Physicians' implementation of dietitians' recommendations: a study of the effectiveness of dietitians

The status of clinical nutrition in hospitals of Guilan province, Iran - A mixed-method study

Introduction

Background: nutritional therapy has an important role in the development of medical care services, and quantitative and qualitative assessments of the status of clinical nutrition in hospitals is crucial. This study aimed to explore the current status of clinical nutrition in hospitals of Guilan province, Iran. Methods: this quantitative-qualitative (mixed method) study was performed on public hospitals in Guilan province, Iran (n = 26). The required information was collected by visiting the hospitals and interviewing with hospital dietitians. The data collection tool had two quantitative and qualitative subscales. The quantitative subscale included a 21-item checklist containing information about the referral system, cooperation of hospital staff in clinical nutrition, clinical nutrition staff status, enteral nutrition, and parenteral nutrition. Results: in more than 55 % of hospitals the patients were not adequately referred to a dietitian. In about 31.2 % of hospitals, cooperation of other departments in the field of clinical nutrition was insufficient. In 37 % of hospitals with intensive care unit (ICU), enteral nutrition was not provided properly. Only 27 % of the hospital properly provided parenteral nutrition for their patients. The most important problems mentioned by hospital dietitians included noncompliance of the food services employers with recommended diets, insufficient number of hospital dietitians, and lack of per case payment method for dietitians. Coverage of diet services by health insurance was the most common suggestion of dietitians to promote diet therapy in public hospitals. Conclusion: the situation of providing nutritional services to patients in public hospitals is not favorable in terms of quantity and quality in Guilan province, Iran. Designing the necessary policies and reorient the clinical nutrition system in hospitals to promote patients' health and accelerate patient recovery is warranted.

The Long-Term Consumption of Oats in Celiac Disease Patients Is Safe: A Large Cross-Sectional Study

A strict gluten-free diet (GFD) can be diversified by non-contaminated oats, but there is a shortage of long-term studies concerning its safety. We compared long-term treatment outcomes and factors associated with the introduction of oats between celiac patients on a GFD with or without oats. Eight hundred sixty-nine previously diagnosed celiac patients were interviewed. The validated Gastrointestinal Symptom Rating Scale (GSRS), Psychological General Well-Being (PGWB), and Short-Form 36 Health Survey (SF-36) questionnaires were used to assess symptoms and quality of life, serological tests were performed, and results of histology were confirmed from patient records. We found the median duration of GFD to be 10 years and 82% using oats. Factors predicting the consumption of oats were diagnosis after the year 2000, advice from a dietitian, detection by screening, and mild clinical presentation. Oat consumers and non-consumers did not differ in dietary adherence (96.5% vs. 97.4%, p = 0.746), the prevalence of symptoms (22.9% vs. 22.5%, p = 0.931), positivity for endomysial antibodies (8.8% vs. 6.0%, p = 0.237), histological recovery after one year (63.1% vs. 60.0%, p = 0.773), malignancy (4.8% vs. 3.3%, p = 0.420), osteoporosis/osteopenia (9.2% vs. 11.0%, p = 0.489), or fractures (26.9% vs. 27.9%, p = 0.791). The oat consumers had better SF-36 physical role limitations and general health scores. Based on our results, the long-term consumption of oats in celiac disease patients is safe and may improve quality of life.

Factors Underlying Variation in Receipt of Physician Advice on Diet and Exercise: Applications of the Behavioral Model of Health Care Utilization

Purpose.

To identify factors associated with receipt of physician advice on diet and exercise, including patient sociodemographic characteristics, health-related needs, and health care access, using Andersen's model of health care utilization.

Design.

A cross-sectional analysis was performed using data from the 2000 National Health Interview Survey (NHIS).

Setting.

NHIS data were collected through personal household interviews by Census interviewers. The overall response rate for the 2000 NHIS adult sample was 82.6%.

Subjects.

Subjects were a representative sample of the American civilian, noninstitutionalized population aged 18 and older. After eliminating missing data and respondents who reported they did not see a doctor in the past 12 months, sample sizes for physician advice on diet and exercise were n = 26,255 and n = 26,158, respectively.

Measures.

Using the 2000 NHIS, the prevalence of receipt of physician advice on diet and exercise was assessed. Multiple logistic regression analyses were performed to examine the associations between receipt of physician advice on diet and exercise and potential predictors, adjusting for all covariates.

Results.

By self-report, 21.3% and 24.5% of respondents received physician advice on diet and exercise, respectively. Being middle-aged (adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI], 1.0–1.29 for diet; AOR = 1.55, 95% CI = 1.33–1.79 for exercise) and having a baccalaureate degree or higher (AOR = 1.78, 95% CI = 1.52–2.08 for diet; AOR = 1.75, 95% CI = 1.47–2.07) were associated with a higher likelihood of receiving physician advice on diet and exercise. African-Americans (AOR = .78, 95% CI = .67–.92) and foreign-born immigrants (AOR = .57, 95% CI = .38–.86) were less likely to receive physician advice on exercise. The prevalence of physician advice was higher for persons who chose hospital outpatient departments as a usual source for care (AOR = 2.36, 95% CI = 1.66–3.36 for diet; AOR = 2.39, 95% CI = 1.68–3.4 for exercise) than for adults with other types of usual care sites. Poorer self-rated health status (AOR = 5.2, 95% CI = 4.12–6.57 for diet; AOR = 2.63, 95% CI = 2.04–3.38 for exercise) and obesity (AOR = 2.32, 95% CI = 2.02–2.66 for diet; AOR = 3.01, 95% CI = 2.46–3.69 for exercise) was positively associated with the likelihood of receiving physician advice on diet and exercise.

Conclusions.

Effective strategies to increase receipt of physician advice should include efforts to improve access to regular source of care and patient-physician communication. Sociodemographic factors remain independent and important predictors of who obtains such advice.

Interdisciplinary Discrepancies Between Parenteral Nutrition Macronutrient Prescribing and Recommendations: Is Body Mass Index a Factor?

BACKGROUND

Formal nutrition training in medical schools and residencies is lacking and needed. Registered dietitians (RDs) are formally trained in nutrition support and considered experts in the nutrition field. Our purpose was to examine prescribing and recommending discrepancies of parenteral nutrition macronutrients between medical residents (MRs) and RDs and compare results with the ASPEN clinical care guidelines. We also looked at discrepancies among obese patients, due to their increased risk of mortality.

MATERIALS AND METHODS

The primary end point of this retrospective review was discrepancies in nonprotein calories (NPCs) and grams of protein (PRO) between MRs and RDs. The secondary end point was discrepancies in NPCs and PRO between MRs and RDs among patients stratified by body mass index category.

RESULTS

MRs prescribed 300 NPCs more versus RDs ( P < .001). When compared with RDs, MRs prescribed fewer NPCs for underweight patients and more for obese patients ( P < .001). The same analysis found that the PRO discrepancies significantly varied by body mass index classification as well ( P = .022). When these results were compared with the ASPEN clinical care guidelines, RDs adhered closer to the guidelines than did MRs in terms of permissive underfeeding of obese patients.

CONCLUSION

It is widely accepted that MRs are in need of increased formal training, and the results of our study confirm this need and suggest a short-term solution of increasing order-writing privileges for the RD. RDs with this privilege may adhere more closely to clinical care guidelines and therefore increase patient safety.

Nutrition reconciliation and nutrition prophylaxis: toward total health

Malnutrition by definition may be an abnormality in either under- or overnutrition. Nutrition reconciliation means that all patients have their nutritional status reconciled on admission to and discharge from the hospital. Nutrition reconciliation is defined as the process of maximizing health by helping align an individual's current diet to the diet prescribed for him or her by the health care team. Nutrition prophylaxis is a proactive intervention to prevent a medical complication.

Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition

The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.

A systematized interdisciplinary nutritional care plan results in improved clinical outcomes

OBJECTIVE

This study investigated identification and treatment of patients at-risk for malnutrition and extended inpatient length of stay.

DESIGN

Data were collected retrospectively from the medical records for a period of 6 months. The records were reviewed for (1) adherence to RD recommendation, (2) decreasing serum albumin during hospital stay, (3) length of hospital stay, (4) readmission within 30 days, (5) age, (6) gender, (7) past medical history, (8) primary and secondary diagnoses, (9) the presence or absence of a diet order and (10) medications.

SUBJECTS AND PARTICIPANTS

Medical records were reviewed for diagnoses associated with nutrition-related complications. Patient's records were excluded for length of stay less than 4 days, or in-hospital death.

RESULTS

The mean LOS was 10 days shorter when the advice was followed (p=0.0074).

CONCLUSIONS

Patients at high nutritional risk have a shorter LOS and have fewer complications when the RD advice is followed.

Implementation of Dietitian Recommendations for Enteral Nutrition Results in Improved Outcomes

A primary role of the registered dietitian (RD) is to assess nutritional needs of patients in states of physiological stress and illness and to recommend changes to diet and tube feedings when warranted. However, implementation of changes is dependent upon the physician accepting the recommendations of the RD. This study evaluated outcomes of two groups of enterally fed patients in a long-term acute-care facility in northwest Louisiana: (a) those for whom the physician accepted RD recommendations; and (b) those for whom the physician did not accept RD recommendations. Data showed that physician-prescribed enteral formulas provided 10.0% less kilocalories and 7.8% less protein than the RD-assessed needs. t tests showed that when RD recommendations were implemented, patients had a significantly shorter length of stay (28.5+/-1.8 vs 30.5+/-4.8 days, P<0.05), as well as significantly improved albumin (0.13+/-0.17 vs -0.44+/-0.21 g/dL [1.3+/-1.7 vs -4.4+/-2.1 g/L], P<0.05) and weight gains (0.51+/-0.1 vs -0.42+/-0.2%, P<0.05) when compared to those who continued with physician's orders. These data suggest that if RDs had the authority to write nutrition orders and provide early nutrition intervention, patient care would improve.

Communication between family physicians and registered dietitians in the outpatient setting

OBJECTIVE

To elicit how registered dietitians and family physicians communicate in the outpatient setting.

DESIGN

A descriptive pilot study using two mailed surveys was conducted to elicit aspects of outpatient communication between registered dietitians and family physicians. A sample of nutrition correspondence from registered dietitians to family physicians was also requested.

SUBJECTS

Surveys were distributed to 504 licensed dietitians and 626 family physicians.

STATISTICAL ANALYSES

Descriptive statistics were used to analyze survey results.

RESULTS

Responses were received from 389 registered dietitians (77% return rate) and 235 family physicians (37.5% return rate). We received 104 sample notes of correspondence with physicians from dietitians. Among dietitians, 80% reported that they always assess a patient's lifestyle and educational level before choosing an educational approach, and 69% send the nutrition treatment plan to the referring family physician. Among family physicians, 49% often or always find the communications they receive from registered dietitians to be helpful. However, 41% of family physicians reported that they rarely receive detailed nutrition assessments or recommendations about the referred patient from the dietitian, and 54% of all family physicians surveyed often think that this lack of feedback compromises patient care.

APPLICATIONS/CONCLUSION

Dietitians can improve communications with family physicians by standardizing the format and focus of nutrition correspondence and assuring that the referring family physician receives the patient's nutrition care plan. These simple changes would close a very important communication loop, forge stronger partnerships between dietitians and family physicians, and potentially improve patient outcomes.

Nutrient Intake Report: a coordination of patient dietary assessment between physicians and registered dietitians

The Nutrient Intake Report (NIR) is based on a 7-day dietary recall questionnaire used previously in research for dietary assessment and adapted for clinical use. Used to provide information and counseling as part of total patient care, the NIR acts as a cornerstone for dietary education and interaction between physician, registered dietitian, and patient. The NIR is ordered by physicians or registered dietitians, scanned and assessed by a registered dietitian, and incorporated into the laboratory section of the medical record. It documents the patient's dietary intake in the context of his or her diagnosis and general health status. The NIR also opens a dialogue between physicians and registered dietitians. Incorporation of the NIR into the medical record makes the work of the registered dietitian available to other health practitioners, which is welcome in an era when licensing and reimbursement are contingent on systematic documentation of dietary assessment and its role in patient care.

Nephrologists' and internal medicine physicians' expectations of renal dietitians and general clinical dietitians

OBJECTIVE

To document and compare nephrologists' and internal medicine physicians' expectations of renal dietitians and general clinical dietitians.

DESIGN

Subjects completed a mailed survey. Respondents provided demographic information and used a 5-point Likert scale to note whether each of 14 job functions was appropriate for general clinical dietitians, renal dietitians, or both.

SUBJECTS

Five hundred forty-one physicians registered with the Ohio State Medical Board (OSMB) were surveyed. Within this group were 283 nephrologists (the population of nephrologists registered with the OSMB) and 258 internal medicine physicians (selected randomly by the OSMB). A total of 133 physicians (25%) returned the survey; 119 surveys were usable: 70 from nephrologists and 49 from internists.

STATISTICAL ANALYSES PERFORMED

A composite variable was created by coding and summing physicians' responses regarding dietitian job functions. This variable was averaged for both physician categories. A t test was conducted to compare composite variable results between the two physician groups.

RESULTS

At least 50% of nephrologists and internists agreed that both types of dietitians should conduct nutrition assessments, determine patients' energy needs, evaluate medication-nutrient interactions, recommend diet and tube-feeding orders, instruct patients about physician-ordered diets, and teach nutrition concepts to hospital interns. Few physicians agreed that either type of dietitian should order diets, tube feedings, or diet instructions.

APPLICATIONS/CONCLUSIONS

Clinical dietitians can educate physicians about dietitians roles informally in their institutions and formally by supporting programs like The American Dietetic Association Physician Nutrition Education Program. In addition, dietetics educators can hone their students' communication and problem-solving skills to promote positive physician-dietitian interaction.

Physicians prefer goal-oriented note format more than three to one over other outcome-focused documentation

To assess preference for outcome-focused nutrition notes, two note formats were selected from the literature and tested against a modified, goal-oriented format. Focus charting and intervention, evaluation, and revision (IER) formats were compared with a charting-by-exception style that was modified to include goals and reassessment of risk. Notes were handwritten in each format and contained the same information. Physicians were asked to choose their preference and explain why that format was selected. Initially, focus charting was tested against the goal-oriented format. The more popular of the two was then tested against the IER format. Nineteen physicians were surveyed by a registered dietitian for each comparison. Physicians preferred the goal-oriented format over focus charting and IER formats 9:1 and 3:1, respectively. In the first survey, physicians preferred the goal-oriented format because the plan was clearly stated, thereby rendering the note easier to understand. The goal-oriented format was preferred in the second survey because the note was considered to be concise and easy to read and contained expected outcomes. Physicians want short communication that includes easily identifiable goals and plans. We recommend that experienced dietitians use the goal-oriented format developed for this study, and preferred by physicians, for follow-up nutrition notes.

Computerized patient record: are we prepared for our future practice?

OBJECTIVE

To survey members of The American Dietetic Association (ADA) regarding care documentation systems, computerization of patient care records, and factors to be considered in developing a documentation system compatible with a computer-based patient record.

DESIGN

The survey instrument was developed in conjunction with a survey consultant/statistician, then mailed to the study sample.

SUBJECTS/SETTING

The sample of 500 was drawn from three ADA dietetic practice groups expected to include a high percentage of clinical practitioners.

STATISTICAL ANALYSIS PERFORMED

Basic frequency displays were used on all questionnaire items. Pearson correlation coefficients were used among numeric variables, and oneway analysis of variance was used for categoric variables with quantitative variables.

RESULTS

A total of 171 usable surveys were returned (34%), primarily from dietitians working in an acute-care inpatient environment. The SOAP format (subjective, objective, assessment, and plan) was used by 60% of respondents to document nutrition assessments, although a number of other documentation formats were reported. Most commonly used data in nutrition decision making were medical diagnosis, diet order, anthropometric data, and laboratory values. Most commonly used outcomes measures included laboratory values, tolerance of the nutrition regimen, weight changes, and intake changes. Only 15% of respondents reported that they currently used a computerized patient record. Ninety-three percent of respondents favored standardized nutrition diagnoses, and 95% believed standardized nutrition interventions would prove useful.

APPLICATIONS/CONCLUSIONS

We recommend that dietitians evaluate, standardize, and streamline their documentation to prepare for implementation of computerized systems. The diagnoses and interventions presented in this study could be a starting point.

Positive association between dietetics recommendations and achievement of enteral nutrition outcomes of care

OBJECTIVE

To identify planned dietetics outcomes of care, dietitians activities performed an recommendations made, and outcome achievement and its relationship to recommendations followed.

DESIGN

A multisite, single-group prospective pilot study was conducted to describe the care provided by dietitians to patients receiving enteral nutrition care.

SUBJECTS/SETTING

Participants were 172 patients (16 of whom died during hospitalization) receiving at least 75% of nutrient requirements from enteral nutrition products. Subjects were from six acute-care facilities and one rehabilitation facility in the Chicago metropolitan area.

MAIN OUTCOME MEASURES

Dietitians identified planned outcomes of care to be accomplished and documented activities performed during the provision of care. Data were collected to measure outcome achievement and to determine whether dietitians' recommendations were followed.

STATISTICAL ANALYSES PERFORMED

Descriptive data are reported as frequencies or means +/- standard error. Odds ratios were constructed to estimate the association between dietitians' enteral care recommendations and the achievement of planned outcomes of care.

RESULTS

Whether or not enteral nutrition outcomes of care were achieved was positively associated with dietitians' recommendations. The odds of patients' achieving the recommended energy intake goal (P < .001) or increasing (P < .01) or maintaining (P < .04) visceral protein stores were at least four times greater when dietitians' recommendations were followed than when they were not. In addition, dietetics activities performed at the local level were similar to established practices.

APPLICATIONS

Dietitians can identify and measure outcomes of dietetics-related care that demonstrate positive contributions to the interdisciplinary enteral nutrition care process.

Professional roles of dietitians: do dietitians and physicians agree?

In some quarters, dietitians and physicians do not agree on a role for dietetic practitioners. Dietitians seem to be more highly regarded, and their counsel is sought and advice heeded when both health professionals work on developing collegial relationships. Education matters: a course in nutrition for physicians-to-be and more depth in the sciences for dietetic students are major factors in establishing partnerships in patient care.

Position of the American Dietetic Association: nutrition--an essential of medical education

The public is increasingly nutrition conscious and actively seeks reliable sources of nutrition education. Physicians with appropriate training in nutrition can and should be a powerful force in providing accurate nutrition information and quality health care. As physician educators, dietetics professionals can facilitate this outcome. Appropriate use of nutrition resources and professionals will efficiently and effectively maintain or improve the nutritional status of the public and, ultimately, the health of our nation.