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Call me maybe? Telephone clinics for coeliac disease dietetic services
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  1. Lisa Vokes1,
  2. Michael FitzPatrick2
  1. 1 Nutrition and Dietetics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
  2. 2 Translational Gastroenterology Unit, Oxford University, Oxford, Oxfordshire, UK
  1. Correspondence to Dr Michael FitzPatrick, Translational Gastroenterology Unit, Oxford University, Oxford OX3 9DU, UK; michael.fitzpatrick{at}ndm.ox.ac.uk

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The COVID-19 pandemic has forced the large-scale rollout of ‘telemedicine’ for outpatient appointments. Therefore, the publication of a study that rigorously examines the efficacy of this approach within gastroenterology is a welcome contribution, and prescient of the authors given that this work was conceived well before we had heard of SARS-CoV-2. As the only therapy for coeliac disease (CD) is a gluten-free diet (GFD), it is especially laudable to see work conceived by, performed, and reported by dietitians. Furthermore, the title indicates that this approach is effective for improving GFD adherence at 6 months. Voila? Let’s take a closer look.

Muhammad and colleagues performed a prospective, single-centre, controlled study of personalised dietary advice for adult patients with histologically confirmed CD.1 The intervention group consisted of patients not adhering to a GFD, while the remaining adherent patients became the control group. All participants were assessed at baseline and up to a year postintervention using validated tools: assessment of GFD adherence (Coeliac Disease Adherence Test (CDAT)), quality of life (Coeliac Disease Assessment Questionnaire (CDAQ)) and GFD knowledge (GF knowledge questionnaire). The intervention comprised a single telephone consultation with a consultant gastroenterologist, during which previously posted literature covering CD and GFD (developed with a registered dietitian) was discussed.

Patients in the intervention group were satisfied with the telemedicine format, and their GFD knowledge improved at 3 months, as did their GFD adherence at 3 and 6 months. However, GFD adherence was not different from baseline at 9 or 12 months, and quality of life measures remained similar for both groups.

How does this inform clinical practice? First, it is not a trivial finding that this intervention improves both knowledge of, and adherence to, a GFD. Dietary interventions and behaviour change are challenging to effect. The efficacy of a single consultation for those struggling with GFD adherence to bring about positive, meaningful changes in dietary behaviour is encouraging. Second, the relatively long follow-up of study subjects revealed that the intervention’s effect waned beyond 9 months. This is helpful when considering how to design dietetic services for patients struggling with GFD adherence, particularly as current guidelines recommend annual review only.2 The authors suggest for 6-month consultations until sustained GFD adherence is achieved.

While GFD adherence is the mainstay of CD treatment, its benefit to patients is mediated via improved symptoms and quality of life, and through immunological disease control (and consequent reduced risk of complications). The secondary endpoint of quality of life did not change with intervention in this trial; however, it may have been too early to see meaningful change. Immunological disease activity was not assessed, and inclusion of CD serology, histology and vitamin/mineral deficiency would strengthen future studies considerably.

Many services rely on the expertise of dietitians to deliver GFD consultations; however, in this study, the intervention was delivered by a consultant gastroenterologist. Dietitians are experts in the intersection of nutrition and health and have specific skills in helping patients with dietary behaviour changes. In addition, the 49 min-long consultation in this study is far longer than most physicians or dietitians could hope to provide and would have significant resource implications. Whether shorter consultations would be as efficacious is unclear and an important area for research in a resource-constrained health service.

But what is the current benchmark for CD dietetic management? BSG guidelines2 make two recommendations: “Patients with CD require follow-up by a dietitian and/or clinician with an interest or expertise in this field” and “When adherence is questioned, it should be reviewed by a dietitian. The National Institute for Health and Care Excellence (NICE) guidelines3 are equally ambiguous. This leaves a wide scope for interpretation, primarily due to an absence of evidence about dietetic interventions. We need to revisit dietetic management of CD with the same attention to detail that other gastroenterological conditions have recently been afforded (eg, irritable bowel syndrome4). The nuances of consultation—the professional involved, dietary counselling techniques, content of patient information materials—need examination also. Alternatives to the traditional 1:1 consultation need to be considered. For instance, dietetic counselling is often performed in group sessions with multiple patients, a similar arrangement to that successfully implemented via video conferencing for pulmonary rehabilitation in Scotland.5

Beyond CD, the COVID-19 pandemic has driven rapid introduction of telemedicine in gastroenterology far in advance of the existing evidence. This necessarily rapid implementation of telemedicine has leapfrogged the usual pace of NHS service development; by comparison, the implementation of a home parenteral nutrition telemedicine service pre-COVID took nearly 2 years.6

Many benefits of telemedicine are clear: convenience for patients (and clinicians), reduced time, cost and stress of travel and the considerable impact on greenhouse gas emissions from private transport, still the preferred method of patient travel.5 6 However, there are known shortcomings and risks of telemedicine. Many patients would not choose a telemedicine appointment; during a trial of telemedicine gastroenterology follow-up appointments in Israel during the COVID-19 pandemic, only 20% of patients chose telemedicine approaches, with the rest preferring to defer their appointment.7 Those avoiding telemedicine were more likely to be older or men, and there is a risk of entrenching inequities in care through technological rollout. Moreover, patients report concerns with telemedicine consultations, including the lack of clinical examination, feeling uncomfortable sharing more personal information and technical issues compromising consultation quality.5 7

By necessity, telemedicine has been introduced to almost all gastroenterology services in the past year; however, it is important to match the mode of care to the patient, with some patient groups more appropriately assessed face to face.7 8 Post-COVID, further research and service evaluation are urgently needed to fully appreciate the risks and benefits of telemedicine in specific gastroenterology services to ensure potential deleterious consequences are identified.

This study, led by dietitian researchers and delivered by the multidisciplinary team, makes a valuable contribution both to CD management and to the use of telemedicine more widely. It also highlights the paucity of evidence we have to inform quality criteria for CD dietetic care. We need more high-quality multidisciplinary research like this, driven by dietitians, physicians, and patients, to inform how we deliver the cornerstone of CD management: the GFD.

Ethics statements

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References

Footnotes

  • Twitter @Doctorfitz

  • Contributors LV and MF conceived and wrote the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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