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Family medicine physicians’ report strong support, barriers and preferences for Registered Dietitian Nutritionist care in the primary care setting

Family medicine physicians’ report strong support, barriers and preferences for Registered... Abstract Background Previous studies have examined barriers (e.g. time) for Family Medicine Providers (FMPs) to provide nutrition and lifestyle counseling, however, to date no studies have examined access or interest to Registered Dietitian Nutritionist (RDN) care for patients. Objective The objective of this study was to explore FMP access, referral practices, barriers and preferences for RDN care. Methods A cross-sectional online survey, with content and face validation was conducted with Family Medicine Departments within large academic health care systems in the Southeastern United States. The main variables of interest included: FMP access, interest, current referrals and referral preferences for RDN care, barriers to referrals and overall perceptions regarding RDN care. Descriptive analysis of close-ended responses was performed with SPSS 26.0. Open-ended responses were analysed using inductive content analysis. Results Over half of the respondents (n = 151) did not have an RDN on-site (64%) yet were highly interested in integrating an RDN (94.9%), with reported preferences for full-time on-site, part-time on-site or off-site RDN care (49.1%, 39.5% and 11.4% respectively). The greatest reported barriers to RDN referrals were perceived cost for the patient (64.47%) and uncertainty how to find a local RDN (48.6%). The most consistent theme reported in the open-ended responses were concerns regarding reimbursement, e.g. ‘Insurance does not cover all of the ways I would like to use an RDN’. Conclusions FMPs report interest and value in RDN services despite multiple perceived barriers accessing RDNs care. Opportunities exist for interprofessional collaboration between dietetic and FMP professional groups to address barriers. Chronic disease, interprofessional relations, nutritionists, physicians, primary health care, referral and consultation Key Messages This study identified low overall access to but strong interest in RDN care. Physicians reported cost and uncertainty connecting to an RDN as barriers. Referral to and perceptions of RDN care centred around chronic diseases. Opportunities for interprofessional collaboration may address barriers. Introduction Half the American population have been diagnosed with a diet and lifestyle-related chronic disease (CD), such as diabetes, hypertension or heart disease (1). These CDs account for 90% of the $3.3 trillion spent on health care expenditures annually within the United States (US) (2,3). Obesity is a primary risk factor for CDs, and 39.8% of the US population were classified as obese in 2016 (4). The annual cost of obesity alone is estimated to be $147 billion (5). To address lifestyle-related obesity and related CDs, primary care has been identified as the health care setting where these preventative services, counselling, patient education and management should occur (6). Although diet and lifestyle counselling are outlined as a component of primary care, there is evidence that many physicians face many barriers to the provision of lifestyle and nutrition counselling (7–9). For example, Yarnall et al. (9) estimated that it would take 21.7 hours a day for physicians to address preventative care and health promotion as outlined by the US Preventative Services Task Force (USPSTF), in addition to acute and general medical care tasks. Recently, and possibly to alleviate this gap, the USPSTF released updated obesity management recommendations which included referring obese adults to Registered Dietitian Nutritionists (RDNs) (10,11). Referrals by physicians to qualified providers are critical to provide support in addressing the epidemic of obesity and related CDs within the US. Referral to an RDN offers physicians support and the benefits of RDN care on patients’ outcomes in this setting has been demonstrated. For example, in a systematic review examining patient outcomes associated with RDN care in primary care settings by Mitchell et al. (12), there were consistent significant improvements in patients’ weight and HbA1c levels. Diverse, low-income patients with fewer resources to support diet and lifestyle changes and greater burdens of obesity and CDs have also demonstrated impact and benefits of RDN care in the primary care setting (13,14). In addition to clinical benefits and improved patient outcomes, RDN care has demonstrated health care cost savings, leading to an increased scope of reimbursable services covered by insurers in the US (15). The Academy of Nutrition and Dietetics (AND) has promoted the role of the RDN in primary care settings through the development of several practitioner toolkits (16,17), and evidence exists of the benefits of RDN care in the primary care setting. Despite this support, studies examining physician’s access to, referral practices, barriers and preferences as well as overall interest and perceptions regarding RDN care are greatly lacking. Within primary care, Family Medicine Providers (FMPs) serve patients through all stages of life and emphasize not only the management of CDs, but also the provision of preventative care and individual counselling (18). Due to the broad scope of FMP care and patient populations served, FMP’s access, use, barriers and preferences for RDN should be investigated to identify gaps and areas for potential collaboration to support physician–RDN interprofessional collaboration to improve patient outcomes. Therefore, the objective of this study was to explore FMP referral practices, barriers and preferences for RDN care. Methods Study design This cross-sectional included a web-based survey distributed to FMPs utilizing convenience sampling from major regional and/or academic health care systems in the Southeastern US. The survey was developed specifically for this project and was content and face validated with further description in a subsequent section below. A summary of the survey distribution and targeted recruitment is provided in Figure 1. The recruitment email sent to Family Medicine Department/Programs included an overview of the study, a link for the survey, as well as a description of the incentive to encourage participation among a hard to reach clinician target audience. Respondents were invited to enter their email at the end of the survey for a five-dollar Starbucks gift card which was emailed to them. This incentive decision was based on a narrative literature review by Thorpe et al. (19) who identified preference by physicians for small, immediate ‘tokens of appreciation’ versus larger incentives. The Institutional Review Board at East Carolina University approved the study prior to all data collection. The study was identified as exempt from ethics approval and written consent was not required as the study protocol did not include collection of any personally identifiable or sensitive data. Although written consent was waived, the following statement was provided to all participants in the recruitment email to address consent ‘If you are interested in voluntarily participating in the study below please click on the following link to access the survey’. Figure 1. Open in new tabDownload slide Family medicine provider study recruitment, distribution and data collection procedures. Figure 1. Open in new tabDownload slide Family medicine provider study recruitment, distribution and data collection procedures. Survey development The initial survey draft was developed by the principal investigator (LS) who had prior experience examining medical provider perceptions and delivery of nutrition care within primary care settings. The survey validation involved three stages. The first stage included content review and feedback provided by nutrition experts (n = 17) who were identified based on clinical experience working with physicians within outpatient and/or primary care settings and/or research examining primary care delivery. Feedback was received from 65% (n = 11) of reviewers and included suggestions for re-wording, additions and additional or refined answer choices. The second stage of validation included content and face validation by physicians working in primary care. The survey was sent via email to six physician reviewers. Feedback was received by 66% (n = 4) of physician reviewers, resulted in re-wording of questions, adding or refining answer choices, plus the addition of three questions. The final stage of survey development included review of the survey by the North Carolina Academy of Family Medicine Physicians (NCAFP) board and director. No modifications to the survey were requested by NCAFP. The final survey included an 18-item survey with 17 close-ended questions and one open-ended question (Supplement A). Statistical analysis Descriptive analysis of close-ended questions was performed with SPSS software version 26.0 and included frequencies, percentages, means and standard deviations (Tables 1 and 2). Data obtained in open-ended questions were analysed utilizing inductive analysis as outlined by Elo et al. (20) in which all responses are considered versus only the use of responses which fall within predetermined categories are used. Trustworthiness was addressed through the provision of specific details for how analysis was performed as described below (21). Responses (direct quotes) from FMPs were independently reviewed by two members of the research team and were individually coded. Codes were then collapsed (categorized) for themes. Consensus was reached regarding all reported themes. For further demonstration of trustworthiness, example quotes per theme are provided in the open-ended data table (see results, Table 3). Table 1. Provider/facility descriptives from family medicine physicians in Southeastern US, April–October 2019 (n = 151) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) BP, blood pressure; FQHC, Federally Qualified Health Center; RDN, registered dietitian nutritionist.aOther included: post-surgery/healing, disease state diet/specific diet, weight management, disordered eating and pregnancy. bOther included: disease state diet, disordered eating, post-surgery healing, pregnancy, sports nutrition and well-child. Open in new tab Table 1. Provider/facility descriptives from family medicine physicians in Southeastern US, April–October 2019 (n = 151) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) BP, blood pressure; FQHC, Federally Qualified Health Center; RDN, registered dietitian nutritionist.aOther included: post-surgery/healing, disease state diet/specific diet, weight management, disordered eating and pregnancy. bOther included: disease state diet, disordered eating, post-surgery healing, pregnancy, sports nutrition and well-child. Open in new tab Table 2. Physicians barriers and interests in RDN care from family medicine practices in the United Sates Geographic Southeast, April–October 2019 (n = 151) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Open in new tab Table 2. Physicians barriers and interests in RDN care from family medicine practices in the United Sates Geographic Southeast, April–October 2019 (n = 151) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Open in new tab Table 3. Content analysis results/family medicine survey question of family medicine practices in the United States Geographic Southeast April–October 2019: is there anything else we did not ask that you believe would be useful for us to know/consider? Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Open in new tab Table 3. Content analysis results/family medicine survey question of family medicine practices in the United States Geographic Southeast April–October 2019: is there anything else we did not ask that you believe would be useful for us to know/consider? Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Open in new tab Results A total of 177 FMP completed the survey, of which 151 were applicable for statistical analysis. Twenty-six surveys were discarded because of lack of physician credentials (e.g. nurse practitioners, physician assistants, Pharm D, n = 19) and seven incomplete surveys. Of the final sample (n = 151) the majority (n = 105, 69.5%) worked in practices affiliated with larger health care systems and had been in practice for a mean of 11.9 years, SD 11.0 years (Table 1). Most physicians (64%) did not currently have an RDN on-site. Those without RDNs were interested in RDN care (94.9%) and expressed a preference for full-time or part-time on-site versus off-site (49.1%, 39.5% and 11.4% respectively). For those physicians with an RDN on-site, over half of those RDNs were full time (69.2%). The overwhelming majority of physicians with access to an on-site RDN, reported regular referrals (94.2%). Diabetes and weight management were the most common type of physician referral to an RDN (80.8% and 78.1%, respectively). Similarly, those without RDNs on-site were primarily interested in weight and diabetes management for referrals although a variety of services were described (84.8% and 82.8%, respectively). Perceived barriers to patient referrals for RDN services were also reported by FMPs. Uncertainty of benefit of RDN services received a wide array of responses with the greatest trend towards disagreement, with 34.7% strongly disagreeing and 25.0% disagreeing (Table 2). Other barriers showed more consistent trends of agreement or disagreement with the greatest perceived barrier to be cost for the patient (39.7% agreed, 24.7% strongly agreed that cost is a barrier to referring patients). Lack of patient interest and/or value received mixed perceptions with some strongly disagreeing with this as a barrier (27.8%), whereas others agreeing (26.4%). FMPs provided general information or perceptions in response to a final open-ended question, ‘Is there anything else we did not ask that you believe would be useful for us to know/consider?’ The most consistently initiated responses were concerns regarding insurance coverage and reimbursement barriers for RDN care (Table 3). Several FMPs also provided specific ideas of services they would like RDNs to provide, such as cooking classes and group visits. Other FMPs expressed interest in having an RDN on-site, e.g. ‘Physicians would love to have a dietitian in their practice, especially me as a physician and Medical Director’, ‘Having onsite [dietitian] would be ideal…’, and one mentioned the benefit of an on-site RDN for a ‘warm hand off’ with patients. Of concern, some voiced frustrations with finding a quality RDN due to perceived lack of knowledge and skill of the RDN and/or patients reporting a poor experience. Specific barriers to integrating RDNs into FMP practices also included the need for bilingual RDNs, lack of space and/or difficulties finding an RDN with a desire to work with low-income populations or within rural areas. Discussion The objective of this study was to explore FMP referral practices, barriers and preferences for RDN care. To the author’s knowledge, this study is the first to specifically examine FMPs’ access to, use of, perceptions and preferences regarding RDN services. The findings from this explorative study suggest strong support and interest by FMPs for RDN patient care, limited access to RDNs on-site, preferred use (referrals) for CD and obesity focussed nutrition care. In addition, barriers to RDN services were outlined with the greatest perceived barrier the potential cost for the patient and uncertainty how to connect with (find) a local RDN. Study findings and potential practice implications for FMPs, RDNs and both family medicine and dietetic professional groups are further outlined in the subsequent section below. Over half of FMPs respondents did not have access to an RDN on-site, and of those FMPs without an on-site RDN, almost all desired a part-time or full-time RDN within their practice. Despite a reported desire for RDN services, many FMPs reported several barriers. These barriers primarily focussed on perceived cost, lack of reimbursement for RDN provided nutrition services and some cited uncertainty on how to find or connect with an RDN. These barriers present several opportunities. First, with regard to connecting with an RDN, this can be made through local dietetics groups and/or existing online databases for local credentialed RDNs. Second, nutrition reimbursement continues to improve, and it is possible that FMPs may not be aware of these new and ever evolving nutrition care billing and reimbursement opportunities (15,22). For example, bill H.R.6971 for the Medical Nutrition Therapy Act of 2020 is currently under consideration to expand care by RDNs for Medicare patients (22). The reimbursable RDN services also vary between insurers. Presently Medicare coverage includes RDN provided care for diabetes, renal disease and obesity treatment, however, specific conditions covered by Medicaid and private insurers vary by state (23–25). Medicare reimbursement for RDN services may be of particular value as RDNs can assist physicians in improving patient care and support to receive bonuses available to practices which meet targeted Medicare patient outcomes through the Quality Payment Program (23,26,27) Third, the development of interprofessional affiliations through local family medicine and dietetic practice groups to address previously outlined barriers. State and sometimes even local dietetic groups have reimbursement representatives who stay up to date with the most current billing and reimbursement information and an invitation to update FMP professional groups may be beneficial. In addition, such alliances would also afford potential interprofessional collaboration and continuing education across both professions. On-site access to RDNs by FMPs offers other important clinical benefits. For example, models of care for FMPs to treat and manage CDs, especially diabetes, include self-management, decision support with nutrition and lifestyle behaviours and care coordination with specialists such as RDNs, many of whom are also certified diabetes educators (28). Care coordination and communication between providers, particularly for management of CDs supports FMPs reported preference for an RDN to be accessible on-site within the clinic. Lastly, CDs such as diabetes have strong RDN reimbursement with RDNs already established care providers with a demonstrated track record of improving patients’ clinical outcomes for CDs (12,13,15,29–31). The current prevalence of CDs within the US warrants further support for CD focussed care models, particularly those which can support physicians in addressing underlying lifestyle and dietary risk factors (1). Of concern, the majority of FMPs surveyed in this study did not have access to an RDN to support CD management. The limited access to RDNs reported by FMPs in this study was surprising considering the majority of FMP respondents were affiliated with larger health care systems where it might be assumed resources and access would be higher than that of private and/or community-based clinics. It is possible overall on-site RDN access is even lower than reported in this study. This should be an area of continued research. Some FMPs suggested RDNs serve multiple clinics; however, other FMPs reported wanting an RDN present for ‘warm hand off’ visits as needed. Most FMPs wanted an RDN on-site either part-time or full-time, and referrals to off-site RDNs were FMP’s least preferred option. While having an RDN serve multiple clinics may address access barriers, it would not support opportunities for a ‘warm hand off’ or care coordination if RDNs were not on-site full-time. Furthermore, increased RDN engagement in primary care settings can help resolve gaps of nutrition care while fulfilling FMPs’ preferences for consistent RDN care. Innovative strategies are needed to integrate and expand RDN access and resources for FMPs and patients. Regardless of how RDNs are incorporated into primary care settings, they have a critical role to play to support physicians in achieving improved patient outcomes. While FMPs did report additional areas of interest for nutrition care overall, their focus was on the management of existing CDs or early stage CDs (e.g. pre-diabetes). The reported interest for RDN care focussing on preventative care was far more limited. This lack of preventative focus may be attributed to a health care model that historically has focussed on acute treatment versus a preventative care model. It may also be possible that the focus of FMPs on CDs is related to traditional reimbursement for these conditions and their experience with what may be perceived as a ‘traditional’ RDN scope of practice (e.g. diabetes). Many RDNs practice in specialty areas (e.g. gastrointestinal, food allergies and intolerances). The limited scope of referrals for potential areas of RDN care could be associated with limited interprofessional education and exposure to RDN provided nutrition care during medical training (32–34). It is also possible that the limited scope for referrals could be due to lack of exposure to a quality RDN, as several FMPs reported difficulty finding a RDN they desired to refer patients too. Despite potential barriers to RDN access and referrals, there is an increasing emphasis on interprofessional education across health care which may help address this potential gap. The AND, RDNs primary professional organization, strongly supports interprofessional education during medical training (35). Limitations Although this explorative study contributes valuable findings and fills existing gaps regarding interprofessional practice between FMPs and RDNs, this study is not without limitations. The sample included self-selected respondents which may increase the risk of personal bias. However, it is also possible the use of a gift card may have reduced social bias as individuals who were less interested or biased towards the topic may have elected to participate. Sampling was also limited to the Southeastern US which may reduce the generalizability of findings. This choice was made as FMPs within this area face comparable patient populations and overall socio-environmental factors as well as incentives to participate would not be available for a larger study. The sampling method also did not afford calculation of a response rate as access to list-serves per organization were limited and directors/chairs forwarded the invitation by choice. This decision was made to simplify survey distribution to target a historically difficult to reach group (physicians) (19). While there are limitations to this approach, perceptions reported in this exploratory study were consistent which potentially strengthen the findings. Lastly, to alleviate participant burden, the survey was kept brief, which limited the extensiveness of the data collected and analysed. In the future, a larger, nationally representative survey of FMP access, perceptions and referral practices and barriers may be warranted as well to further investigate RDN access and barriers. Conclusions This study identified strong FMP interest and support of RDNs with preferences for RDN services centering around CD care. The most consistent barrier reported among FMPs regarding their use of RDNs within primary care were potential cost for the patient and difficulty locating an RDN. These barriers may also present opportunities for collaboration between family medicine and dietetic professional groups. Interprofessional affiliation and collaboration would allow RDNs to update FMPs on current reimbursement potential, connect interested physicians/providers with local RDNs, as well as provide greater awareness around the scope of dietetics practices. In addition, continued efforts to support interprofessional education during medical training may also support increased recognition and integration of RDN provided nutrition care into the primary care setting. Lastly, the continued emphasis within health care on patient outcomes in combination with evidence of strong support and interest of FMPs for RDN care will likely afford continued expansion of access to RDNs in the primary care setting. Future research should also examine interprofessional practice and care models which include RDNs, current reimbursement practices and continued evaluation of the impact of RDN patient care. Declaration Funding: the study was funded by internal resources through the College of Allied Health Sciences at East Carolina University. Ethical approval: this study was approved and identified as exempt by the University and Medical Center Institutional Review Board at East Carolina University—UMCIRB 18-001863 on 9/5/2018. Conflict of interest: the first and corresponding author LRS previously held the position of a reimbursement representative with the North Carolina Academy of Nutrition and Dietetics (2018–19). LVH has no disclosures. Data availability The data underlying this article cannot be shared publicly due to protect the privacy of individuals that participated in the study. References 1. National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) . About Chronic Disease.https://www.cdc.gov/chronicdisease/about/index.htm (accessed on 11 October 2018 ; last updated 5 September 2018). 2. Buttorff C , Ruder T, Bauman M Multiple Chronic Conditions in the United States Cdc-pdf[PDF—392 KB]External . Santa Monica, CA : Rand Corp. , 2017 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 3. Center for Medicare & Medicaid Services . National Health Expenditure Data for 2016—Highlights Cdc-pdf[PDF—74 KB]External . https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet (accessed on 10 September 2020, last updated 24 March 2020). Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. Centers for Disease Control and Prevention . Adult Obesity Facts.https://www.cdc.gov/obesity/adult/causes.html (accessed on 22 October 2018 ; last updated 5 March 2018). 5. Finkelstein EA , Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer- and service-specific estimates . Health Aff (Millwood) 2009 ; 28 ( 5): w822 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Institute of Medicine (US) Committee on the Future of Primary Care ; Donaldson MS, Yordy KD, Lohr KNet al. . (eds). Primary Care: America’s Health in a New Era. Washington, DC : National Academies Press (US) , 1996 . 2, Defining Primary Care. https://www.ncbi.nlm.nih.gov/books/NBK232631/ (accessed on 20 January 2020). 7. Yarnall KS , Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003 ; 93 ( 4): 635 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Østbye T , Yarnall KS, Krause KMet al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005 ; 3 ( 3): 209 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Yarnall KS , Østbye T, Krause KMet al. Family physicians as team leaders: “time” to share the care . Prev Chronic Dis 2009 ; 6 ( 2): A59 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 10. U.S. Preventative Services Task Force . About the USPSTF. https://www.uspreventiveservicestaskforce.org/ (accessed on 10 October 2018 ). 11. US Preventive Services Task Force . Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults US Preventive Services Task Force recommendation statement . JAMA 2018 ; 320 ( 11): 1163 – 71 . Crossref Search ADS PubMed WorldCat 12. Mitchell LJ , Ball LE, Ross LJ, Barnes KA, Williams LT. Effectiveness of dietetic consultations in primary health care: a systematic review of randomized control trials . Acad Nutr Diet 2017 ; 117 ( 12): 1941 – 62 . Google Scholar Crossref Search ADS WorldCat 13. Warner MF , Miklos KE, Strowman SR, Ireland K, Pojednic RM. 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Meeting the Need for Obesity Treatment: A Toolkit for the RD/PCP Partnership. Academy of Nutrition and Dietetics , 2012 . http://www.eatrightpro.org/~/media/eatrightpro%20files/practice/patient%20care/medical%20nutrition%20therapy/meeting%20the% (accessed on 2 January 2019 ). 18. The American Academy of Family Physicians: Family Medicine Specialty. https://www.aafp.org/about/the-aafp/family-medicine-specialty.html (accessed on 17 May 2019 ). 19. Thorpe C , Ryan B, McLean SLet al. How to obtain excellent response rates when surveying physicians . Fam Pract 2009 ; 26 ( 1): 65 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 20. Elo S , Kyngäs H. The qualitative content analysis process . J Adv Nurs 2008 ; 62 ( 1): 107 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 21. Elo S , Kääriäinen M, Kanste Oet al. Qualitative content analysis: a focus on trustworthiness . SAGE Open 2014 ; 4 ( 1): 215824401452263 . Google Scholar Crossref Search ADS WorldCat 22. 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Reynolds R , Dennis S, Hasan Iet al. . A systematic review of chronic disease management interventions in primary care . BMC Fam Pract 2018 ; 19 ( 11 ), doi:10.1186/s12875-017-0692-3. Google Scholar OpenURL Placeholder Text WorldCat 29. Al-Shookri A , Khor GL, Chan YM, Loke SC, Al-Maskari M. Effectiveness of medical nutrition treatment delivered by dietitians on glycaemic outcomes and lipid profiles of Arab, Omani patients with Type 2 diabetes . Diabet Med 2012 ; 29 ( 2): 236 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Marincic PZ , Hardin A, Salazar MVet al. . Diabetes self-management education and medical nutrition therapy improve patient outcomes: a pilot study documenting the efficacy of registered dietitian nutritionist interventions through retrospective chart review . J Acad Nutr Diet 2017 ; 117 ( 8): 1254 – 64 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Briggs Early K , Stanley K. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes . J Acad Nutr Diet 2018 ; 118 ( 2): 343 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Danek RL , Berlin KL, Waite GN, Geib RW. Perceptions of nutrition education in the current medical school curriculum . Fam Med 2017 ; 49 ( 10): 803 – 6 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 33. Devries S , Willett W, Bonow RO. Nutrition education in medical school, residency training, and practice . JAMA 2019 ; 321 ( 14): 1351 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Mogre V , Stevens FCJ, Aryee PA, Amalba A, Scherpbier AJJA. Why nutrition education is inadequate in the medical curriculum: a qualitative study of students’ perspectives on barriers and strategies . BMC Med Educ 2018 ; 18 ( 1): 26 . Google Scholar Crossref Search ADS PubMed WorldCat 35. Hark LA , Deen D. Position of the Academy of Nutrition and Dietetics: interprofessional education in nutrition as an essential component of medical education . J Acad Nutr Diet 2017 ; 117 ( 7): 1104 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Family medicine physicians’ report strong support, barriers and preferences for Registered Dietitian Nutritionist care in the primary care setting

Sastre, Lauren, R; , Van Horn, Leslie T
Family Practice , Volume 38 (1) – Feb 4, 2021
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Oxford University Press
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Abstract

Abstract Background Previous studies have examined barriers (e.g. time) for Family Medicine Providers (FMPs) to provide nutrition and lifestyle counseling, however, to date no studies have examined access or interest to Registered Dietitian Nutritionist (RDN) care for patients. Objective The objective of this study was to explore FMP access, referral practices, barriers and preferences for RDN care. Methods A cross-sectional online survey, with content and face validation was conducted with Family Medicine Departments within large academic health care systems in the Southeastern United States. The main variables of interest included: FMP access, interest, current referrals and referral preferences for RDN care, barriers to referrals and overall perceptions regarding RDN care. Descriptive analysis of close-ended responses was performed with SPSS 26.0. Open-ended responses were analysed using inductive content analysis. Results Over half of the respondents (n = 151) did not have an RDN on-site (64%) yet were highly interested in integrating an RDN (94.9%), with reported preferences for full-time on-site, part-time on-site or off-site RDN care (49.1%, 39.5% and 11.4% respectively). The greatest reported barriers to RDN referrals were perceived cost for the patient (64.47%) and uncertainty how to find a local RDN (48.6%). The most consistent theme reported in the open-ended responses were concerns regarding reimbursement, e.g. ‘Insurance does not cover all of the ways I would like to use an RDN’. Conclusions FMPs report interest and value in RDN services despite multiple perceived barriers accessing RDNs care. Opportunities exist for interprofessional collaboration between dietetic and FMP professional groups to address barriers. Chronic disease, interprofessional relations, nutritionists, physicians, primary health care, referral and consultation Key Messages This study identified low overall access to but strong interest in RDN care. Physicians reported cost and uncertainty connecting to an RDN as barriers. Referral to and perceptions of RDN care centred around chronic diseases. Opportunities for interprofessional collaboration may address barriers. Introduction Half the American population have been diagnosed with a diet and lifestyle-related chronic disease (CD), such as diabetes, hypertension or heart disease (1). These CDs account for 90% of the $3.3 trillion spent on health care expenditures annually within the United States (US) (2,3). Obesity is a primary risk factor for CDs, and 39.8% of the US population were classified as obese in 2016 (4). The annual cost of obesity alone is estimated to be $147 billion (5). To address lifestyle-related obesity and related CDs, primary care has been identified as the health care setting where these preventative services, counselling, patient education and management should occur (6). Although diet and lifestyle counselling are outlined as a component of primary care, there is evidence that many physicians face many barriers to the provision of lifestyle and nutrition counselling (7–9). For example, Yarnall et al. (9) estimated that it would take 21.7 hours a day for physicians to address preventative care and health promotion as outlined by the US Preventative Services Task Force (USPSTF), in addition to acute and general medical care tasks. Recently, and possibly to alleviate this gap, the USPSTF released updated obesity management recommendations which included referring obese adults to Registered Dietitian Nutritionists (RDNs) (10,11). Referrals by physicians to qualified providers are critical to provide support in addressing the epidemic of obesity and related CDs within the US. Referral to an RDN offers physicians support and the benefits of RDN care on patients’ outcomes in this setting has been demonstrated. For example, in a systematic review examining patient outcomes associated with RDN care in primary care settings by Mitchell et al. (12), there were consistent significant improvements in patients’ weight and HbA1c levels. Diverse, low-income patients with fewer resources to support diet and lifestyle changes and greater burdens of obesity and CDs have also demonstrated impact and benefits of RDN care in the primary care setting (13,14). In addition to clinical benefits and improved patient outcomes, RDN care has demonstrated health care cost savings, leading to an increased scope of reimbursable services covered by insurers in the US (15). The Academy of Nutrition and Dietetics (AND) has promoted the role of the RDN in primary care settings through the development of several practitioner toolkits (16,17), and evidence exists of the benefits of RDN care in the primary care setting. Despite this support, studies examining physician’s access to, referral practices, barriers and preferences as well as overall interest and perceptions regarding RDN care are greatly lacking. Within primary care, Family Medicine Providers (FMPs) serve patients through all stages of life and emphasize not only the management of CDs, but also the provision of preventative care and individual counselling (18). Due to the broad scope of FMP care and patient populations served, FMP’s access, use, barriers and preferences for RDN should be investigated to identify gaps and areas for potential collaboration to support physician–RDN interprofessional collaboration to improve patient outcomes. Therefore, the objective of this study was to explore FMP referral practices, barriers and preferences for RDN care. Methods Study design This cross-sectional included a web-based survey distributed to FMPs utilizing convenience sampling from major regional and/or academic health care systems in the Southeastern US. The survey was developed specifically for this project and was content and face validated with further description in a subsequent section below. A summary of the survey distribution and targeted recruitment is provided in Figure 1. The recruitment email sent to Family Medicine Department/Programs included an overview of the study, a link for the survey, as well as a description of the incentive to encourage participation among a hard to reach clinician target audience. Respondents were invited to enter their email at the end of the survey for a five-dollar Starbucks gift card which was emailed to them. This incentive decision was based on a narrative literature review by Thorpe et al. (19) who identified preference by physicians for small, immediate ‘tokens of appreciation’ versus larger incentives. The Institutional Review Board at East Carolina University approved the study prior to all data collection. The study was identified as exempt from ethics approval and written consent was not required as the study protocol did not include collection of any personally identifiable or sensitive data. Although written consent was waived, the following statement was provided to all participants in the recruitment email to address consent ‘If you are interested in voluntarily participating in the study below please click on the following link to access the survey’. Figure 1. Open in new tabDownload slide Family medicine provider study recruitment, distribution and data collection procedures. Figure 1. Open in new tabDownload slide Family medicine provider study recruitment, distribution and data collection procedures. Survey development The initial survey draft was developed by the principal investigator (LS) who had prior experience examining medical provider perceptions and delivery of nutrition care within primary care settings. The survey validation involved three stages. The first stage included content review and feedback provided by nutrition experts (n = 17) who were identified based on clinical experience working with physicians within outpatient and/or primary care settings and/or research examining primary care delivery. Feedback was received from 65% (n = 11) of reviewers and included suggestions for re-wording, additions and additional or refined answer choices. The second stage of validation included content and face validation by physicians working in primary care. The survey was sent via email to six physician reviewers. Feedback was received by 66% (n = 4) of physician reviewers, resulted in re-wording of questions, adding or refining answer choices, plus the addition of three questions. The final stage of survey development included review of the survey by the North Carolina Academy of Family Medicine Physicians (NCAFP) board and director. No modifications to the survey were requested by NCAFP. The final survey included an 18-item survey with 17 close-ended questions and one open-ended question (Supplement A). Statistical analysis Descriptive analysis of close-ended questions was performed with SPSS software version 26.0 and included frequencies, percentages, means and standard deviations (Tables 1 and 2). Data obtained in open-ended questions were analysed utilizing inductive analysis as outlined by Elo et al. (20) in which all responses are considered versus only the use of responses which fall within predetermined categories are used. Trustworthiness was addressed through the provision of specific details for how analysis was performed as described below (21). Responses (direct quotes) from FMPs were independently reviewed by two members of the research team and were individually coded. Codes were then collapsed (categorized) for themes. Consensus was reached regarding all reported themes. For further demonstration of trustworthiness, example quotes per theme are provided in the open-ended data table (see results, Table 3). Table 1. Provider/facility descriptives from family medicine physicians in Southeastern US, April–October 2019 (n = 151) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) BP, blood pressure; FQHC, Federally Qualified Health Center; RDN, registered dietitian nutritionist.aOther included: post-surgery/healing, disease state diet/specific diet, weight management, disordered eating and pregnancy. bOther included: disease state diet, disordered eating, post-surgery healing, pregnancy, sports nutrition and well-child. Open in new tab Table 1. Provider/facility descriptives from family medicine physicians in Southeastern US, April–October 2019 (n = 151) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) Survey question . n (%) . Mean . SD . What are your credentials?  MD 131 (86.8)  DO 19 (12.6)  MD/MPH 1 (0.7) How long have you been in practice? (years) 11.9 11.0 How long have you been employed at your current practice? (years) 3.0 7.2 Which of the following best describes your practice?  Owned by or affiliated with a larger health care system 105 (69.5)  Private practice 4 (2.6)  Public Health Clinic (e.g. FQHC) 14 (9.3)  Other (e.g. Academic, Residency, Clinic) 28 (18.5) Do you have an RDN employed by your practice and/or co-located in your clinic?  Yes 54 (36.0)  No 96 (64.0) If yes, did you learn about the RDN’s services?  You sought an RDN and located her/him 12 (23.5)  RDN connected with you 16 (31.4)  Other (e.g. RDN already at practice) 23 (45.1) Do you refer patients to the RDN at your practice?  Yes 49 (94.2)  No 3 (5.8) If yes, is he or she:  Part time 13 (25.0)  Full time 36 (69.2)  Other (e.g. unsure) 3 (5.8) If you have an RDN on-site or refer to an RDN off site which of the following reasons, do you refer for? (select all that apply)  Diabetes management 122 (80.8)  Weight management 118 (78.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 63 (41.7)  Cardiovascular disease/hypertension 53 (35.1)  Renal disease 38 (25.2)  Preventative (general heath) 37 (24.5)  Other (open ended)a 15 (9.9) If you do not currently have an RDN working with your patients would you be interested in using the services of an RDN  Yes 94 (94.9)  No 5 (5.1) If yes, which of the following would you prefer:  Prefer to refer patients to an off-site RDN 13 (11.4)  Have a part-time RDN on-site (1–2 days a week) 45 (39.5)  Have full-time RDN on-site everyday 56 (49.1) Which of the following services offered by an RDN do you believe would be the most beneficial for your patients?  Weight management 128 (84.8)  Diabetes management 125 (82.8)  Cardiovascular disease/hypertension 97 (64.1)  CD specific prevention (e.g. pre-diabetes, pre-hypertension/elevated BP 96 (63.6)  Renal disease 69 (45.7)  Preventative (general heath) 84 (55.6)  Otherb 13 (8.6) BP, blood pressure; FQHC, Federally Qualified Health Center; RDN, registered dietitian nutritionist.aOther included: post-surgery/healing, disease state diet/specific diet, weight management, disordered eating and pregnancy. bOther included: disease state diet, disordered eating, post-surgery healing, pregnancy, sports nutrition and well-child. Open in new tab Table 2. Physicians barriers and interests in RDN care from family medicine practices in the United Sates Geographic Southeast, April–October 2019 (n = 151) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Open in new tab Table 2. Physicians barriers and interests in RDN care from family medicine practices in the United Sates Geographic Southeast, April–October 2019 (n = 151) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Survey question . If you currently do not refer to an RDN, which of the following describes why? . Strongly disagree . Disagree . Neutral . Agree . Strongly agree . . n (%) . n (%) . n (%) . n (%) . n (%) . Lack of patient interest/value 20 (27.8) 14 (19.4) 17 (23.6) 19 (26.4) 2 (2.8) Potential cost for patient 4 (5.5) 6 (8.2) 16 (21.9) 29 (39.7) 18 (24.7) Uncertainty regarding what services are provided by an RDN 17 (23.6) 19 (26.4) 17 (23.6) 15 (20.8) 4 (5.6) Uncertainty of benefit of RDN services to patient 25 (34.7) 18 (25.0) 11 (15.3) 15 (20.8) 3 (4.2) Uncertainty of how/who to connect with for RDN services 13 (18.1) 14 (19.4) 10 (13.9) 27 (37.5 8 (11.1) Open in new tab Table 3. Content analysis results/family medicine survey question of family medicine practices in the United States Geographic Southeast April–October 2019: is there anything else we did not ask that you believe would be useful for us to know/consider? Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Open in new tab Table 3. Content analysis results/family medicine survey question of family medicine practices in the United States Geographic Southeast April–October 2019: is there anything else we did not ask that you believe would be useful for us to know/consider? Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Themesa . Example quotes (survey responses, verbatim) . n . Insurance/cost “Cost of services not covered by insurance” n = 21 “Difficult for community health center to afford this service.” “Insurance does not pay for all the ways I would like to use an RDN” “…lack of insurance coverage - especially for Medicaid.” Service preferences “I would like group visit at the practice…” n = 11 “…I would like to include cooking classes” Finding a quality RDN “…the dietician services I refer to seem inadequate to address other issues I send patients there for, primarily obesity and weight loss…. If a dietician can’t adequately address weight loss, how can I even help the patient n = 8 The most important thing is that it’s very hard to find a GOOD RDN that takes insurance.” Sometimes I am hesitant to refer because I’ve had some patients report they felt “judged” and then are upset with me for referring” Desire an RDN on-site “…Physicians would love to have a dietician in their practice (especially me as a physician and Medical Director)” n = 5 “Having onsite would be ideal…” It would be ideal if more RDNs had “at the elbow” availability. Meaning, if I identify a patient that would benefit, they could be seen by RDN same day immediately after my appointment…” Barriers to having an RDN “…Our dream would be to have someone bilingual (English/Spanish) but such people are apparently extremely hard to find.” n = 4 “…have had an RDN on site for many years, but now work with off-site RDNs because of space…” “…easy availability for patients are the major barriers…” “Outside access is difficult in a rural area…” Physician training “I believe family physicians typically desire to share about nutrition…” n = 3 “…majority of MDs do not have a formal curriculum for nutrition in medical school. This might bias their practice and how frequently they refer out to dietitians” Not enough patient commitment “Many patients refuse to see a RDN and that is why we don’t send them. Or we do refer them and they no-show to the appointment or go once and never go back.” n = 3 “Pt commitment bit barrier” Open in new tab Results A total of 177 FMP completed the survey, of which 151 were applicable for statistical analysis. Twenty-six surveys were discarded because of lack of physician credentials (e.g. nurse practitioners, physician assistants, Pharm D, n = 19) and seven incomplete surveys. Of the final sample (n = 151) the majority (n = 105, 69.5%) worked in practices affiliated with larger health care systems and had been in practice for a mean of 11.9 years, SD 11.0 years (Table 1). Most physicians (64%) did not currently have an RDN on-site. Those without RDNs were interested in RDN care (94.9%) and expressed a preference for full-time or part-time on-site versus off-site (49.1%, 39.5% and 11.4% respectively). For those physicians with an RDN on-site, over half of those RDNs were full time (69.2%). The overwhelming majority of physicians with access to an on-site RDN, reported regular referrals (94.2%). Diabetes and weight management were the most common type of physician referral to an RDN (80.8% and 78.1%, respectively). Similarly, those without RDNs on-site were primarily interested in weight and diabetes management for referrals although a variety of services were described (84.8% and 82.8%, respectively). Perceived barriers to patient referrals for RDN services were also reported by FMPs. Uncertainty of benefit of RDN services received a wide array of responses with the greatest trend towards disagreement, with 34.7% strongly disagreeing and 25.0% disagreeing (Table 2). Other barriers showed more consistent trends of agreement or disagreement with the greatest perceived barrier to be cost for the patient (39.7% agreed, 24.7% strongly agreed that cost is a barrier to referring patients). Lack of patient interest and/or value received mixed perceptions with some strongly disagreeing with this as a barrier (27.8%), whereas others agreeing (26.4%). FMPs provided general information or perceptions in response to a final open-ended question, ‘Is there anything else we did not ask that you believe would be useful for us to know/consider?’ The most consistently initiated responses were concerns regarding insurance coverage and reimbursement barriers for RDN care (Table 3). Several FMPs also provided specific ideas of services they would like RDNs to provide, such as cooking classes and group visits. Other FMPs expressed interest in having an RDN on-site, e.g. ‘Physicians would love to have a dietitian in their practice, especially me as a physician and Medical Director’, ‘Having onsite [dietitian] would be ideal…’, and one mentioned the benefit of an on-site RDN for a ‘warm hand off’ with patients. Of concern, some voiced frustrations with finding a quality RDN due to perceived lack of knowledge and skill of the RDN and/or patients reporting a poor experience. Specific barriers to integrating RDNs into FMP practices also included the need for bilingual RDNs, lack of space and/or difficulties finding an RDN with a desire to work with low-income populations or within rural areas. Discussion The objective of this study was to explore FMP referral practices, barriers and preferences for RDN care. To the author’s knowledge, this study is the first to specifically examine FMPs’ access to, use of, perceptions and preferences regarding RDN services. The findings from this explorative study suggest strong support and interest by FMPs for RDN patient care, limited access to RDNs on-site, preferred use (referrals) for CD and obesity focussed nutrition care. In addition, barriers to RDN services were outlined with the greatest perceived barrier the potential cost for the patient and uncertainty how to connect with (find) a local RDN. Study findings and potential practice implications for FMPs, RDNs and both family medicine and dietetic professional groups are further outlined in the subsequent section below. Over half of FMPs respondents did not have access to an RDN on-site, and of those FMPs without an on-site RDN, almost all desired a part-time or full-time RDN within their practice. Despite a reported desire for RDN services, many FMPs reported several barriers. These barriers primarily focussed on perceived cost, lack of reimbursement for RDN provided nutrition services and some cited uncertainty on how to find or connect with an RDN. These barriers present several opportunities. First, with regard to connecting with an RDN, this can be made through local dietetics groups and/or existing online databases for local credentialed RDNs. Second, nutrition reimbursement continues to improve, and it is possible that FMPs may not be aware of these new and ever evolving nutrition care billing and reimbursement opportunities (15,22). For example, bill H.R.6971 for the Medical Nutrition Therapy Act of 2020 is currently under consideration to expand care by RDNs for Medicare patients (22). The reimbursable RDN services also vary between insurers. Presently Medicare coverage includes RDN provided care for diabetes, renal disease and obesity treatment, however, specific conditions covered by Medicaid and private insurers vary by state (23–25). Medicare reimbursement for RDN services may be of particular value as RDNs can assist physicians in improving patient care and support to receive bonuses available to practices which meet targeted Medicare patient outcomes through the Quality Payment Program (23,26,27) Third, the development of interprofessional affiliations through local family medicine and dietetic practice groups to address previously outlined barriers. State and sometimes even local dietetic groups have reimbursement representatives who stay up to date with the most current billing and reimbursement information and an invitation to update FMP professional groups may be beneficial. In addition, such alliances would also afford potential interprofessional collaboration and continuing education across both professions. On-site access to RDNs by FMPs offers other important clinical benefits. For example, models of care for FMPs to treat and manage CDs, especially diabetes, include self-management, decision support with nutrition and lifestyle behaviours and care coordination with specialists such as RDNs, many of whom are also certified diabetes educators (28). Care coordination and communication between providers, particularly for management of CDs supports FMPs reported preference for an RDN to be accessible on-site within the clinic. Lastly, CDs such as diabetes have strong RDN reimbursement with RDNs already established care providers with a demonstrated track record of improving patients’ clinical outcomes for CDs (12,13,15,29–31). The current prevalence of CDs within the US warrants further support for CD focussed care models, particularly those which can support physicians in addressing underlying lifestyle and dietary risk factors (1). Of concern, the majority of FMPs surveyed in this study did not have access to an RDN to support CD management. The limited access to RDNs reported by FMPs in this study was surprising considering the majority of FMP respondents were affiliated with larger health care systems where it might be assumed resources and access would be higher than that of private and/or community-based clinics. It is possible overall on-site RDN access is even lower than reported in this study. This should be an area of continued research. Some FMPs suggested RDNs serve multiple clinics; however, other FMPs reported wanting an RDN present for ‘warm hand off’ visits as needed. Most FMPs wanted an RDN on-site either part-time or full-time, and referrals to off-site RDNs were FMP’s least preferred option. While having an RDN serve multiple clinics may address access barriers, it would not support opportunities for a ‘warm hand off’ or care coordination if RDNs were not on-site full-time. Furthermore, increased RDN engagement in primary care settings can help resolve gaps of nutrition care while fulfilling FMPs’ preferences for consistent RDN care. Innovative strategies are needed to integrate and expand RDN access and resources for FMPs and patients. Regardless of how RDNs are incorporated into primary care settings, they have a critical role to play to support physicians in achieving improved patient outcomes. While FMPs did report additional areas of interest for nutrition care overall, their focus was on the management of existing CDs or early stage CDs (e.g. pre-diabetes). The reported interest for RDN care focussing on preventative care was far more limited. This lack of preventative focus may be attributed to a health care model that historically has focussed on acute treatment versus a preventative care model. It may also be possible that the focus of FMPs on CDs is related to traditional reimbursement for these conditions and their experience with what may be perceived as a ‘traditional’ RDN scope of practice (e.g. diabetes). Many RDNs practice in specialty areas (e.g. gastrointestinal, food allergies and intolerances). The limited scope of referrals for potential areas of RDN care could be associated with limited interprofessional education and exposure to RDN provided nutrition care during medical training (32–34). It is also possible that the limited scope for referrals could be due to lack of exposure to a quality RDN, as several FMPs reported difficulty finding a RDN they desired to refer patients too. Despite potential barriers to RDN access and referrals, there is an increasing emphasis on interprofessional education across health care which may help address this potential gap. The AND, RDNs primary professional organization, strongly supports interprofessional education during medical training (35). Limitations Although this explorative study contributes valuable findings and fills existing gaps regarding interprofessional practice between FMPs and RDNs, this study is not without limitations. The sample included self-selected respondents which may increase the risk of personal bias. However, it is also possible the use of a gift card may have reduced social bias as individuals who were less interested or biased towards the topic may have elected to participate. Sampling was also limited to the Southeastern US which may reduce the generalizability of findings. This choice was made as FMPs within this area face comparable patient populations and overall socio-environmental factors as well as incentives to participate would not be available for a larger study. The sampling method also did not afford calculation of a response rate as access to list-serves per organization were limited and directors/chairs forwarded the invitation by choice. This decision was made to simplify survey distribution to target a historically difficult to reach group (physicians) (19). While there are limitations to this approach, perceptions reported in this exploratory study were consistent which potentially strengthen the findings. Lastly, to alleviate participant burden, the survey was kept brief, which limited the extensiveness of the data collected and analysed. In the future, a larger, nationally representative survey of FMP access, perceptions and referral practices and barriers may be warranted as well to further investigate RDN access and barriers. Conclusions This study identified strong FMP interest and support of RDNs with preferences for RDN services centering around CD care. The most consistent barrier reported among FMPs regarding their use of RDNs within primary care were potential cost for the patient and difficulty locating an RDN. These barriers may also present opportunities for collaboration between family medicine and dietetic professional groups. Interprofessional affiliation and collaboration would allow RDNs to update FMPs on current reimbursement potential, connect interested physicians/providers with local RDNs, as well as provide greater awareness around the scope of dietetics practices. In addition, continued efforts to support interprofessional education during medical training may also support increased recognition and integration of RDN provided nutrition care into the primary care setting. Lastly, the continued emphasis within health care on patient outcomes in combination with evidence of strong support and interest of FMPs for RDN care will likely afford continued expansion of access to RDNs in the primary care setting. 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Family Practice – Oxford University Press

Published: Feb 4, 2021

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