Patient information letters on nutrition: development and implementation

¹ From the Department of Family Medicine, University Medical Center Nijmegen, Nijmegen, the Netherlands (JJvB); and Dutch College of General Practitioners, Utrecht, the Netherlands (AJMD).

² Presented at the Third Heelsum International Workshop, held in Heelsum, the Netherlands, December 10–12, 2001.

³ Supported by a grant from the Dutch Dairy Foundation for Nutrition and Health.

⁴ Reprints not available. Address correspondence to AJM Drenthen, Dutch College of General Practitioners, PO Box 3231, 3502 GE Utrecht, the Netherlands. E-mail: t.drenthen{at}nhg-nl.org.

Correspondence: Reprints not available. Address correspondence to AJM Drenthen, Dutch College of General Practitioners, PO Box 3231, 3502 GE Utrecht, the Netherlands. E-mail: t.drenthen{at}nhg-nl.org.

ABSTRACT  
Background: In 1998 the Dutch College of General Practitioners (NHG) began developing patient information letters (PILs), based on the practice guidelines for family physicians (FPs) (NHG standards). Five nutritional guidance letters have since been developed with the Dutch Nutrition Center.

Methods: In August–September 2001 a survey was done among a random sample of 200 FPs who subscribe to the PILs. They received a questionnaire about the use and implementation of the PILs in general, and about the nutrition letters specifically.

Results: Responses were received from 133 FPs (67%). Of these FPs, 89% use the PILs in their practice. Only 5% of FPs say that they use the PILs on nutrition sufficiently; 32% think they should use them a bit more, whereas 63% make much too little use of the nutrition letters. The most important barriers for using the letters are that FPs do not think about them at the right moment (66%), do not know the content enough (32%), find that using them is too time-consuming (29%), have computer problems (17%), and have too little knowledge about nutritional advice (11%); only 6% do not see dietary advice as an FP’s task. The most important reason for not using the nutrition letters is the fact that the letters are not integrated into their FP information system (23%).

Conclusions: Implementation of PILs takes time, and there are great advantages to integrating them into the existing Family Practice Information Systems.

Key Words: Nutrition • general practitioners • family physician • patient information letters • electronic medical registration • ICPC-diagnostic code

INTRODUCTION  
The family physician’s (FP) work involves several nutrition-related diagnoses (1–3). These are diverse and run from the well-known nutritional advice in diabetic and cardiovascular patients (4) to, for instance, the usual intervention in patients with chronic obstructive pulmonary disease (5). Another field of nutritional interest is the prevalence of malnutrition and its association with disease complications (6, 7) or the endless discussion about salt and hypertension (8). In other words, nutritional intervention should be part of the regular therapy.

Performing a nutritional checkup is not all that easy, however. Although simple questions can provide most of the relevant information (9, 10), FPs have limited time for providing nutritional advice (11) and their vocational training in nutrition is brief (12). Still, nutrition is considered to be an essential part of the FP’s daily work (13) and stays on the FP’s agenda (14). The question is, How can an FP manage to give the most evidence- or practice-based nutritional advice to each patient (15, 16)?

In 1989 the Dutch College of General Practitioners (Nederlands Huisartsen Genootschap ) started developing its guidelines (standards) on the diagnosis, investigation, and treatment of clinical conditions (17, 18). Since 1998 NHG has been distributing patient information letters (PILs). These letters follow the NHG practice guidelines and are an explanation of the diagnosis, relevant investigations, and pharmacologic and nonpharmacologic treatment in question—given in comprehensible language.

At first the PILs were on paper only. Then there were floppy disk versions. The various electronic medical systems (EMS) support the letters. Here the connection with the International Classification of Primary Care (ICPC) code diagnosis of the patient is the entrance to the supporting information material (19). Besides the NHG guidelines and the prescription advice, the PILs are integrated into this system. Finally, since the beginning of 2001 the PILs have been integrated into 3 of the 7 FP information systems (about 32% of all FPs). At the moment about 90% of all Dutch FPs use an electronic medical dossier.

The NHG members pay for these PILs; about 1500 Dutch FPs have an active subscription. But because most FPs share the letters with 1 or 2 colleagues, almost half of the 7000 Dutch FPs have access to the PILs. In September 2001 there were 142 PILs. Twice a year the FPs receive 15–20 new or updated PILs.

Besides the subscribers, all Dutch FPs received in December 2001 a CD-ROM, the so-called Electronic Prescription System, with background information for use during the consultation. It is also linked to the ICPC code for diagnosis.

In 1999 the NHG started to update the nutritional paragraphs in the relevant letters and to develop single nutritional guidance letters. These letters are computerized and even linked with the classified diagnosis (ICPC) of the patient (19). As soon as the patient’s diagnosis is made, a simple connection within the patient’s own electronic medical dossier can be made to the letters. Hard copies can be printed and handed out.

The development of these letters and paragraphs was a cooperative effort of NHG and the Dutch Nutrition Center. All NHG practice guidelines with any nutritional scope were earmarked. After that, 2 types of diagnoses were distinguished: diagnosis needing just a paragraph on nutrition in the PIL, and diagnosis needing a full independent letter (Table 1). The nutritional content of the corresponding PIL was checked. With FPs and nutritionists working closely together, a balanced text was made. This concept was evaluated by the NHG editorial staff and reviewed by a nutritional scientist and a dietitian. In the meantime, a panel of 7 patients was asked to comment on the readability of the letters. After authorization of the NHG staff, the letters were published. Five letters are now complete:

View this table:
TABLE 1 . Standards with nutritional elements from the Dutch College of General Practitioners (NHG) and the division between patient information letters on nutrition and nutritional paragraphs¹  

• Healthy nutrition for adults,
  
• Nutritional advice on diabetes mellitus,
  
• Nutritional advice on high cholesterol,
  
• Nutritional advice on hypertension, and
  
• Nutritional advice on pregnancy.
  

A translated example of the diabetes letter on nutrition is given in Table 2.

View this table:
TABLE 2 . Patient information letter from the Dutch College of General Practitioners (NHG) on diabetes mellitus type 2 dietary advice  
To get an impression of the implementation of these new letters, a survey was done with the following questions:

• Do you know the PILs on nutrition?
  
• Do you use the PILs on nutrition?
  
• Do you agree with the content of the PILs on nutrition?
  
• Do you meet difficulties in using the PILs on nutrition?
  

METHODS  
In August–September 2001 a small survey was done among a random sample of 200 (of the 1500) FPs who subscribe to the PILs. They received a questionnaire concerning the use of the PILs in general and about the specific nutrition letters. Informed consent was not requested. In January 2002 the nonresponders received a new questionnaire.

RESULTS  
Responses were received from 133 FPs (67%): 78% male, 22% female. Eighty-nine percent reported using the PILs in their practice. The most important results of the PILs on nutrition are summarized in Table 3. The nutrition letters on diabetes mellitus (74%) and cholesterol (73%) are the best known. Respectively, 66% and 62% of the FPs use these nutrition letters. A high percentage—93% or more—endorse the content of the various nutrition letters.

View this table:
TABLE 3 . Percentage of family practitioners who know, use, and agree with the content of patient information letters (n = 133)  
Only 5% of FPs say that they use the PILs on nutrition sufficiently; 32% think they should use them more, whereas 63% say they make much too little use of the nutrition letters. The most important barriers to using the letters are that FPs do not think about it at the right moment (66%), do not know the content enough (32%), find that using them is too time-consuming (29%), have computer problems (17%), and have too little knowledge about nutritional advice (11%); only 6% do not see dietary advice as an FP’s task. The most important reason for not using the nutrition letters is the fact that the letters are not integrated into their FP information system (23%).

DISCUSSION  
Our study was just a small survey with limited participants and setup. Moreover, the PILs on nutrition had been in use for only a year at the time of the survey. Most FPs know the PILs with nutritional advice, but a minority of FPs use them in daily practice.

An FP needs to find adequate information for his or her patient during the 10 min they spend together. About 66% of the respondents explain that it can be hard to think of all the right nutritional advice while patients are still in the office. Having an electronic version of well-balanced evidence- or at least practice-based information offers great advantages—one being time savings. Integration of these PILs on nutrition with the electronic medical dossier of the patient involved allows for tailor-made counseling, so the FPs have wanted the PILs to be connected to the diagnostic code (ICPC). All the FPs agreed that having PILs developed by FP experts, nutritional experts, an editorial board, and a patients panel seemed to work well.

Moreover, using an electronic route to obtain information is becoming more and more the fashion (20), not only for patients but for medical students seeking instruction (21, 22). The electronic version via the EMS will in the future provide the possibility to consult validated nutritional websites. At those sites, more in-depth information could be gathered. Relatively complicated questions could be answered regarding, for instance, the interaction between foods and drugs, food allergies, and the relevance of functional foods in particular patients. When patients and FPs both know more, old wives’ tales will have less sway over treatment, and treatment effectiveness will improve (23, 24).

CONCLUSION  
Although FPs are enthusiastic about the content of the PILs on nutrition, their implementation takes time. Digital integration offers great advantages in this domain.

REFERENCES  

1. Van Binsbergen JJ. Nutritional factors in Dutch family medicine: an inventory. Am J Clin Nutr 1997;65(suppl):1967S–73S.
2. Peirera Gray D. Dietary advice in British General Practice. Eur J Clin Nutr 1999;53:S3–8.
3. Van Weel C. Nutritional guidance in general practice—a conceptual framework. Eur J Clin Nutr 1999;53(suppl):S108–11.
4. Buttriss J. Nutrition in general practice: promoting health and preventing disease. London: Royal College of General Practitioners, 1995.
5. Schols AMWJ, Wouters EFM. Nutritional abnormalities and supplementation in chronic obstructive pulmonary disease. Clin Chest Med 2000;21:753–62.
6. Naber TH, Schermer T, de Bree A, et al. Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr 1997;66:1232–9.
7. Edington J, Winter PD, Coles SJ, Gale CR, Martyn CN. Outcomes of undernutrition in patients in the community with cancer or cardiovascular disease. Proc Nutr Soc 1999;58:655–61.
8. Cutler JA, Follmann D, Allender PS. Randomized trials of sodium reduction: an overview. Am J Clin Nutr 1997;65(suppl):643S–51S.
9. Hark L, Deen D. Taking a nutrition history: a practical approach for family physicians. Am Fam Phys 1999;59:1521–8;1531–2.
10. Little P, Barnett J, Kinmonth AL, et al. Can dietary assessment in general practice target patients with unhealthy diets? Br J Gen Pract 2000;50:43–5.
11. Hiddink GJ, Hautvast JGAJ, Van Woerkum CMJ, Fieren CJ, Van ‘t Hof MA. Nutrition guidance by primary-care physicians: perceived barriers and low involvement. Eur J Clin Nutr 1995;49:842–51.
12. Maiburg HJS, Hiddink GJ, Van ‘t Hof MA, Rethans JJ, Van Ree JJ. The NECTAR-Study: development of nutrition modules for general practice vocational training: determinants of nutrition guidance practice of GP-trainees. Eur J Clin Nutr 1999;53(suppl):S83–8.
13. Truswell AS. Family physicians and patients: is effective nutrition interaction possible? Eur J Clin Nutr 2000;71:6–12.
14. Moore H, Adamson AJ, Gill T, Waine C. Nutrition and health care agenda: a primary care perspective. Fam Pract 2000;17:197–202.
15. Calfas KJ, Zabinski MF, Rupp J. Practical nutrition assessment in primary care settings: a review. Am J Prev Med 2000;18:289–99.
16. Worsley A. How to improve the impact of nutrition guidance by general physicians: public health versus individual patient? Eur J Clin Nutr 1999;53(suppl):S101–7.
17. Grol R, Thomas S, Roberts R. Development and implementation of guidelines for family practice: lessons from the Netherlands. J Fam Practice 1995;40:435–9.
18. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001;39:II-46–54.
19. Van Binsbergen JJ, Drenthen AJM. ICPC-code approach of nutritional questions in general practice: a look at the future. Eur J Clin Nutr 1999;53(suppl):S22–4.
20. Van Woerkum CMJ. Nutrition guidance by primary care physicians: models and circumstances. Eur J Clin Nutr 1999;53(suppl):S19–21.
21. Kolasa KM. Developments and challenges in family practice nutrition education for residents and practicing physicians: an overview of the North American experience. Eur J Clin Nutr 1999;53(suppl):S89–96.
22. Maiburg HJS, Rethans JJE, Schuwirth LWT, Mathus-Vliegen LMH, van Ree JW. Controlled trial of effect of computer-based nutrition course on knowledge and practice of general practitioner trainees. Am J Clin Nutr 2003;77(suppl):1019S–24S.
23. Mant D. Effectiveness of dietary intervention in general practice. Am J Clin Nutr 1997;65(suppl):1933S–8S.
24. Grol R, Dalhuijsen J, Thomas S, In ‘t Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317:858–61.