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. 2017 Jun 13;2(4):e029.
doi: 10.1097/pq9.0000000000000029. eCollection 2017 Jul-Aug.

Application of Conjoint Analysis to Improve Reliability of Dietician Consultation in Pediatric Celiac Disease

Sakil Kulkarni  1 , Kim Liss  1 , Charles M Samson  1
Affiliations

Application of Conjoint Analysis to Improve Reliability of Dietician Consultation in Pediatric Celiac Disease

Sakil Kulkarni et al. Pediatr Qual Saf. .

Abstract

Introduction: Celiac disease (CD) management involves lifelong adherence to a gluten-free diet, making the dietician a key member in CD care. However, our institution lacked a standardized process for dietary consultation in newly diagnosed CD.

Methods: To understand provider CD care preferences, a 24-1 fractional factorial conjoint analysis was performed. Attributes studied (2 levels each) included type of initial follow-up gastroenterology (GI) provider, interval from diagnosis to follow-up, concurrence of initial dietary consultation with gastroenterology visit, and on-going follow-up GI provider. CD care was standardized in July 2014 to facilitate concurrent visits with the clinician and dietician during the same clinical session. Changes to mean time of dietary consultation and reliability of dietary consultation were monitored using an individual-control and G-control chart, respectively. Standard control chart rules were followed.

Results: Conjoint analysis identified shorter time to initial follow-up visit and concurrent GI/dietician visits as more important attributes in newly diagnosed CD subjects' care. Types of follow-up provider during first or subsequent visits were identified as less important attributes. After initiation of a standardized follow-up process, a special cause was identified in December 2015 with a decrease in the mean time to dietary consultation from 30 to 20 days. In addition, standardized follow-up resulted in a more reliable process as evident by a special cause on the G-control chart in February 2015.

Conclusion: Conjoint analysis identified attributes thought to be important in CD follow-up care. After redesign of our care process, a decrease in time to dietary consultation with improved reliability was observed.

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Figures

Fig. 1.
Fig. 1.
Response plots showing mean rank orders for the 4 attributes (1 = most ideal, 8 = least ideal) at 2 levels: timing of dietician consultation (concurrent with GI follow-up versus separate), timing of initial follow-up (within 1 week of diagnosis versus 4 weeks of diagnosis), initial follow-up provider (primary GI provider versus celiac-specific provider), and subsequent follow-up provider (primary GI provider versus celiac-specific provider).
Fig. 2.
Fig. 2.
Dot diagram showing higher effect size for concurrent dietician consultation (D, effect size 2.56) and the timing of the visit at 1 week after diagnosis (T, effect size 2.59). Attributes with lower effect sizes were the type of follow-up provider during initial follow-up visit (P, effect size 0.5) or type of follow-up provider at subsequent follow-up visits (F, effect size 0.5). There were no identified interactions between the different variables tested (points X1, X2, and X3).
Fig. 3.
Fig. 3.
Mean rank order cube showing interactions between 3 attributes: initial follow-up provider [primary GI provider (PP) versus celiac-specific provider (CP)], timing of dietician consultation [concurrent with GI follow-up (C) versus separate (S)], and timing of visit (1 week versus 4 weeks after establishing diagnosis of celiac disease).
Fig. 4.
Fig. 4.
Individual statistical process control chart showing days from celiac disease diagnosis to evaluation by a dietician. Baseline centerline was determined by the 20 data points before the process change. Two special causes were identified on the run chart: (1) a special cause was noted on December 4, 2014 due to a point above the upper control limit (demonstrated by green-circle), (2) a special cause starting on December 8, 2014 due to 8 consecutive points being below the centerline (demonstrated by red-circle), which resulted in a change in the centerline. The phase 2 centerline was determined using all data points on and after December 8, 2014.
Fig. 5.
Fig. 5.
G-statistical process chart showing the number of consecutive newly diagnosed celiac disease subjects before a subject was never evaluated by a dietician at our institution.
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