for cancer survivors beyond the acute care setting.

Patient-Led, Technology-Assisted Malnutrition Risk Screening in Hospital: A Feasibility Study.

Malnutrition risk screening is crucial to identify at-risk patients in hospitals; however, screening rates can be suboptimal. This study evaluated the feasibility, acceptability, and potential cost-effectiveness of patient-led, technology-assisted malnutrition risk screening. A prospective multi-methods study was conducted in a 750-bed public hospital in Australia. Patients were recruited from seven wards and asked to complete an electronic version of the Malnutrition Screening Tool (e-MST) on bedside computer screens. Data were collected on feasibility, acceptability, and cost. Feasibility data were compared to pre-determined criteria on recruitment (≥50% recruitment rate) and e-MST completion (≥75% completion rate). Quantitative acceptability (survey) data were analyzed descriptively. Patient interview data were analyzed thematically. The economic evaluation was from the perspective of the health service using a decision tree analytic model. Both feasibility criteria were met; the recruitment rate was 78% and all 121 participants (52% male, median age 59 [IQR 48-69] years) completed the e-MST. Patient acceptability was high. Patient-led e-MST was modeled to save $3.23 AUD per patient and yield 6.5 more true malnutrition cases (per 121 patients) with an incremental cost saving per additional malnutrition case of 0.50 AUD. Patient-led, technology-assisted malnutrition risk screening was found to be feasible, acceptable to patients, and cost-effective (higher malnutrition yield and less costly) compared to current practice at this hospital.

Long-Term Effect of Salt Substitution for Cardiovascular Outcomes : A Systematic Review and Meta-analysis.

BACKGROUND: Salt substitution is a simple yet increasingly promising strategy to improve cardiovascular outcomes. PURPOSE: To evaluate the long-term effects of salt substitution on cardiovascular outcomes. DATA SOURCES: PubMed, EMBASE, Cochrane CENTRAL, and CINAHL searched from inception to 23 August 2023. Trial registries, citation analysis, and hand-search were also done. STUDY SELECTION: Randomized controlled trials (RCTs) comparing provision of or advice to use a salt substitute with no intervention or use of regular salt among adults for 6 months or longer in total study duration. DATA EXTRACTION: Two authors independently screened articles, extracted data, and assessed risk of bias. Primary outcomes include mortality, major cardiovascular events (MACE), and adverse events at 6 months or greater. Secondary and post hoc outcomes include blood pressure, cause-specific mortality, and urinary excretion at 6 months or greater. Random-effects meta-analyses were done and certainty of effect estimates were assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). DATA SYNTHESIS: Of the 16 included RCTs, 8 reported on primary outcomes. Most (n = 7 of 8) were done in China or Taiwan, 3 were done in residential facilities, and 7 included populations of older age (average 62 years) and/or with higher-than-average cardiovascular risk. In this population, salt substitute may reduce risk for all-cause mortality (6 RCTs; 27 710 participants; rate ratio [RR], 0.88 [95% CI, 0.82 to 0.93]; low certainty) and cardiovascular mortality (4 RCTs; 25 050 participants; RR, 0.83 [CI, 0.73 to 0.95]; low certainty). Salt substitute may result in a slight reduction in MACE (3 RCTs; 23 215 participants; RR, 0.85 [CI, 0.71 to 1.00]; very low certainty), with very low-certainty evidence of serious adverse events (6 RCTs; 27 995 participants; risk ratio, 1.04 [CI, 0.87 to 1.25]). LIMITATIONS: The evidence base is dominated by a single, large RCT. Most RCTs were from China or Taiwan and involved participants with higher-than-average cardiovascular risk; therefore, generalizability to other populations is very limited. CONCLUSION: Salt substitution may reduce all-cause or cardiovascular mortality, but the evidence for reducing cardiovascular events and for not increasing serious adverse events is uncertain, particularly for a Western population. The certainty of evidence is higher among populations at higher cardiovascular risk and/or following a Chinese diet. PRIMARY FUNDING SOURCE: National Health and Medical Research Council. (PROSPERO: CRD42022327566).

Acetyl-CoA carboxylase obstructs CD8+ T cell lipid utilization in the tumor microenvironment.

The solid tumor microenvironment (TME) imprints a compromised metabolic state in tumor-infiltrating T cells (TILs), hallmarked by the inability to maintain effective energy synthesis for antitumor function and survival. T cells in the TME must catabolize lipids via mitochondrial fatty acid oxidation (FAO) to supply energy in nutrient stress, and it is established that T cells enriched in FAO are adept at cancer control. However, endogenous TILs and unmodified cellular therapy products fail to sustain bioenergetics in tumors. We reveal that the solid TME imposes perpetual acetyl-coenzyme A (CoA) carboxylase (ACC) activity, invoking lipid biogenesis and storage in TILs that opposes FAO. Using metabolic, lipidomic, and confocal imaging strategies, we find that restricting ACC rewires T cell metabolism, enabling energy maintenance in TME stress. Limiting ACC activity potentiates a gene and phenotypic program indicative of T cell longevity, engendering T cells with increased survival and polyfunctionality, which sustains cancer control.

Exercise care by general practitioners: Providing sustainable solutions for patients living with chronic disease.

BACKGROUND: Most Australian adults are insufficiently physically active, creating an economic and moral imperative to support exercise care in general practice. OBJECTIVE: To provide an overview of exercise care in general practice to support sustained solutions for patients living with chronic disease. DISCUSSION: Exercise care should be considered a fundamental component of high-quality consultations, including assessing, advocating and monitoring for physical activity. Exercise levels and cardiorespiratory fitness can be considered 'vital signs' for tracking over time. Modest gains in physical activity levels have clinical benefits, warranting approaches that engage patients in any amount of time in exercise. Resources are available to support general practitioners (GPs) to incorporate exercise care into routine consultations. GPs can print or save the links provided in this paper and use platforms such as GoShare to connect patients to the resources. Over 15 exercise-specific clinical practice guides are available through The Royal Australian College of General Practitioners' Handbook of non-drug interventions.

Comparing dietary strategies to manage cardiovascular risk in primary care: a narrative review of systematic reviews.

BACKGROUND: Nutrition care in general practice is crucial for cardiovascular disease (CVD) prevention and management, although comparison between dietary strategies is lacking. AIM: To compare the best available (most recent, relevant, and high-quality) evidence for six dietary strategies that are effective for primary prevention/absolute risk reduction of CVD. DESIGN AND SETTING: A pragmatic narrative review of systematic reviews of randomised trials focused on primary prevention of cardiovascular events. METHOD: Studies about: 1) adults without a history of cardiovascular events; 2) target dietary strategies postulated to reduce CVD risk; and 3) direct cardiovascular or all-cause mortality outcomes were included. Six dietary strategies were examined: energy deficit, Mediterranean-like diet, sodium reduction (salt reduction and substitution), the Dietary Approaches to Stop Hypertension (DASH) diet, alcohol reduction, and fish/fish oil consumption. Reviews were selected based on quality, recency, and relevance. Quality and certainty of evidence was assessed using GRADE. RESULTS: Twenty-five reviews met inclusion criteria; eight were selected as the highest quality, recent, and relevant. Three dietary strategies showed modest, significant reductions in cardiovascular events: energy deficit (relative risk reduction [RRR] 30%, 95% confidence interval [CI] = 13 to 43), Mediterranean-like diet (RRR 40%, 95% CI = 20 to 55), and salt substitution (RRR 30%, 95% CI = 7 to 48). Still, some caveats remain on the effectiveness of these dietary strategies. Salt reduction, DASH diet, and alcohol reduction showed small, significant reductions in blood pressure, but no reduction in cardiovascular events. Fish/fish oil consumption showed little or no effect; supplementation of fish oil alone showed small reductions in CVD events. CONCLUSION: For primary prevention, energy deficit, Mediterranean-like diets, and sodium substitution have modest evidence for risk reduction of CVD events. Strategies incorporated into clinical nutrition care should ensure guidance is person centred and tailored to clinical circumstances.

What makes a good general practice consultation: an exploratory pilot study with people from a low socioeconomic background.

BACKGROUND: Whilst patients from low socioeconomic (SES) backgrounds are at increased risk of developing chronic health conditions, typically managed within general practice, they report less positive consultation experiences with general practitioners (GP). To our knowledge, existing research does not provide an in-depth understanding of GP conducts contribute to positive consultations. AIM: To identify the factors that patients from low SES backgrounds perceive as essential for creating good consultation experiences. DESIGN & SETTING: This qualitative research was performed in Melbourne GP clinics. METHOD: We used an appreciative inquiry approach, focused on positive consultation experiences, previously shown to be helpful for researching sensitive topics. Nine patients with low SES backgrounds who reported positive consultation experiences, undertook a semi-structured qualitative interview whilst watching the video-recording of their GP consultation. Four different GPs were captured in the recordings. Inductive thematic coding was performed by two researchers. RESULTS: Four categories were developed relating to: (1) the doctor's demeanour and the patient's feelings, (2) the therapeutic relationship, (3) the doctor's therapeutic skill set and (4) communication techniques. In each interview, the discussion about the video-recorded consultation often triggered reflections about previous consultations with the respective GP. CONCLUSION: For patients from low SES groups, positive consultation experiences were underpinned by perceived continuity of care with a specific GP who consistently showed good communication skills and key interpersonal characteristics. This research is a small step towards increasing our understanding of the experience of individuals with low SES backgrounds in primary care and the existing health inequities within this.

What next for behaviour change professional development in general practice? insights from an environmental scan and workshops.

BACKGROUND: A key role of general practice professionals (i.e., general practitioners [GPs], and general practice nurses [GPNs]) is to support patients to change behaviours. Traditional approaches to assisting patients with, and learning about, behaviour change have modest outcomes. AIM: To explore behaviour change with GPs and GPNs and the availability of related professional development (PD) opportunities. DESIGN & SETTING: Multi-methods study comprising an environmental scan survey of behaviour change tools and PD opportunities, and online workshops with Australian GPs and GPNs. METHOD: Survey data were analysed using qualitative content analysis, informing the design of the workshops. Workshop data included: observation, note-taking, and collaborative reflection, which were analysed thematically and synthesised with survey data. RESULTS AND CONCLUSION: Survey responses (n=18) and two virtual workshops (W1 n=30, W2 n=8). There was diversity in awareness of existing behaviour change tools and resources. Preferences for future tools and PD opportunities related to specific aspects of its design, content, activities, and delivery. Three themes developed from the workshop data relating to relationships, continuity, and context. In the absence of tools and resources, GPs and GPNs in our study discussed behaviour change as something that occurs best through a patient-centred alliance that is continuing, respectful, grounded in trust and an understanding of their patient, and prioritises patient autonomy. Future general practice behaviour change PD should support clinicians to 'assist' patients and recognise the social and contextual influences on behaviour.

The prevalence of psychological distress in adults newly diagnosed with type 2 diabetes: Data from the Australian 3D case-series study.

ISSUE ADDRESSED: This cross-sectional analysis of the Australian 3D study aimed to determine the prevalence of psychological distress and describe its associated characteristics in adults recently diagnosed with type 2 diabetes. METHODS: Adults (aged 18 years and over) who were recently diagnosed with type 2 diabetes (<6 months prior) were recruited through the Australian National Diabetes Services Scheme in 2018-2019. Demographic and health data were collected via interview-administered telephone surveys. Hierarchical regression was used to analyse whether demographic, self-care and clinical characteristics were associated with psychological distress, as measured by the K10 questionnaire. RESULTS: Of the participants (n = 223), 26.3% presented with psychological distress, with 8.4% reporting mild, 8.4% reporting moderate and 9.5% reporting severe psychological distress. Neither age, sex, body mass index or taking anti-depressant medications were associated with the presence of psychological distress (p > .05). Being a smoker, living situation, less physical activity and poorer healthy eating beliefs and intentions were significantly associated with psychological distress in those not taking anti-depressant medications (p < .05). Being female was significantly associated with psychological distress in those taking anti-depressant medications (p < .05). CONCLUSION: The study found that psychological distress is highly prevalent in adults recently diagnosed with type 2 diabetes. Behavioural factors such as smoking and low physical activity, as well as psycho-social factors such as living situation, poor healthy eating beliefs and intentions were significantly associated with psychological distress. This has implications for the management of people with newly diagnosed type 2 diabetes. SO WHAT?: Psychological distress is highly prevalent in Australian adults newly diagnosed with type 2 diabetes, emphasising the urgent need for enhanced psychological care to support this group.

Intestinal permeability and inflammatory features of juvenile age correlate with the eventual systemic autoimmunity in lupus-prone female SWR × NZB F1 (SNF1) mice.

The incidence of systemic lupus erythematosus (SLE) is about nine times higher in women than in men, and the underlying mechanisms that contribute to this gender bias are not fully understood. Previously, using lupus-prone (SWR × NZB)F1 (SNF1) mice, we have shown that the intestinal immune system could play a role in the initiation and progression of disease in SLE, and depletion of gut microbiota produces more pronounced disease protection in females than in males. Here, we show that the gut permeability features of lupus-prone female SNF1 mice at juvenile ages directly correlate with the expression levels of pro-inflammatory factors, faecal IgA abundance and nAg reactivity and the eventual systemic autoantibody levels and proteinuria onset. Furthermore, we observed that the disease protection achieved in female SNF1 mice upon depletion of gut microbiota correlates with the diminished gut inflammatory protein levels, intestinal permeability and circulating microbial DNA levels. However, faecal microbiota transplant from juvenile male and females did not result in modulation of gut inflammatory features or permeability. Overall, these observations suggest that the early onset of intestinal inflammation, systemic autoantibody production and clinical stage disease in lupus-prone females is linked to higher gut permeability in them starting at as early as juvenile age. While the higher gut permeability in juvenile lupus-prone females is dependent on the presence of gut microbes, it appears to be independent of the composition of gut microbiota.

Exploring Australian dietitians' experiences and preparedness for working in residential aged care facilities.

BACKGROUND: Dietitians are increasingly working in residential aged care facilities (RACF). As such, supporting the RACF dietetic workforce is imperative. This qualitative study explored dietitians' experiences and preparedness for working in RACFs. METHODS: A qualitative descriptive approach from a non-singular reality relational position was used. Recruitment occurred through convenience and snowball sampling, including contacting a list of dietitians who had previously consented to be contacted for research. The interviews included a semi-structured approach. Data were analysed using constant comparison and reflexive thematic analysis. RESULTS: Thirty-one dietitians (n = 29 female; median age, 39 years) with a range of career experience participated in an interview. Interviews ranged from 25 to 68 min (mean duration, 41 min). Five themes and 14 subthemes were identified. Themes were: (1) joining the aged care workforce was not initially considered a career option, (2) difficulty sustaining satisfaction working in aged care, (3) navigating practical challenges working with residents while prioritising quality care, (4) poor acknowledgement of the dietitian role by staff and (5) grappling with a moral desire to improve the aged care sector. CONCLUSION: Dietitians face many challenges in fulfilling their role in RACFs, including RACF staff's poor understanding of dietitians' scope and a lack of procedural support for their daily activities. Dietitians report that genuine improvements in their job satisfaction and experiences of older adults require structural reform within the government, beyond their locus of control.

Where the joy comes from: a qualitative exploration of deep GP-patient relationships.

BACKGROUND: Relationship-based, whole person care is foundational to quality general practice. Previous research has identified several characteristics of deep General Practitioner (GP)-patient relationships and their association with improved patient concordance, satisfaction and perceived health outcomes. Psychological attachment theory has been used to understand therapeutic relationships, but has only been explored to a limited extent in the general practice context. Additionally, evolving changes in sociocultural and commercial practice contexts may threaten relationship-based care. In view of this, we aimed to explore the nature and experience of deep GP-patient relationships, as identified by patients, from GP and patient perspectives. METHODS: Semi-structured interview design. An initial survey assessed patients' perceived depth of their relationship with their GP, using the Health Care Provider Attachment Figure Survey and Patient-Doctor Depth of Relationship Scale. Patients who reported a deep relationship, and their GPs, were purposively selected for individual interviews exploring their experience of these relationships. A post-interview survey assessed interviewees' attachment styles, using the Modified and Brief Experiences in Close Relationships Scale. Patient interviewees also rated the patient-centredness of their GP's clinic using the Person-Centred Primary Care Measure. Transcripts were analysed using thematic analysis. RESULTS: Thirteen patients and five GPs were interviewed. Four themes characterised deep relationships: the 'professional'; human connection; trust; and 'above and beyond'. Patient, GP and practice team all contributed to their cultivation. CONCLUSIONS: We present a revised conceptual framework of deep GP-patient relationships. Deep relationships come to the fore in times of patient trouble. Like attachment relationships, they provide a sense of safety, caring and support for patients experiencing vulnerability. They can stretch GP boundaries and capacity for self-care, but also provide joy and vocational satisfaction. Patients may not always desire or need deep relationships with their GP. However, findings highlight the importance of enabling and cultivating these for times of patient hardship, and challenges of doing so within current healthcare climates.

Delphi Plus: A novel methodology for identifying evidence-based data standards for health service decision-making.

The underlying tenet of evidence-based decision-making in health services is assessing all the relevant evidence. Using the traditional qualitative and quantitative approaches to identifying evidence may not capture the full spectrum of factors that need to be addressed. A selective mixed-method approach may provide a comprehensive assessment of the relevant knowledge. This paper adds to the methodological literature by outlining a novel sequential, mixed-method, exploratory process for identifying evidence-based data standards that may be used for health service decision-making. The three-phase process, entitled Delphi Plus, engages peer-nominated topic-specific experts to assess all publicly available and practice-based items and, through a series of reviews, reach an evidence-based consensus on standards for decision-making. Each process phase is outlined in-depth and supplemented by practical learnings gained through its implementation. The Delphi Plus methodology provides the first comprehensive process for combining the published and practised data to develop evidence-based data standards. The routine use of Delphi Plus would provide a framework for benchmarking in health services, enabling greater monitoring and evaluation of client outcomes and improving quality care. This manuscript describes the process of implementing Delphi Plus and provides an example of data standards generated from its use, which directly inform the Australian Government's Primary Health Care 10 Year Plan.