Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials

Use of digital food records in clinical settings: lessons in translation from a randomised controlled trial

BACKGROUND

Digital food records offer efficiencies in collecting and assessing dietary information remotely; however, research into factors impacting their translation into clinical settings is limited.

METHODS

The study examined factors that may impact the integration of digital food records into clinical dietetic practice by assessing (1) the source and rate of data errors received, (2) the impact of dietitian-adjusted data on dietary variables and (3) the acceptance of use in a complex chronic condition cohort. Adults from specialist clinics enroled in a randomised controlled feasibility trial participated. Participants recorded their dietary intake using a mobile food diary application (Research Food diary, Xyris Software Pty Ltd.); it was analysed via electronic nutrition analysis software (FoodWorks, Xyris Software Pty Ltd.). Records were verified and corrected by a dietitian. Dietary variables assessed before (participant-unadjusted data) and after (dietitian-adjusted data) were compared by the Wilcoxon signed-rank test, Bland-Altman and Passing-Bablok analysis. Surveys and Interviews assessed participants'; acceptance of the mobile application's usability.

RESULTS

Errors appeared in 93% of records. Dietitian-adjusted median data were higher for most variables compared to participant-unadjusted median data (p < 0.05, median changes between 0.0% and 64.7%) of 59 participant records (median age 51 years, interquartile range 38-58). There was poor agreement between participant-unadjusted and dietitian-adjusted data for some dietary variables. Sixty-four percent surveyed (n = 32/50) found the app easy to use, whereas 29 interviews provided insights into facilitators and challenges of use.

CONCLUSIONS

Significant barriers to integrating digital food records into clinical settings exist requiring dietitian adjustment to correct errors which has major implications for estimates of diet quality and intake.

The Effect of Telehealth on Cost of Health Care During the COVID-19 Pandemic: A Systematic Review

Background: As the COVID-19 public health emergency (PHE) altered delivery of health care, alternate forms of health care delivery were adopted. The usage of telehealth expanded during the PHE to reduce exposure to COVID-19, which provides the opportunity to understand how expanded telehealth access affected costs of care. The objective of this work was to evaluate the association between telehealth adoption and health care-related costs during the COVID-19 PHE. Methods: We conducted a systematic review by searching PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL from database inception to May 26, 2023. In June 2023, we also searched Telehealth.HHS.gov and the Rural Health Research Gateway. We sought to identify studies across three main search domains: telehealth, COVID-19, and cost. We analyzed costs based on an economic perspective: patient, health care payer, and health care sector. Results: Out of 8,557 studies screened, 12 studies met the inclusion criteria. Studies had high heterogeneity in telehealth modality and cost perspectives. Included studies had, on average, a moderate risk of bias and lacked standardized outcomes that would have aided in across-study comparisons. We found that the COVID-19 PHE was associated with an increase in spending on telehealth services and decreased patient health care costs, which limited changes in monthly total health care spending. Results were variable, however, based on the telehealth application studied. Conclusions: Telehealth may be associated with cost savings from a patient perspective and from a broader health care sector perspective. Future research should focus on the role of integrated telehealth applications and long-term costs using the societal perspective.

Viewpoint: Better Late Than Never: Nutrition Education Opportunities for Physicians in the United States

Diet and nutrition have an important impact on chronic disease and mortality and have spurred growth in the food is medicine approach. Yet, in the United States (US), post-graduate nutrition education and training for physicians remain limited. This may change as American policies focused on nutrition security, quality care and health equity advance and create new incentives for practicing clinicians to engage in nutrition-focused education and training. This viewpoint summarises why nutrition is essential for quality medical care, nutrition knowledge of US physicians, evolving US policies and advocacy for nutrition in medicine and opportunities for nutrition-focused continuing medical education and training. Clinicians trained in nutrition are important to lead innovation and research in nutrition-focused clinical care and to define best practices and optimise population health.

Utilizing technology for diet and exercise change in complex chronic conditions across diverse environments (U-DECIDE): feasibility randomised controlled trial

BACKGROUND

Diet and exercise are important components of treatment for complex chronic conditions, however access to allied health support is limited. When available, support is often siloed and fragmented. Digital health incorporating patient choice may help to align health care services with preferences and goals. This study evaluated the implementation of a ubiquitously accessible patient-centred digital health diet and exercise service.

METHODS

U-DECIDE was a single-centre, 26-week randomised controlled trial set in kidney and liver disease clinics in a tertiary hospital in Brisbane, Australia. Participants were adults with a complex chronic condition referred for dietetic consultation with at least one feature of the metabolic syndrome. All participants received a dietary consultation, an activity monitor and usual care. Intervention participants were offered one text message per week and access to additional digital health options (increased text message frequency, nutrition app, exercise app, group-based diet and/or exercise video consultations). The primary outcome of feasibility was determined by safety (study-related serious adverse events: SRSAEs), recruitment (≥ 50% eligible patients), retention (≥ 70%), exposure uptake (≥ 75% of intervention group had greater access to health professional contact than comparator) and video consultation adherence (≥ 80% attendance). Secondary outcomes included process evaluation metrics and clinical outcomes.

RESULTS

Of 67 participants (intervention n = 33, comparator n = 34), 37 (55%) were men, median (IQR) age was 51 (41-58) years. The most chosen digital health options were the nutrition app (n = 29, 88%) and exercise video consultations (n = 26, 79%). Only one participant chose no additional digital health options. The intervention group had no SRSAEs. The study exceeded targets for recruitment (52%), retention (81%) and exposure uptake (94%). Video consultation adherence was 42%. Engagement across digital health options was inconsistent.

CONCLUSIONS

Digital health options incorporating patient choice were feasible and can be offered to people with complex chronic disease as a service model option.

TRIAL REGISTRATION

Australia and New Zealand Trials Register: Trial Registration Number: ACTRN12620001282976. Registered 27th November 2020.

A Cost-Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition

BACKGROUND

Malnutrition is a significant and prevalent issue in hospital settings, associated with increased morbidity and mortality, longer hospital stays, higher readmission rates, and greater healthcare costs. Despite the potential impact of nutritional interventions on patient outcomes, there is a paucity of research focusing on their economic evaluation in the hospital setting. This study aims to fill this gap by conducting a cost-consequence analysis (CCA) of nutritional interventions targeting malnutrition in the hospital setting.

METHODS

We performed a CCA using data from recent systematic reviews and meta-analyses, focusing on older adult patients with or at risk of malnutrition in the hospital setting. The analysis included outcomes such as 30-day, 6-month, and 12-month mortality; 30-day and 6-month readmissions; hospital complications; length of stay; and disability-adjusted life years (DALYs). Sensitivity analyses were conducted to evaluate the impact of varying success rates in treating malnutrition and the proportions of malnourished patients seen by dietitians in SingHealth institutions.

RESULTS

The CCA indicated that 28.15 DALYs were averted across three SingHealth institutions due to the successful treatment or prevention of malnutrition by dietitians from 1 April 2021 to 31 March 2022, for an estimated 45,000 patients. The sensitivity analyses showed that the total DALYs averted ranged from 21.98 (53% success rate) to 40.03 (100% of malnourished patients seen by dietitians). The cost of implementing a complex nutritional intervention was USD 218.72 (USD 104.59, USD 478.40) per patient during hospitalization, with additional costs of USD 814.27 (USD 397.69, USD 1212.74) when the intervention was extended for three months post-discharge and USD 638.77 (USD 602.05, USD 1185.90) for concurrent therapy or exercise interventions.

CONCLUSION

Nutritional interventions targeting malnutrition in hospital settings can have significant clinical and economic benefits. The CCA provides valuable insights into the costs and outcomes associated with these interventions, helping healthcare providers and policymakers to make informed decisions on resource allocation and intervention prioritization.

Clinical Service Incorporating Mobile Technology on Weight Loss in Patients With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Translation From Research Trial

BACKGROUND

The prevalence and healthcare cost of metabolic dysfunction-associated steatotic liver disease (MASLD) has increased alongside the epidemic surge in obesity and Type 2 diabetes. Weight loss through lifestyle modification remains the primary effective therapy for MASLD. Incorporation of mobile technology in lifestyle interventions has been previously found to be efficacious and cost-effective in facilitating weight loss. However, there is a paucity of studies that have successfully translated lifestyle research into clinical service for weight loss to alleviate disease burden. Our study aimed to describe the process of translating a mobile technology-enabled trial into a tertiary hospital outpatient dietetics service for patients with MASLD.

METHODS

The Iowa Model of Evidence-Based Practice to Improve Quality Care was used as a framework for this paper to guide implementation at the organizational level.

RESULTS

Regular engagement of key operational staff and the hospital management team facilitated open discussions of the challenges faced and enabled rapid implementation of strategies that contributed to the smooth piloting of the service. A service adoption rate of 81% was achieved. Preliminary outcome evaluation found that the percentage of patients achieving ≥ 5% weight loss from baseline at 6 months was comparable at 54% and 52% for the service and trial groups, respectively.

CONCLUSIONS

Evaluation of the implementation process found that a hybrid model of care (in-person consultation supplemented with app coaching) preserved interpersonal connections while maximizing the convenience and scalability of mobile app-enabled service. Although high digital acceptance and adoption rates propelled by COVID-19-supported telehealth, it is prudent to assess patient's access to technology and digital literacy and offer resources to help them benefit from telehealth services.

Can Telehealth Improve Access to Dietary Management in Patients Receiving Dialysis? Insights from Consumers

Timely, effective, and individualised dietary interventions are essential for patients undergoing dialysis. However, delivery of dietary advice is challenging due to limited access to renal dietitians, as well as logistic and scheduling difficulties for patients receiving dialysis. The objectives of this study were to explore consumer perspectives regarding dietary advice utilising telehealth technology. Twenty-two participants (seventeen patients receiving dialysis, five caregivers) were purposively recruited from a local dialysis centre and participated in one of three focus groups. Each focus group was recorded, transcribed, and analysed using inductive thematic analysis. One overarching theme: "a desire to learn" was apparent. The four themes that facilitated this process are herein described: Meaningful communication-a need for improved and individualised communication about diet using positively framed messages with consistency among clinicians. Conducive information-a preference for tailored, current, and clear dietary information (plain language was preferred, with practical advice on making dietary changes). Appropriate timing-health advice at the right time (consumers felt overwhelmed, not supported enough with timely advice, and experienced difficulty attending appointments in addition to dialysis treatments). Contemporary modalities-delivering information using different technologies (consumers preferred a combination of delivery methods for dietetic advice including text/SMS/App messages as an adjunct to face-to-face care). The results showed that consumers believe that telehealth options are an acceptable adjunct to receive dietary advice in a timely manner, and feedback from patients and caregivers has informed the design of a clinical trial to incorporate the use of telehealth to improve the management of serum phosphate.