- Email: [email protected]
Authors’ Response
practice applications
LETTERS TO THE EDITOR
Is the Only Outcome that Counts Related to Registered Dietitians’ Recommendations? To the Editor: We read with interest Braga and colleagues’ retrospective chart review investigating the impact of registered dietitians’ (RDs’) recommendations in long-term acute care (1). The authors are to be commended for taking on a difficult-to-quantify subject. The current interest in defining and measuring advanced dietetic practice makes clinical research such as this imperative to identifying a tiered categorization of dietetics practice. However, their study has several flaws that cannot be overlooked and may lead to confusion and misinformation. Study methods are flawed in that there is inadequate definition of malnutrition. The authors state that patients were included if there was a “documented diagnosis of malnutrition” without defining what that entailed. There was no power analysis done; the authors do not disclose why they decided to stop at 50 charts in each arm of the study. To further confuse the issue, the authors reviewed 272 charts, of which the RDs recommended changes in 251. There was no explanation for the selection of the medical records included in the final analysis. Did the authors simply choose the records that would best support their hypothesis? Methods for reporting nutrient intake also suffered from incomplete reporting. There is no explanation of the methods the RDs used to determine energy and protein requirements, other than the RDs “rounded up.” A significant change in albumin levels is reported without a comparison of baseline levels. Were there differences in albumin at the start as well as at the conclusion of the review? There is also a threat to validity in that without reporting on severity of illness and potential inflammatory processes, serum albumin levels cannot be used to determine nutrition status (2). The connection between
1030
length of stay and albumin levels has been reported (3); therefore, the outcomes reported in this study may be totally disconnected from the enteral nutrition therapy. It is possible that the improved serum albumin denotes recovery and, hence, patients were getting better and were able to be discharged earlier. Without adequate reporting or analysis, the authors err in concluding that the only outcome that counts here, length of stay, is related to RDs’ recommendations. Could this be related instead to the authors’ bias and errors in study design? We are certainly in support of enhanced responsibilities for advancedlevel RDs in caring for patients receiving complex nutrition therapies. Given the current lack of clear definition of advanced practice in dietetics, it is imperative that well-designed clinical studies in this area become a priority of the profession of dietetics. Pamela Charney, PhD, RD Author and Consultant Seattle, WA M. Patricia Fuhrman, MS, RD, FADA Nutrition Support Specialist St Louis, MO References 1. Braga JM, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc. 2006;106: 281-284. 2. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc. 2004;104:1258-1264. 3. McClave SA, Mitoraj TE, Thielmeier KA, Greenburg RA. Differentiating subtypes (hypoalbuminemic vs marasmic) of protein-calorie malnutrition: Incidence and clinical significance in a university hospital setting. J Parenter Enteral Nutr. 1992;16:337-342.
Journal of the AMERICAN DIETETIC ASSOCIATION
doi: 10.1016/j.jada.2006.05.261
Authors’ Response: The authors appreciate the comments of Charney and Fuhrman and agree wholeheartedly with their concluding statement: It is imperative that well-designed clinical studies in this area become a priority of the profession of dietetics. Our research project grew out of frustration with physicians’ lack of response to registered dietitians’ (RDs’) recommendations for enteral feedings, a problem that unfortunately is not limited to our facility. Perhaps more research that documents the effectiveness of RDs in the provision of nutrition support would increase the likelihood that more physicians would fully utilize RD services. The purpose of our study was to show that RDs’ recommendations, if implemented, could improve patient outcomes. We recognize that our study was small in scale and had limitations. However, we believe it can be used as a pilot or springboard for future research in this area. That being said, we wish to clarify several points. We reviewed 272 medical charts in order to find 50 where RDs’ recommendations were taken and 50 where RDs’ recommendations were not taken. The review included some in which the RD did not recommend changes in tube feedings. We reviewed the charts in reverse chronological order and used for our comparison the first 50 that met the criteria for each arm of the study, thus eliminating the potential bias suggested by Charney and Fuhrman. Not having any data on which to do a power analysis, we decided that 50 in each group was reasonable. Since we did find significant differences there was no reason to go back and determine the minimum number of subjects required to detect significant differences. Although patients may or may not have had an official diagnosis of malnutrition documented in their medical records, patients were included who fit one of the following criteria: ⬍90% of ideal body weight and serum albumin ⬍3.0 g/dL, or body mass index ⬍21 and serum albumin ⬍3.0 g/dL. There were no differences in
© 2006 by the American Dietetic Association
LETTERS TO THE EDITOR age, sex, diagnoses, type of tube feeding, weight, or serum albumin between the two groups at baseline. It is true that serum albumin may not be the best indicator of nutritional status; however, it has been correlated with recovery. We reported changes in weight and albumin, as well as length of stay as markers for improved recovery, which we believe can be attributed to improved nutritional care when RDs’ recommendations were implemented, regardless of the methods used to determine protein and energy requirements. It is true that this would have been a stronger study with a larger sample and with additional outcome measures. However, we believe that the results do contribute to the overall knowledge base. Our profession desperately needs more studies that will document the effectiveness of RDs, and we encourage dietetics practitioners to design and implement outcomes based research studies as part of their jobs. The more research we have that documents the importance of the RD in improved patient outcomes, the more our profession can advance. Alice E. Hunt, PhD, RD Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA Janet F. Pope, PhD, RD Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA
ARCHIVED JOURNAL ARTICLES The Journal currently has archived articles back to 1993. Full-text and PDF articles are available to ADA members and Journal subscribers for viewing and for download. To view archived articles and the current issue of the Journal online, go to www.adajournal.org.
Jennifer Braga, MS, RD Clinical Dietitian Doctor’s Hospital Shreveport, LA Elaine Molaison, PhD, RD Assistant Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA doi: 10.1016/j.jada.2006.05.293
July 2006 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1031
LETTERS TO THE EDITOR
Is the Only Outcome that Counts Related to Registered Dietitians’ Recommendations? To the Editor: We read with interest Braga and colleagues’ retrospective chart review investigating the impact of registered dietitians’ (RDs’) recommendations in long-term acute care (1). The authors are to be commended for taking on a difficult-to-quantify subject. The current interest in defining and measuring advanced dietetic practice makes clinical research such as this imperative to identifying a tiered categorization of dietetics practice. However, their study has several flaws that cannot be overlooked and may lead to confusion and misinformation. Study methods are flawed in that there is inadequate definition of malnutrition. The authors state that patients were included if there was a “documented diagnosis of malnutrition” without defining what that entailed. There was no power analysis done; the authors do not disclose why they decided to stop at 50 charts in each arm of the study. To further confuse the issue, the authors reviewed 272 charts, of which the RDs recommended changes in 251. There was no explanation for the selection of the medical records included in the final analysis. Did the authors simply choose the records that would best support their hypothesis? Methods for reporting nutrient intake also suffered from incomplete reporting. There is no explanation of the methods the RDs used to determine energy and protein requirements, other than the RDs “rounded up.” A significant change in albumin levels is reported without a comparison of baseline levels. Were there differences in albumin at the start as well as at the conclusion of the review? There is also a threat to validity in that without reporting on severity of illness and potential inflammatory processes, serum albumin levels cannot be used to determine nutrition status (2). The connection between
1030
length of stay and albumin levels has been reported (3); therefore, the outcomes reported in this study may be totally disconnected from the enteral nutrition therapy. It is possible that the improved serum albumin denotes recovery and, hence, patients were getting better and were able to be discharged earlier. Without adequate reporting or analysis, the authors err in concluding that the only outcome that counts here, length of stay, is related to RDs’ recommendations. Could this be related instead to the authors’ bias and errors in study design? We are certainly in support of enhanced responsibilities for advancedlevel RDs in caring for patients receiving complex nutrition therapies. Given the current lack of clear definition of advanced practice in dietetics, it is imperative that well-designed clinical studies in this area become a priority of the profession of dietetics. Pamela Charney, PhD, RD Author and Consultant Seattle, WA M. Patricia Fuhrman, MS, RD, FADA Nutrition Support Specialist St Louis, MO References 1. Braga JM, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc. 2006;106: 281-284. 2. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc. 2004;104:1258-1264. 3. McClave SA, Mitoraj TE, Thielmeier KA, Greenburg RA. Differentiating subtypes (hypoalbuminemic vs marasmic) of protein-calorie malnutrition: Incidence and clinical significance in a university hospital setting. J Parenter Enteral Nutr. 1992;16:337-342.
Journal of the AMERICAN DIETETIC ASSOCIATION
doi: 10.1016/j.jada.2006.05.261
Authors’ Response: The authors appreciate the comments of Charney and Fuhrman and agree wholeheartedly with their concluding statement: It is imperative that well-designed clinical studies in this area become a priority of the profession of dietetics. Our research project grew out of frustration with physicians’ lack of response to registered dietitians’ (RDs’) recommendations for enteral feedings, a problem that unfortunately is not limited to our facility. Perhaps more research that documents the effectiveness of RDs in the provision of nutrition support would increase the likelihood that more physicians would fully utilize RD services. The purpose of our study was to show that RDs’ recommendations, if implemented, could improve patient outcomes. We recognize that our study was small in scale and had limitations. However, we believe it can be used as a pilot or springboard for future research in this area. That being said, we wish to clarify several points. We reviewed 272 medical charts in order to find 50 where RDs’ recommendations were taken and 50 where RDs’ recommendations were not taken. The review included some in which the RD did not recommend changes in tube feedings. We reviewed the charts in reverse chronological order and used for our comparison the first 50 that met the criteria for each arm of the study, thus eliminating the potential bias suggested by Charney and Fuhrman. Not having any data on which to do a power analysis, we decided that 50 in each group was reasonable. Since we did find significant differences there was no reason to go back and determine the minimum number of subjects required to detect significant differences. Although patients may or may not have had an official diagnosis of malnutrition documented in their medical records, patients were included who fit one of the following criteria: ⬍90% of ideal body weight and serum albumin ⬍3.0 g/dL, or body mass index ⬍21 and serum albumin ⬍3.0 g/dL. There were no differences in
© 2006 by the American Dietetic Association
LETTERS TO THE EDITOR age, sex, diagnoses, type of tube feeding, weight, or serum albumin between the two groups at baseline. It is true that serum albumin may not be the best indicator of nutritional status; however, it has been correlated with recovery. We reported changes in weight and albumin, as well as length of stay as markers for improved recovery, which we believe can be attributed to improved nutritional care when RDs’ recommendations were implemented, regardless of the methods used to determine protein and energy requirements. It is true that this would have been a stronger study with a larger sample and with additional outcome measures. However, we believe that the results do contribute to the overall knowledge base. Our profession desperately needs more studies that will document the effectiveness of RDs, and we encourage dietetics practitioners to design and implement outcomes based research studies as part of their jobs. The more research we have that documents the importance of the RD in improved patient outcomes, the more our profession can advance. Alice E. Hunt, PhD, RD Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA Janet F. Pope, PhD, RD Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA
ARCHIVED JOURNAL ARTICLES The Journal currently has archived articles back to 1993. Full-text and PDF articles are available to ADA members and Journal subscribers for viewing and for download. To view archived articles and the current issue of the Journal online, go to www.adajournal.org.
Jennifer Braga, MS, RD Clinical Dietitian Doctor’s Hospital Shreveport, LA Elaine Molaison, PhD, RD Assistant Professor of Nutrition and Dietetics Louisiana Tech University Ruston, LA doi: 10.1016/j.jada.2006.05.293
July 2006 ● Journal of the AMERICAN DIETETIC ASSOCIATION
1031