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Renal Dietitians' Perceptions of the Value of Subjective Global Assessment: A Mixed Methods Study
ORIGINAL RESEARCH
Renal Dietitians’ Perceptions of the Value of Subjective Global Assessment: A Mixed Methods Study Shelly Messenger, MRSc, RD,* Lesley Bainbridge, BSR(PT), MEd, PhD,† and Liz DaSilva, MS, RD‡ Objective: The objective of this study is to assess how renal registered dietitians (RDs) in Canada perceive the value of Subjective Global Assessment (SGA) to assess protein-energy wasting for clients with chronic kidney disease. Design and Methods: A sequential exploratory mixed method approach included 2 focus groups (n 5 6 and 8) and a national survey (n 5 54). Two online focus groups were conducted 1 month apart followed by an online survey. Participants included renal RDs working with Stage 5 chronic kidney disease (dialysis and non-dialysis) patients. Results: Five main themes (consistency, organizational/environment, confidence, interpretation, and education) emerged. Renal RDs support using a tool to provide a standardized process for nutrition assessment and feel SGA is an effective educational tool; however, barriers such as time, privacy, confidence in the tool, as well as ability to perform physical assessment, interpretation, and subjectivity limit the use of SGA. Renal RDs feel that it is important to examine nutrition interventions in conjunction with SGA results. Conclusion: The main results of the study describing the limitations to the clinical use of the SGA tool revolve around RDs’ time, confidence, ability to interpret the SGA tool, and how SGA is used by administration. The results support the need for educators and administrators to communicate the use of SGA results and provide education opportunities focusing on the use of validated, reliable, responsive tools to assess nutrition status as well as hands-on physical assessment. In some situations, an alternative validated version of SGA or screening tool may be appropriate. Ó 2019 by the National Kidney Foundation, Inc. All rights reserved.
Introduction
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HE TERM PROTEIN-ENERGY wasting (PEW) is recommended by the International Society of Renal Nutrition and Metabolism to describe the loss of protein mass and/or energy supplies in patients with chronic kidney disease (CKD)1 and contributes to increased mortality, hospitalizations, and decreased quality of life.1,2 PEW includes inadequate dietary nutrient intake, but also involves other factors such as metabolic derangements, dialysis associated catabolism, inflammation, loss of kidney function, and co-morbid conditions.3,4 As noted by Gracia-Iguacel et al.,5 prevalence of PEW in dialysis patients varies widely (18%-75%) depending on how it is defined and the tools used for assessment. A meta-analysis by Carrero et al.6 identified a prevalence of PEW in 11%-54% of CKD Stage 3-5 *
Clinical Dietitian, Fraser Health Authority, Abbotsford, BC, Canada. Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. ‡ Research Dietitian, Fraser Health Authority, Surrey, BC, Canada. Support and Financial Disclosure: This study was funded through a small donation from the British Columbia renal dietitians group. This group had no other involvement in the development or conduct of the study. Address correspondence to Shelly Messenger, MRSc, RD, 11352 240a st., Maple Ridge, BC V2W 0A4, Canada. E-mail: shelly.messenger@ †
fraserhealth.ca Ó
2019 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 https://doi.org/10.1053/j.jrn.2019.04.004
Journal of Renal Nutrition, Vol -, No - (-), 2019: pp 1-9
patients and 28%-54% of dialysis patients, with the majority of studies using the Subjective Global Assessment (SGA) as the assessment tool. To date, there is no consensus regarding which tool to use to assess for the presence or risk of PEW. In 1982, Baker et al.7 developed the SGA tool as a simple, inexpensive way to assess and categorize malnutrition and tested its validity and reliability in a surgical patient population. Since then, others have made adaptations to the SGA and tested its validity and reliability in the CKD population. A review of nutritional assessment tools in CKD revealed that the SGA,8-10 7-point SGA,8,11-15 and patient generated SGA (PG-SGA)16 are each valid methods of diagnosing malnutrition, while the SGA8,9,17 and 7-point SGA12,13,15,18,19 predict morbidity and mortality. In addition to assessment of malnutrition, Sum et al.20 showed the 7-point SGA to have 78.6% sensitivity and 59.1% specificity in identifying PEW risk. The SGA A/B/C was found to have predictive validity in a study with a CKD (non-dialysis) population9 which demonstrated significantly higher rate of death and hospitalization in the malnourished (SGA B/C) group compared to a nourished group (SGA A). Most recently, Paudel et al.19 demonstrated that the 7-point SGA was highly predictive of mortality in peritoneal dialysis patients. Multivariate analysis of the 7point SGA as a categorical value, 1-5 (malnourished) compared to 6-7 (nourished), had a hazard ratio [HR] of 3.30 (95% confidence interval [CI] 2.09-5.26).19 Studies using SGA A/B/C with hemodialysis and peritoneal 1
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dialysis patients10 and the 7-point SGA in hemodialysis patients15 have both shown to have moderate inter-rater reliability (IRR)21 (weighted kappa of 0.60 and 0.52, respectively). Clinical practice guidelines currently recommend the use of SGA in practice22,23 noting the best method of SGA scoring still needs to be determined. Other guidelines recommend SGA be used as a clinical marker1 or in conjunction with other indices to assess nutrition status.24,25 Other tools have been developed such as the International Society of Renal Nutrition and Metabolism’s 4-category diagnostic criteria to determine PEW5 in CKD patients; however, it includes biochemical parameters similar to the Malnutrition Inflammation Score.26 Given SGA identifies nutritional factors associated with PEW, morbidity and mortality risk, and is a relatively quick and easy tool to use, its use in clinical practice by renal RDs warrants investigation. The research question that guided this study was: How do renal RDs perceive the value of SGA to assess PEW for clients with CKD? Specifically, the objectives were to (1) explore experiences of renal RDs with utilizing SGA in practice including barriers and/or facilitators; (2) identify clinical reasoning of renal RDs for using SGA or not; (3) determine if experiences and reasoning differs between experienced versus novice renal RDs; and (4) examine the needs of renal RDs to increase their confidence in and use of the SGA tool.
Literature Search A literature search was conducted using CINAHL, Medline (Ovid), Embase (Ovid), Health and Psychosocial Instruments, Proquest Dissertations & Theses Global, and Google Scholar. Keywords and subject headings included dietitian perceptions and attitudes in combination with validated tools, nutrition assessment, or SGA, and limited to renal dialysis up to March 2018. We identified 6 papers reporting renal RD use of SGA in clinical practice, 2 of which included the same data. McKnight et al.27 noted that 14% (n 5 59) of Canadian renal RDs use SGA in practice. This is in contrast to 40% (n 5 65) of Australian renal RDs28 and 28.5% (n 5 747) to 42% (n 5 868) of US renal RDs who use SGA.29-31 No prior research studies were identified that specifically explored renal RDs’ perspectives on the use of SGA using a mixed method approach.
Figure 1. Timeline of sequential exploratory mixed methods approach.
have masters degrees and research experience and all with experience with renal patients and use of SGA. Questions were assessed for face validity, to provide guidance for timing and utility of questions and checking for question meaning and structure, respectively.34
Sampling and Study Participants Recruitment of participants occurred in the province of British Columbia for the focus groups and expanded across Canada for the survey using volunteer convenience sampling.35 We invited renal RDs who work with adult, inpatient and outpatient Stage 5 (dialysis and non-dialysis) CKD clients (Table 1). Excluded were renal RDs who worked with CKD Stages 1-4 patients only. This allowed for a broader range of participants (geographical diversity, practice experience, users and non-users of SGA), contributing to the transferability of the results.36 Seventy-five email invitations were sent to individual renal RDs to participate in the focus groups by a core member of the British Columbia renal RD group. The goal for focus groups was 6-8 participants per focus group. This sample size was chosen to allow for adequate time during sessions for feedback from all participants.36 All volunteers were assigned to a focus group. Two hundred fifty initial email invitations were sent to individual renal RDs to participate in the survey by the lead for the Canadian Association of Renal Dietitians. Reminder emails to complete the survey were sent at weeks 1 and 3. The survey was open for 4 weeks. As an incentive to participate, one raffle for the focus groups and one raffle for the survey was held for participants and $50 was donated to each recipient’s choice of charity. Study Conduct
Methodology Research Design This is a 2-phase, sequential exploratory mixed methods study (Fig. 1) consisting of an initial qualitative data collection phase followed by a quantitative phase.32 The initial focus groups revealed detailed perspectives of SGA in practice and informed the development of a subsequent national survey.32,33 Focus group and survey questions were evaluated by 4 RDs chosen by the researcher, 2 of whom
Focus Groups Two focus groups (n 5 6 and n 5 8) were conducted via Skype for BusinessÔ (Appendix 1) 1 month apart. Online focus groups were chosen since they are comparable to face-to-face groups in terms of data quality.37 After the focus groups were completed, the transcripts without identifiers were sent to all focus group participants for their review and feedback, allowing for accuracy of transcripts as well as the initial theme development.38,39 Based on
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT Table 1. Demographic Data of Participants
Concept Use of SGA Often (majority of new patients/clients and/or reassessments) Occasionally (some new patients/clients and/or reassessments) Rarely (used before but sporadically) Never Training for SGA Introduction to the theory Hands-on Introduction to theory and hands-on None Areas of practice—of all participating RDs (49/68 practice in multiple areas) Peritoneal dialysis In-center hemodialysis Community hemodialysis Home hemodialysis Chronic kidney disease (non-dialysis) In-patient dialysis Transplant Years of practice in renal area ,1 year 1-5 years 6-10 years .10 years Years of practice as dietitian ,1 year 1-5 years 6-10 years .10 years Self-consideration of practice level Competent (starting out) Proficient (thorough understanding of practice) Experienced or expert (high degree of skill or knowledge, practice is intuitive) No. of patients followed Range Mean Mode Location of practice Rural (township, municipality) Urban setting (city) Both rural and urban
Focus Group (n 5 14), n (%)
Survey (n 5 54), n (%)
1 (7)
n 5 53 10 (19)
8 (57)
13 (24)
3 (21) 2 (14)
19 (36) 11 (21) n 5 54 22 (41) 6 (11) 26 (48) 0 (0) n 5 54
4 (29) 0 (0) 10 (71) 0 (0)
6 (43) 5 (36) 5 (36) 6 (43) 8 (57) 4 (29) 1 (7)
0 (0) 7 (50)
20 (37) 32 (59) 14 (26) 12 (22) 28 (52) 13 (24) 2 (4) n 5 53 2 (4) 12 (23) 16 (30) 23 (43) n 5 54 0 (0) 10 (19) 5 (9) 39 (72) n 5 54 3 (6) 18 (33)
7 (50)
33 (61)
5-400 175 Bimodal 100, 120 n 5 14 2 (14) 11 (79) 1 (7)
25-800 280 100
1 (7) 4 (28.5) 4 (28.5) 5 (36) 0 (0) 0 (0) 4 (29) 10 (71)
n 5 54 6 (11) 48 (89) 0 (0)
RD, registered dietitian; SGA, Subjective Global Assessment.
feedback, no significant changes were made to the transcripts or theme development. Survey The online platform Qualtrics software, Version May 2018, CopyrightÓ 2018, was used for the 40-question survey (Appendix 2) which took approximately 15 minutes to complete. A total of 54 participants completed the survey.
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Analysis and Data Management An inductive thematic analysis approach was used to analyze the focus group transcripts.40 Removal of participant names and identifiers helped ensure data confidentiality as did sharing transcripts with only one co-investigator. Two researchers actively reviewed transcripts and contributed to the analysis. Quotes that appeared to provide insight into the research questions were highlighted and subsequently coded which formed the backbone for emerging sub-themes.36 The majority of sub-themes were present in both focus groups, while some important sub-themes from just one of the focus groups were included based on the researcher’s understanding of the topic of interest.36 Sub-themes were then developed into survey questions (Appendix 2). Responses to survey questions used Likert agreement scales41 and were analyzed using descriptive statistics.42 Agreement responses supported the use of sub-themes in the final theme development. Method triangulation, a strategy to strengthen credibility, was carried out by comparing the literature with the themes that developed from focus groups and survey results to determine similarities in findings.36,43 Rigor Study credibility was addressed by reflexive journaling throughout the research process—allowing for transparency of researcher bias, preconceptions, and how the relationship with participants may affect their contributions.39,43 In addition to being the main contributor to the research process, including facilitating the focus groups, the main researcher was a peer of focus group participants. Ideally, this contributed minimal concern from participants around power differential.39 In addition, an audit trail was kept to improve confirmability and dependability.39 Transferability, the provision of sufficient details of the research process, is found in the audit trail as well as assessing agreement of focus group themes with a larger survey.36
Results Demographic Results Fourteen renal RDs participated in 2 focus groups (n 5 6 and n 5 8) and the survey had a 22% response rate (54/250). Of the 68 renal RDs (Table 1) who participated in the focus groups and survey, 100% had some SGA training (Fig. 2). Frequency of use of SGA is noted in Figure 3. Figure 4 describes the proportion of survey respondents who use SGA to determine a patient/client’s change in nutritional status. Although significance was not calculated, of those who rated themselves as ‘‘expert,’’ 19/40 (48%) of participants used the SGA occasionally or often, similar to those who rated themselves as proficient, 12/25 (48%). Renal RDs with greater than 10 years of experience, 24/50 (48%), compared to those with less than
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Figure 4. Usage of SGA to determine change in nutrition status. SGA, Subjective Global Assessment. Figure 2. Usage of SGA with training. RD, registered dietitian; SGA, Subjective Global Assessment.
10 years of experience, 8/18 (44%), used SGA occasionally or often.
Theme Development Five main themes and 9 sub-themes emerged from the focus group and survey results. 1. Consistency of practice: Consisting of the subthemes (i) standardization and (ii) face validity. i. Standardization: Data from the focus groups suggested that having a tool to help assess nutrition status of clients is important for standardization of practice—43/54 (79%) of survey participants agreed (Appendix 2, Q10) and 38/54 (70%) felt it was important to have a tool to provide that standardized process (Q11). ‘‘.very important to have a tool to assess nutrition status because it creates a standardized process, ensures a quality in the care we provide if we all are basing our assessment on best practice standards.’’ (P2)
Figure 3. Usage of SGA by renal dietitians. SGA, Subjective Global Assessment.
ii. Face validity: The majority of participants agreed with 5 common components of nutrition assessment (Q12-16) (Fig. 5). Further questions revealed that 32/42 (76%) of participants agreed that using SGA encourages them to include a physical examination in their nutritional assessment (Q37). SGA ‘‘forces’’ you to do more physical assessment – ‘‘being a bit more thorough than just looking at the trends.’’ (P3a)
Of those renal RDs who do not use or do not always use SGA, 20/50 (40%) either rarely or never include a physical examination in their nutritional assessments (Q38), with only 3/20 (15%) of these participants practicing in CKD clinic areas. Also of note, 25/50 (50%) of participants indicated that their confidence in performing physical assessment was a barrier to their using SGA (Q39). ‘‘I think the physical exam is still the most challenging part for me. I think it’s easy to look at how much weight clients lost.but sometimes I’m limited by what they’re wearing and sometimes it’s my training and experience of doing physical assessments, to really feel 100% confident.’’ (P4a)
2. Organizational/Environment: Consisting of the sub-themes, SGA limited by (i) time, (ii) privacy, and (iii) concerns about the use of SGA results by health organization administration. i. Time: Of those renal RDs working in a clinic setting, 35/43 (81%) agreed they did not have adequate time to include SGA in their nutritional
Figure 5. Dietitians agreement of importance of nutritional assessment components. GI, gastrointestinal.
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT
assessment (Q31) compared to 23/42 (55%) of renal RDs who work with dialysis patients and specified that they did have adequate time (Q32). Of those renal RDs who noted that they do not have adequate time, more than half follow greater than 200 patients, 21/34 (62%). ‘‘.I think a big challenge would be time restraints in a clinic setting, an outpatient clinic setting’’ (P7a) ‘‘I definitely have more time to use it in the in-center dialysis clients, because I can easily go and follow them up with recommendations.’’ (P4a)
ii. Privacy: An additional barrier to the use of SGA mentioned by participants and agreed upon by 38/50 (76%) of survey respondents was a lack of privacy in the dialysis unit/clinic or what patients/clients wear (Q28). ‘‘In the out-patient setting the biggest barrier is how patients are dressed.physical assessment is particularly challenging while patients are hooked to a hemodialysis machine’’ (survey participant) ‘‘.awkward and not overly practical in a community setting to do an SGA - having patients in a waiting room or in their hemo chair with other people around them’’ (P3)
iii. Administrative use: In an era of increased need to support dietitian intervention and outcomes, documentation and validated tools are being encouraged as part of standardized care. Concerns were noted about use of SGA results by health organization administration in Canada. Survey participants, 38/42 (88%), agreed that if SGA is to be used to justify renal RD service funds, it should be used in conjunction with the time spent performing the entire patient/client’s nutrition assessment and implementing nutrition intervention(s) (Q33).
‘‘For patients we follow long term you have a sense of whether they are malnourished’’ – ‘‘whether it’s chronic malnutrition or it’s acute just by the change - the visual change’’ (P5) SGA ‘‘Validates your other assessment, but I still feel like your overall nutrition assessment without it is just as important if not more important’’ (P3)
Of those who felt comfortable enough with the SGA tool to answer the question, 28/41 (69%) felt they were more likely to use SGA when they suspected a patient/client was malnourished (Q21). Similarly, 27/41 (66%) agreed that they were more likely to use SGA when they were uncertain of nutrition status (Q24). ‘‘Sometimes I feel like I don’t use it because it’s obvious one way or another and I can tell from looking at the patient.I tend to prefer to do it on patients who I’m a little less sure of, more in the middle ground.’’ (P4a)
4. Interpretation: Consisting of the sub-themes of (i) challenges with the ‘‘B’’ category and (ii) a lack of objectivity when assessing functional capacity. i. Challenges with ‘‘B’’ category: Participants commonly spoke about the challenges of interpreting SGA. This was confirmed by 39/51 (76%) of survey participants who felt it was difficult to interpret the SGA ‘‘B’’ category (Q27). ‘‘With transfers of SGA it becomes a bit challenging given the grey area of B – one person’s B might be closer to a C or to an A – I feel your charting and assessment is a better indicator’’ (P8a)
ii. Objectivity of functional status: Participants agreed, 28/51 (55%), that functional capacity was challenging to interpret (Q35). In addition, 35/50 (70%) of participants would prefer a more objective measure to assess functional capacity (Q36).
‘‘My fear is that it becomes only clients with SGA B or C are going to get nutrition intervention and time with RDs.’’ (P4a)
RD would prefer to use more objective measure in addition to clinical judgment. Hand grip strength would provide a more meaningful result – ‘‘I like having objective measures’’ (P2a)
‘‘I don’t think it’s the only way to measure who needs nutritional intervention.I think part of that is someone looking at that as a stand-alone tool – if you look at the tool itself and not the assessment’’ (P7)
‘‘I always wonder, what comes first, the malnutrition that causes the dysfunction or the dysfunction in the person’s physical capacity that leads them to not be able to get food.’’ (P6a)
3. Confidence: This theme developed from the focus group discussions and consists of sub-themes of RD use of clinical judgment in place of SGA. Seventy percent of participants (36/51) agreed that they felt their clinical judgment was adequate to assess malnutrition without using SGA (Q23).
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5. Education: Consisting of the sub-theme benefits of SGA as a supportive educational tool. Of those RDs who are preceptors, 24/31 (77%) felt that the use of SGA promoted a positive educational experience between preceptor and dietetic students (Q29). Participants also agreed, 31/41 (76%), that SGA is a useful tool to educate patient/clients about nutrition (Q30).
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MESSENGER ET AL ‘‘.tool made me look at clients differently.when I talked to patients about muscle wasting and the changes that happen, they sort of buy into, ‘oh yes’, I have noticed muscle loss..I do need to take my protein powder’’ (P5) ‘‘I had an intern and we used the SGA on a few of our hemodialysis clients and it was a really good learning experience’’. ‘‘to look at the difficult signs and be more comfortable with that right from the beginning of her training.’’.‘‘also created a good debate between us’’ (P4a)
Lack of Consensus There were themes/sub-themes that emerged from the focus groups but lacked consensus from the survey including the following: (1) ‘‘SGA does not change my intervention or recommendations’’; (2) ‘‘I feel that I am duplicating my charting when I include SGA’’; and (3) ‘‘I do not see value in the SGA.’’ Of note, some focus group participants have been requested by administration to use SGA in their practice; however, this information was not formally collected in the survey. There may be a relationship between participants who use SGA by choice versus by request and their overall impression or clinical value of SGA.
Discussion The results of this study show that renal RDs are supportive of using a tool to standardize practice and see SGA as a useful tool to help educate patients and interns. Some renal RDs felt their clinical judgment was adequate without the use of SGA to assess nutrition status, and relative to other components fewer felt the physical assessment was an important component to nutrition assessment. Challenges noted with SGA use include time, privacy, confidence in physical examination, subjectivity of the tool, and how SGA results are utilized by health organization administration. As well, interpretation of functional status is a concern for renal RDs. In this study, participants’ use of SGA often (16%) was comparable to the 14% (n 5 59) noted by the Canadian McKnight et al. study27; however, they did not differentiate between often and occasional use. If we combine often and occasional use in this study (47%), it is comparable to data from the Australia28 and US29-31 studies as well the 34% use noted in a Canadian acute care center.44 Given renal RD’s support for having a standardized process to assess nutrition status and a tool to direct the process, it may be beneficial to include a brief discussion during SGA training about the validation and reliability studies in the CKD population.9,10,12,14 Having background knowledge of how a tool has been validated may support a renal RD’s understanding of and ability to discuss the tool and how it contributes to a standardized process and ultimately patient care. Barriers to using SGA reported in the literature included insufficient training, lack of privacy,30 time, skill, and
self-efficacy.28,45 Similar barriers were identified in this study—lack of privacy including what a patient is wearing, confidence in skill level specific to physical assessment, and limited time to allow for completion of the SGA. Insufficient training was not a common theme from the focus groups. However, it does appear that training quality may be important given results suggest that including hands-on in addition to theory training may promote SGA use in practice (Fig. 1). Of those renal RDs who ‘‘do not’’ or ‘‘do not always’’ use SGA, 40% do not include a physical component in their nutritional assessment. Also of note, 50% of renal RDs surveyed had concerns regarding their confidence in performing physical assessment and it acted as a barrier to their use of SGA. Studies have shown that alterations in muscle and fat mass are the most common finding in identifying PEW18,14 and that muscle wasting is associated with mortality in hemodialysis patients.46 Given its role in whole body homeostasis, preservation of muscle mass is a vital goal of treating PEW.4 This also suggests the need for continuing education opportunities for renal RDs focused on hands-on techniques of physical examination. A lack of time was a limitation to the use of SGA for 81% of renal RDs working in a clinic environment. The PG-SGA tool has been shown to have high sensitivity (83%) and specificity (92%) at predicting SGA category and may help triage patients.16 It is important to note that the PG-SGA may have limitations with patients or caregivers who are unable to complete the tool due to cognitive impairment or language barriers. SGA requires a practitioner to utilize clinical judgment; however, in this study, renal RDs often feel their judgment alone is as valuable as SGA in confirming malnutrition. This response is supported by Polanyi’s description of ‘‘tacit knowledge’’ where professionals act on their knowledge without having to articulate their actions.47 This may be an efficient process, but the limited ability to explain what one knows can create a lack of credibility.47 Given renal RDs feel SGA promotes a positive educational experience for patients and interns, it is helpful to have a tool to support their judgment. A quick screening tool may also help validate renal RDs’ judgment while decreasing work load of performing SGA on every patient. The Geriatric Nutritional Risk Index has shown promise as a screening tool.48,49 However, further discussion and validation would be required for this tool to be used in other demographics. A considerable number (76%) of participants noted difficulty in interpreting the ‘‘B’’ category of SGA. The validated CANUSA version of 7-point SGA12 provides an opportunity for clarity, but may have an impact on the overall reliability of the tool given its measure of inter-observer reliability (weighted kappa 5 0.52).15 Cooper et al.10 showed the original SGA version to have a moderate inter-observer reliability as well, but with a
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT
slightly higher weighted kappa (0.60). Steenson et al.50 showed improvements in IRR with increasing clinical experience of administering the A/B/C version of SGA, supporting the need for initial and on-going training to maintain a high IRR for users of the SGA tool. Responsiveness is a measure of a tool’s ability to detect change in its construct and is determined using effect size or standardized response mean.51,52 In the case of the SGA, the construct is nutritional status. Limited studies have been performed in regard to SGA and its responsiveness. This may be related to the fact that the SGA is multi-dimensional and each component of SGA has a different measurement scale (categorical or continuous). Campbell et al.8 address the debate of whether it is appropriate or not to report the total SGA score as a true continuous variable. The challenge with the 1-7 rating is the inability to report half value scores (i.e., 3.5/7). Furthermore, measures with limited number of categories, as in the SGA A/B/C, tend not to be responsive given a large change is required to change a category.53,54 It could be argued that this suggests that SGA is better used as a tool to describe the nutritional status of a patient or client at a distinct point in time but not to determine a change in nutrition status over time.54 Of the survey participants, 39% used SGA often or occasionally to determine a change in nutrition status of their patient/ clients over time which suggests the need to discuss how the SGA tool is used in practice. The majority of study participants wanted to see more objective measures to help assess the functional component of SGA. Hand grip strength (HGS) is an objective measure that may meet this need. In an observational study, Matos et al.55 reported a higher risk of death in male patients on hemodialysis for those with lower HGS (HR 3.35, 95% CI 1.67-6.73 for men; HR 1.10, 95% CI 0.49-2.46 for women) after taking into consideration covariates. Although limitations exist, HGS may be a useful adjunct to SGA and further investigation into its use to assess nutritional and functional status in dialysis patients is needed.56,57 In the interim, it may be useful for practitioners to know that the Detsky et al.58 version of SGA does not differentiate between a decline in functional capacity due to nutritional or non-nutritional changes. As well, functional capacity has less of a weighting on the end SGA score compared to weight loss, dietary intake, and fat/muscle loss.58 Concerns were expressed about how the results of SGA are used by administration. Although there is currently no policy linking the use of SGA scores to support RD time, concerns were expressed that it may be used for this purpose in the future. During focus group conversations, there were fears noted that only patients with SGA B or C rating would have supported time with a renal RD. As noted by participant comments, it is possible for a patient to have an SGA rating of A, but still require nutrition
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intervention. In contrast, a patient may be an SGA C but have limited intervention by the renal RD given the circumstances. Participants questioned how these types of issues are addressed by administration and feel that SGA scores should be considered in conjunction with the whole nutrition assessment including interventions. It may be helpful for nutrition managers and educators to communicate the application of SGA statistics with renal RDs and to share how SGA statistics are used to support renal RD time. Limitations of this study include having only 2 focus groups—additional focus groups may have provided further saturation of themes. As well, a more evenly distributed proportion of participants geographically and years of experience may have contributed different results. The longer survey length of 40 questions may have influenced participant responses. Finally, more than one peer debriefer may have enhanced study credibility. Despite these limitations, this was the first study to assess in-depth renal RDs’ perspectives on SGA and its use in clinical practice. Ideally, these views will provide background to support renal RDs in their daily clinical practice assessing nutrition status and to improve overall patient care in CKD clients.
Practical Application In order for a validated nutrition tool to be used by clinicians it needs to be practical and appropriate for the clinical practice area. In some situations, different versions of SGA or a validated screening tool, despite its limitations, may improve rates of standardized documentation of nutrition status or risk by renal RDs. Findings of this study support the need to provide education to SGA users on (1) the value of using a valid, reliable, responsive tool; (2) hands-on physical assessment practice; and (3) how SGA results are compiled and used by administration.
Acknowledgment The authors would like to thank Dr. K. Campbell, PhD, for the discussion and input regarding the responsiveness of the SGA tool. The authors would also like to thank the Fraser Health dietitians involved in piloting the focus group and survey questions as well as the Department of Evaluation and Research Services in Fraser Health for supporting the revision of this manuscript.
Supplementary Data
Supplementary data associated with this article can be found in the online version at https://doi.org/10.1053/j. jrn.2019.04.004.
References 1. Fouque D, Kalantar-Zadeh KK, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int. 2008;73:391-398. 2. Zha Y, Qian Q. Protein nutrition and malnutrition in CKD and ESRD. Nutrients. 2017;9:1-19.
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3. Carrero JJ, Stenvinkel P, Cuppari L, et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM). J Ren Nutr. 2013;23:77-90. 4. Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013;84:1096-1107. 5. Gracia-Iguacel C, Gonzalez-Parra E, Barril-Cuadrado G, et al. Defining protein-energy wasting syndrome in chronic kidney disease: prevalence and clinical implications. Nefrologia. 2014;34:507-519. 6. Carrero JJ, Thomas F, Nagy K, et al. Global prevalence of proteinenergy wasting in kidney disease: a meta-analysis of contemporary observational studies from the International Society of Renal Nutrition and Metabolism. J Ren Nutr. 2018;28:380-392. 7. Baker J, Detsky AS, Wesson DE, et al. A comparison of clinical judgment and objective measurements. N Engl J Med. 1982;306:969-972. 8. Campbell KL, Ash S, Bauer J, Davies PSW. Critical review of nutrition assessment tools to measure malnutrition in chronic kidney disease. Nutr Diet. 2007;64:23-30. 9. Lawson JA, Lazarus R, Kelly K. Prevalence and prognostic significance of malnutrition in chronic renal insufficiency. J Ren Nutr. 2011;11:16-22. 10. Cooper BA, Bartlett LH, Aslani A. Validity of subjective global assessment as a nutritional marker in end stage renal disease. Am J Kidney Dis. 2002;40:126-132. 11. Visser R, Dekker FW, Boeschoten EW. Reliability of the 7-point subjective global assessment scale in assessing nutritional status of dialysis patients. Adv Perit Dial. 1999;15:222-225. 12. Churchill DN, Taylor DW, Keshaviah R. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol. 1996;7:198-207. 13. Santin FG, Bigogno FG, Dias Rodriques JC. Concurrent and predictive validity of composite methods to assess nutritional status in older adults on hemodialysis. J Ren Nutr. 2016;26:18-25. 14. Cuppari L, Meireles MS, Ramos CI. Subjective global assessment for the diagnosis of protein-energy wasting in nondialysis-dependent chronic kidney disease patients. J Ren Nutr. 2014;24:385-389. 15. Steiber A, Leon JB, Secker D, et al. Multicentre study of the validity and reliability of subjective global assessment in the hemodialysis population. J Ren Nutr. 2007;17:336-342. 16. Desbrow B, Bauer J, Blum C. Assessment of nutritional status in hemodialysis patients using patient-generated subjective global assessment. J Ren Nutr. 2005;15:211-216. 17. Chan M, Kelly J, Butterham M, Tapsell L. Malnutrition (subjective global assessment) scores and serum albumin levels, but not body mass index values, at initiation of dialysis are independent predictors of mortality: a 10-year clinical cohort study. J Ren Nutr. 2012;22:547-557. 18. de Mutsert R, Grootendorst DC, Boeschoten EW. Subjective global assessment of nutritional status is strongly associated with mortality in chronic dialysis patients. Am J Clin Nutr. 2009;87:787-793. 19. Paudel K, Visser A, Burke S. Can bioimpedance measurements of lean and fat tissue mass replace subjective global assessments in peritoneal dialysis patients? J Ren Nutr. 2015;26:480-487. 20. Sum S, Marcus AF, Blair D, et al. Comparison of subjective global assessment and protein energy wasting score to nutrition evaluations conducted by registered dietitian nutritionists in identifying protein energy wasting risk in maintenance hemodialysis patients. J Ren Nutr. 2017;27:325-332. 21. Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37:360-363. 22. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Available at: http://www2.kidney. org/professionals/kdoqi/guidelines_nutrition/nut_appx06a.html. Accessed November 12, 2018. 23. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Commentaries Research Recommendations [PDF document]. http://
www.kidney.org/sites/default/files/KDOQI_Clinical_Practice_Guidelines_ RR2012.pdf. Accessed November 12, 2018. 24. Dombros N, Dratwas M, Feriani M, et al. European best practice guidelines for peritoneal dialysis and nutrition in peritoneal dialysis. Nephrol Dial Transpl. 2005;20:ix28-ix33. 25. Fouque D, Vennegoor M, Wee PT, et al. EBPG guideline on nutrition. Nephrol Dial Transpl. 2007;22:ii45-ii87. 26. Kalantar-Zadeh K, Kopple JD, Block G, Humphries MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2001;38:1251-1263. 27. McKnight K, Farmer A, Zuberbuhler L. Identification and treatment of protein-energy malnutrition in renal disease. Can J Diet Pract Res. 2010;71:27-32. 28. Hall-McMahon EJ, Campbell KL. Have renal dietitians successfully implemented evidence-based guidelines into practice? A survey of dietitians across Australia and New Zealand. J Ren Nutr. 2012;22:584-591. 29. Thelan B, Byham-Gray L, Touger-Decker R. Survey of current job functions of renal dietitians. J Ren Nutr. 2009;19:450-461. 30. Burrowes JD, Russell GB, Rocco MV. Multiple factors affect renal dietitians’ use of the NKF-K/DOQI adult nutrition guidelines. J Ren Nutr. 2005;15:407-426. 31. Vergil JM, Wolf RL. Nutrition practices of renal dietitians in hemodialysis centers throughout the United States: a descriptive study. J Ren Nutr. 2010;20:8-16. 32. Creswell JW. Mixed methods procedures. In: Research Design Qualitative, Quantitative, and Mixed Methods Approaches. 3rd ed. Thousand Oaks, CA: Sage Publications; 2009:203-225. 33. Subedi D. Explanatory sequential mixed method design as the third research community of knowledge claim. Am J Educ Res. 2016;4:570-577. 34. Breen RL. A practical guide to focus-group research. J Geogr Higher Educ. 2016;30:463-475. 35. DePoy E, Gitlin LN. Boundary setting in experimental-type designs. In: Introduction to Research Understanding and Applying Multiple Strategies. 4th ed. St. Louis, MO: Elsevier Mosby; 2011:160-174. 36. Carpenter C, Suto M. Managing qualitative data. In: Qualitative Research for Occupational and Physical Therapists: A Practical Guide. Oxford, UK: Blackwell Publishing; 2008:98-112. 37. Boydell N, Fergie G, McDaid L. Avoiding pitfalls and realizing opportunities: reflecting on issues of sampling and recruitment for online focus groups. Int J Qual Methods. 2014;13:206-233. 38. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26:1802-1811. 39. Morrow SL. Quality and trustworthiness in qualitative research in counseling psychology. J Couns Psych. 2005;52:250-260. 40. Braun V, Clark V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. 41. Boone HN, Boone DA. Analyzing Likert data. J Ext. 2012;50. Available at: https://www.joe.org/joe/2012april/tt2.php. 42. Allen IE, Seaman CA. Likert scales and data analysis. Qual Prog. Retrieved from: https://asq.org/quality-progress/2007/07/statistics/ likert-scales-and-data-analyses.html. 43. Korstjens I, Moser A. Practical guidance to qualitative research. Part 4: trustworthiness and publishing. Eur J Gen Pract. 2018;24:120-124. 44. Peters L, O-Connor C, Giroux I. Screening and assessment of nutritional status following stroke: results from a national survey of registered dietitians in Canada. Disabil Rehabil. 2015;37:2413-2417. 45. Hand RK, Burrowes JD. Renal dietitians’ perceptions of roles and responsibilities in outpatient dialysis facilities. J Ren Nutr. 2015;25:404-411. 46. Carrero JJ, Chmielewski M, Axelsson J, et al. Muscle atrophy, inflammation and clinical outcome in incident and prevalent dialysis patients. Clin Nutr. 2008;27:557-564. 47. Fleming MH, Mattingly C. Action and narrative: two dynamics of clinical reasoning. In: Higgs J, Joes S, Loftus S, Christensen N, eds. Clinical
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT Reasoning in the Health Professions. 3rd ed. Oxford: Elsevier Butterworth-Heinemann; 2008:55-64. 48. Yamada K, Furuya R, Takita T, et al. Simplified nutritional screening tools for patients on maintenance hemodialysis. Am J Clin Nutr. 2008;87:106-113. 49. Kobayashi I, Ishimura E, Kato Y, et al. Geriatric Nutritional Risk Index, a simplified nutritional screening index is a significant predictor of mortality in chronic dialysis patients. Nephr Dial Transpl. 2010;25:3361-3365. 50. Steenson J, Vivianti A, Isenring E. New clinicians require ongoing training to ensure high inter-rater reliability of the subjective global assessment. Nutrition. 2013;29:361-362. 51. Husted JA, Cook RJ, Farewell VT. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol. 2000;53: 459-468. 52. Beaton DE, Bombardier C, Katz JN, et al. A taxonomy for responsiveness. J Clin Epidemiol. 2001;54:1204-1217.
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53. Roach KE. Measurement of health outcomes: reliability, validity and responsiveness. J Prosthet Orthot. 2006;6:8-13. 54. Marcelli D, Wabel P, Wieskotten S, et al. Physical methods for evaluating the nutrition status of hemodialysis patients. J Nephrol. 2015;28:523-530. 55. Matos CM, Silva LF, Santana LS, et al. Handgrip strength at baseline and mortality risk in a cohort of women and men on hemodialysis: a 4-year study. J Ren Nutr. 2014;24:157-162. 56. Leal VO, Stockler-Pinto MB, Farage NE, et al. Handgrip strength and its dialysis determinants in hemodialysis patients. Nutrition. 2011;27: 1125-1129. 57. Leal VO, Mafra D, Fouque D, et al. Use of handgrip strength in the assessment of the muscle function of chronic kidney disease patients on dialysis: a systematic review. Nephrol Dial Transpl. 2011;26:1354-1360. 58. Detsky AS, McLaughlin JR, Baker JP. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr. 1987;11:8-13.
Renal Dietitians’ Perceptions of the Value of Subjective Global Assessment: A Mixed Methods Study Shelly Messenger, MRSc, RD,* Lesley Bainbridge, BSR(PT), MEd, PhD,† and Liz DaSilva, MS, RD‡ Objective: The objective of this study is to assess how renal registered dietitians (RDs) in Canada perceive the value of Subjective Global Assessment (SGA) to assess protein-energy wasting for clients with chronic kidney disease. Design and Methods: A sequential exploratory mixed method approach included 2 focus groups (n 5 6 and 8) and a national survey (n 5 54). Two online focus groups were conducted 1 month apart followed by an online survey. Participants included renal RDs working with Stage 5 chronic kidney disease (dialysis and non-dialysis) patients. Results: Five main themes (consistency, organizational/environment, confidence, interpretation, and education) emerged. Renal RDs support using a tool to provide a standardized process for nutrition assessment and feel SGA is an effective educational tool; however, barriers such as time, privacy, confidence in the tool, as well as ability to perform physical assessment, interpretation, and subjectivity limit the use of SGA. Renal RDs feel that it is important to examine nutrition interventions in conjunction with SGA results. Conclusion: The main results of the study describing the limitations to the clinical use of the SGA tool revolve around RDs’ time, confidence, ability to interpret the SGA tool, and how SGA is used by administration. The results support the need for educators and administrators to communicate the use of SGA results and provide education opportunities focusing on the use of validated, reliable, responsive tools to assess nutrition status as well as hands-on physical assessment. In some situations, an alternative validated version of SGA or screening tool may be appropriate. Ó 2019 by the National Kidney Foundation, Inc. All rights reserved.
Introduction
T
HE TERM PROTEIN-ENERGY wasting (PEW) is recommended by the International Society of Renal Nutrition and Metabolism to describe the loss of protein mass and/or energy supplies in patients with chronic kidney disease (CKD)1 and contributes to increased mortality, hospitalizations, and decreased quality of life.1,2 PEW includes inadequate dietary nutrient intake, but also involves other factors such as metabolic derangements, dialysis associated catabolism, inflammation, loss of kidney function, and co-morbid conditions.3,4 As noted by Gracia-Iguacel et al.,5 prevalence of PEW in dialysis patients varies widely (18%-75%) depending on how it is defined and the tools used for assessment. A meta-analysis by Carrero et al.6 identified a prevalence of PEW in 11%-54% of CKD Stage 3-5 *
Clinical Dietitian, Fraser Health Authority, Abbotsford, BC, Canada. Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. ‡ Research Dietitian, Fraser Health Authority, Surrey, BC, Canada. Support and Financial Disclosure: This study was funded through a small donation from the British Columbia renal dietitians group. This group had no other involvement in the development or conduct of the study. Address correspondence to Shelly Messenger, MRSc, RD, 11352 240a st., Maple Ridge, BC V2W 0A4, Canada. E-mail: shelly.messenger@ †
fraserhealth.ca Ó
2019 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 https://doi.org/10.1053/j.jrn.2019.04.004
Journal of Renal Nutrition, Vol -, No - (-), 2019: pp 1-9
patients and 28%-54% of dialysis patients, with the majority of studies using the Subjective Global Assessment (SGA) as the assessment tool. To date, there is no consensus regarding which tool to use to assess for the presence or risk of PEW. In 1982, Baker et al.7 developed the SGA tool as a simple, inexpensive way to assess and categorize malnutrition and tested its validity and reliability in a surgical patient population. Since then, others have made adaptations to the SGA and tested its validity and reliability in the CKD population. A review of nutritional assessment tools in CKD revealed that the SGA,8-10 7-point SGA,8,11-15 and patient generated SGA (PG-SGA)16 are each valid methods of diagnosing malnutrition, while the SGA8,9,17 and 7-point SGA12,13,15,18,19 predict morbidity and mortality. In addition to assessment of malnutrition, Sum et al.20 showed the 7-point SGA to have 78.6% sensitivity and 59.1% specificity in identifying PEW risk. The SGA A/B/C was found to have predictive validity in a study with a CKD (non-dialysis) population9 which demonstrated significantly higher rate of death and hospitalization in the malnourished (SGA B/C) group compared to a nourished group (SGA A). Most recently, Paudel et al.19 demonstrated that the 7-point SGA was highly predictive of mortality in peritoneal dialysis patients. Multivariate analysis of the 7point SGA as a categorical value, 1-5 (malnourished) compared to 6-7 (nourished), had a hazard ratio [HR] of 3.30 (95% confidence interval [CI] 2.09-5.26).19 Studies using SGA A/B/C with hemodialysis and peritoneal 1
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dialysis patients10 and the 7-point SGA in hemodialysis patients15 have both shown to have moderate inter-rater reliability (IRR)21 (weighted kappa of 0.60 and 0.52, respectively). Clinical practice guidelines currently recommend the use of SGA in practice22,23 noting the best method of SGA scoring still needs to be determined. Other guidelines recommend SGA be used as a clinical marker1 or in conjunction with other indices to assess nutrition status.24,25 Other tools have been developed such as the International Society of Renal Nutrition and Metabolism’s 4-category diagnostic criteria to determine PEW5 in CKD patients; however, it includes biochemical parameters similar to the Malnutrition Inflammation Score.26 Given SGA identifies nutritional factors associated with PEW, morbidity and mortality risk, and is a relatively quick and easy tool to use, its use in clinical practice by renal RDs warrants investigation. The research question that guided this study was: How do renal RDs perceive the value of SGA to assess PEW for clients with CKD? Specifically, the objectives were to (1) explore experiences of renal RDs with utilizing SGA in practice including barriers and/or facilitators; (2) identify clinical reasoning of renal RDs for using SGA or not; (3) determine if experiences and reasoning differs between experienced versus novice renal RDs; and (4) examine the needs of renal RDs to increase their confidence in and use of the SGA tool.
Literature Search A literature search was conducted using CINAHL, Medline (Ovid), Embase (Ovid), Health and Psychosocial Instruments, Proquest Dissertations & Theses Global, and Google Scholar. Keywords and subject headings included dietitian perceptions and attitudes in combination with validated tools, nutrition assessment, or SGA, and limited to renal dialysis up to March 2018. We identified 6 papers reporting renal RD use of SGA in clinical practice, 2 of which included the same data. McKnight et al.27 noted that 14% (n 5 59) of Canadian renal RDs use SGA in practice. This is in contrast to 40% (n 5 65) of Australian renal RDs28 and 28.5% (n 5 747) to 42% (n 5 868) of US renal RDs who use SGA.29-31 No prior research studies were identified that specifically explored renal RDs’ perspectives on the use of SGA using a mixed method approach.
Figure 1. Timeline of sequential exploratory mixed methods approach.
have masters degrees and research experience and all with experience with renal patients and use of SGA. Questions were assessed for face validity, to provide guidance for timing and utility of questions and checking for question meaning and structure, respectively.34
Sampling and Study Participants Recruitment of participants occurred in the province of British Columbia for the focus groups and expanded across Canada for the survey using volunteer convenience sampling.35 We invited renal RDs who work with adult, inpatient and outpatient Stage 5 (dialysis and non-dialysis) CKD clients (Table 1). Excluded were renal RDs who worked with CKD Stages 1-4 patients only. This allowed for a broader range of participants (geographical diversity, practice experience, users and non-users of SGA), contributing to the transferability of the results.36 Seventy-five email invitations were sent to individual renal RDs to participate in the focus groups by a core member of the British Columbia renal RD group. The goal for focus groups was 6-8 participants per focus group. This sample size was chosen to allow for adequate time during sessions for feedback from all participants.36 All volunteers were assigned to a focus group. Two hundred fifty initial email invitations were sent to individual renal RDs to participate in the survey by the lead for the Canadian Association of Renal Dietitians. Reminder emails to complete the survey were sent at weeks 1 and 3. The survey was open for 4 weeks. As an incentive to participate, one raffle for the focus groups and one raffle for the survey was held for participants and $50 was donated to each recipient’s choice of charity. Study Conduct
Methodology Research Design This is a 2-phase, sequential exploratory mixed methods study (Fig. 1) consisting of an initial qualitative data collection phase followed by a quantitative phase.32 The initial focus groups revealed detailed perspectives of SGA in practice and informed the development of a subsequent national survey.32,33 Focus group and survey questions were evaluated by 4 RDs chosen by the researcher, 2 of whom
Focus Groups Two focus groups (n 5 6 and n 5 8) were conducted via Skype for BusinessÔ (Appendix 1) 1 month apart. Online focus groups were chosen since they are comparable to face-to-face groups in terms of data quality.37 After the focus groups were completed, the transcripts without identifiers were sent to all focus group participants for their review and feedback, allowing for accuracy of transcripts as well as the initial theme development.38,39 Based on
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT Table 1. Demographic Data of Participants
Concept Use of SGA Often (majority of new patients/clients and/or reassessments) Occasionally (some new patients/clients and/or reassessments) Rarely (used before but sporadically) Never Training for SGA Introduction to the theory Hands-on Introduction to theory and hands-on None Areas of practice—of all participating RDs (49/68 practice in multiple areas) Peritoneal dialysis In-center hemodialysis Community hemodialysis Home hemodialysis Chronic kidney disease (non-dialysis) In-patient dialysis Transplant Years of practice in renal area ,1 year 1-5 years 6-10 years .10 years Years of practice as dietitian ,1 year 1-5 years 6-10 years .10 years Self-consideration of practice level Competent (starting out) Proficient (thorough understanding of practice) Experienced or expert (high degree of skill or knowledge, practice is intuitive) No. of patients followed Range Mean Mode Location of practice Rural (township, municipality) Urban setting (city) Both rural and urban
Focus Group (n 5 14), n (%)
Survey (n 5 54), n (%)
1 (7)
n 5 53 10 (19)
8 (57)
13 (24)
3 (21) 2 (14)
19 (36) 11 (21) n 5 54 22 (41) 6 (11) 26 (48) 0 (0) n 5 54
4 (29) 0 (0) 10 (71) 0 (0)
6 (43) 5 (36) 5 (36) 6 (43) 8 (57) 4 (29) 1 (7)
0 (0) 7 (50)
20 (37) 32 (59) 14 (26) 12 (22) 28 (52) 13 (24) 2 (4) n 5 53 2 (4) 12 (23) 16 (30) 23 (43) n 5 54 0 (0) 10 (19) 5 (9) 39 (72) n 5 54 3 (6) 18 (33)
7 (50)
33 (61)
5-400 175 Bimodal 100, 120 n 5 14 2 (14) 11 (79) 1 (7)
25-800 280 100
1 (7) 4 (28.5) 4 (28.5) 5 (36) 0 (0) 0 (0) 4 (29) 10 (71)
n 5 54 6 (11) 48 (89) 0 (0)
RD, registered dietitian; SGA, Subjective Global Assessment.
feedback, no significant changes were made to the transcripts or theme development. Survey The online platform Qualtrics software, Version May 2018, CopyrightÓ 2018, was used for the 40-question survey (Appendix 2) which took approximately 15 minutes to complete. A total of 54 participants completed the survey.
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Analysis and Data Management An inductive thematic analysis approach was used to analyze the focus group transcripts.40 Removal of participant names and identifiers helped ensure data confidentiality as did sharing transcripts with only one co-investigator. Two researchers actively reviewed transcripts and contributed to the analysis. Quotes that appeared to provide insight into the research questions were highlighted and subsequently coded which formed the backbone for emerging sub-themes.36 The majority of sub-themes were present in both focus groups, while some important sub-themes from just one of the focus groups were included based on the researcher’s understanding of the topic of interest.36 Sub-themes were then developed into survey questions (Appendix 2). Responses to survey questions used Likert agreement scales41 and were analyzed using descriptive statistics.42 Agreement responses supported the use of sub-themes in the final theme development. Method triangulation, a strategy to strengthen credibility, was carried out by comparing the literature with the themes that developed from focus groups and survey results to determine similarities in findings.36,43 Rigor Study credibility was addressed by reflexive journaling throughout the research process—allowing for transparency of researcher bias, preconceptions, and how the relationship with participants may affect their contributions.39,43 In addition to being the main contributor to the research process, including facilitating the focus groups, the main researcher was a peer of focus group participants. Ideally, this contributed minimal concern from participants around power differential.39 In addition, an audit trail was kept to improve confirmability and dependability.39 Transferability, the provision of sufficient details of the research process, is found in the audit trail as well as assessing agreement of focus group themes with a larger survey.36
Results Demographic Results Fourteen renal RDs participated in 2 focus groups (n 5 6 and n 5 8) and the survey had a 22% response rate (54/250). Of the 68 renal RDs (Table 1) who participated in the focus groups and survey, 100% had some SGA training (Fig. 2). Frequency of use of SGA is noted in Figure 3. Figure 4 describes the proportion of survey respondents who use SGA to determine a patient/client’s change in nutritional status. Although significance was not calculated, of those who rated themselves as ‘‘expert,’’ 19/40 (48%) of participants used the SGA occasionally or often, similar to those who rated themselves as proficient, 12/25 (48%). Renal RDs with greater than 10 years of experience, 24/50 (48%), compared to those with less than
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Figure 4. Usage of SGA to determine change in nutrition status. SGA, Subjective Global Assessment. Figure 2. Usage of SGA with training. RD, registered dietitian; SGA, Subjective Global Assessment.
10 years of experience, 8/18 (44%), used SGA occasionally or often.
Theme Development Five main themes and 9 sub-themes emerged from the focus group and survey results. 1. Consistency of practice: Consisting of the subthemes (i) standardization and (ii) face validity. i. Standardization: Data from the focus groups suggested that having a tool to help assess nutrition status of clients is important for standardization of practice—43/54 (79%) of survey participants agreed (Appendix 2, Q10) and 38/54 (70%) felt it was important to have a tool to provide that standardized process (Q11). ‘‘.very important to have a tool to assess nutrition status because it creates a standardized process, ensures a quality in the care we provide if we all are basing our assessment on best practice standards.’’ (P2)
Figure 3. Usage of SGA by renal dietitians. SGA, Subjective Global Assessment.
ii. Face validity: The majority of participants agreed with 5 common components of nutrition assessment (Q12-16) (Fig. 5). Further questions revealed that 32/42 (76%) of participants agreed that using SGA encourages them to include a physical examination in their nutritional assessment (Q37). SGA ‘‘forces’’ you to do more physical assessment – ‘‘being a bit more thorough than just looking at the trends.’’ (P3a)
Of those renal RDs who do not use or do not always use SGA, 20/50 (40%) either rarely or never include a physical examination in their nutritional assessments (Q38), with only 3/20 (15%) of these participants practicing in CKD clinic areas. Also of note, 25/50 (50%) of participants indicated that their confidence in performing physical assessment was a barrier to their using SGA (Q39). ‘‘I think the physical exam is still the most challenging part for me. I think it’s easy to look at how much weight clients lost.but sometimes I’m limited by what they’re wearing and sometimes it’s my training and experience of doing physical assessments, to really feel 100% confident.’’ (P4a)
2. Organizational/Environment: Consisting of the sub-themes, SGA limited by (i) time, (ii) privacy, and (iii) concerns about the use of SGA results by health organization administration. i. Time: Of those renal RDs working in a clinic setting, 35/43 (81%) agreed they did not have adequate time to include SGA in their nutritional
Figure 5. Dietitians agreement of importance of nutritional assessment components. GI, gastrointestinal.
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT
assessment (Q31) compared to 23/42 (55%) of renal RDs who work with dialysis patients and specified that they did have adequate time (Q32). Of those renal RDs who noted that they do not have adequate time, more than half follow greater than 200 patients, 21/34 (62%). ‘‘.I think a big challenge would be time restraints in a clinic setting, an outpatient clinic setting’’ (P7a) ‘‘I definitely have more time to use it in the in-center dialysis clients, because I can easily go and follow them up with recommendations.’’ (P4a)
ii. Privacy: An additional barrier to the use of SGA mentioned by participants and agreed upon by 38/50 (76%) of survey respondents was a lack of privacy in the dialysis unit/clinic or what patients/clients wear (Q28). ‘‘In the out-patient setting the biggest barrier is how patients are dressed.physical assessment is particularly challenging while patients are hooked to a hemodialysis machine’’ (survey participant) ‘‘.awkward and not overly practical in a community setting to do an SGA - having patients in a waiting room or in their hemo chair with other people around them’’ (P3)
iii. Administrative use: In an era of increased need to support dietitian intervention and outcomes, documentation and validated tools are being encouraged as part of standardized care. Concerns were noted about use of SGA results by health organization administration in Canada. Survey participants, 38/42 (88%), agreed that if SGA is to be used to justify renal RD service funds, it should be used in conjunction with the time spent performing the entire patient/client’s nutrition assessment and implementing nutrition intervention(s) (Q33).
‘‘For patients we follow long term you have a sense of whether they are malnourished’’ – ‘‘whether it’s chronic malnutrition or it’s acute just by the change - the visual change’’ (P5) SGA ‘‘Validates your other assessment, but I still feel like your overall nutrition assessment without it is just as important if not more important’’ (P3)
Of those who felt comfortable enough with the SGA tool to answer the question, 28/41 (69%) felt they were more likely to use SGA when they suspected a patient/client was malnourished (Q21). Similarly, 27/41 (66%) agreed that they were more likely to use SGA when they were uncertain of nutrition status (Q24). ‘‘Sometimes I feel like I don’t use it because it’s obvious one way or another and I can tell from looking at the patient.I tend to prefer to do it on patients who I’m a little less sure of, more in the middle ground.’’ (P4a)
4. Interpretation: Consisting of the sub-themes of (i) challenges with the ‘‘B’’ category and (ii) a lack of objectivity when assessing functional capacity. i. Challenges with ‘‘B’’ category: Participants commonly spoke about the challenges of interpreting SGA. This was confirmed by 39/51 (76%) of survey participants who felt it was difficult to interpret the SGA ‘‘B’’ category (Q27). ‘‘With transfers of SGA it becomes a bit challenging given the grey area of B – one person’s B might be closer to a C or to an A – I feel your charting and assessment is a better indicator’’ (P8a)
ii. Objectivity of functional status: Participants agreed, 28/51 (55%), that functional capacity was challenging to interpret (Q35). In addition, 35/50 (70%) of participants would prefer a more objective measure to assess functional capacity (Q36).
‘‘My fear is that it becomes only clients with SGA B or C are going to get nutrition intervention and time with RDs.’’ (P4a)
RD would prefer to use more objective measure in addition to clinical judgment. Hand grip strength would provide a more meaningful result – ‘‘I like having objective measures’’ (P2a)
‘‘I don’t think it’s the only way to measure who needs nutritional intervention.I think part of that is someone looking at that as a stand-alone tool – if you look at the tool itself and not the assessment’’ (P7)
‘‘I always wonder, what comes first, the malnutrition that causes the dysfunction or the dysfunction in the person’s physical capacity that leads them to not be able to get food.’’ (P6a)
3. Confidence: This theme developed from the focus group discussions and consists of sub-themes of RD use of clinical judgment in place of SGA. Seventy percent of participants (36/51) agreed that they felt their clinical judgment was adequate to assess malnutrition without using SGA (Q23).
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5. Education: Consisting of the sub-theme benefits of SGA as a supportive educational tool. Of those RDs who are preceptors, 24/31 (77%) felt that the use of SGA promoted a positive educational experience between preceptor and dietetic students (Q29). Participants also agreed, 31/41 (76%), that SGA is a useful tool to educate patient/clients about nutrition (Q30).
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MESSENGER ET AL ‘‘.tool made me look at clients differently.when I talked to patients about muscle wasting and the changes that happen, they sort of buy into, ‘oh yes’, I have noticed muscle loss..I do need to take my protein powder’’ (P5) ‘‘I had an intern and we used the SGA on a few of our hemodialysis clients and it was a really good learning experience’’. ‘‘to look at the difficult signs and be more comfortable with that right from the beginning of her training.’’.‘‘also created a good debate between us’’ (P4a)
Lack of Consensus There were themes/sub-themes that emerged from the focus groups but lacked consensus from the survey including the following: (1) ‘‘SGA does not change my intervention or recommendations’’; (2) ‘‘I feel that I am duplicating my charting when I include SGA’’; and (3) ‘‘I do not see value in the SGA.’’ Of note, some focus group participants have been requested by administration to use SGA in their practice; however, this information was not formally collected in the survey. There may be a relationship between participants who use SGA by choice versus by request and their overall impression or clinical value of SGA.
Discussion The results of this study show that renal RDs are supportive of using a tool to standardize practice and see SGA as a useful tool to help educate patients and interns. Some renal RDs felt their clinical judgment was adequate without the use of SGA to assess nutrition status, and relative to other components fewer felt the physical assessment was an important component to nutrition assessment. Challenges noted with SGA use include time, privacy, confidence in physical examination, subjectivity of the tool, and how SGA results are utilized by health organization administration. As well, interpretation of functional status is a concern for renal RDs. In this study, participants’ use of SGA often (16%) was comparable to the 14% (n 5 59) noted by the Canadian McKnight et al. study27; however, they did not differentiate between often and occasional use. If we combine often and occasional use in this study (47%), it is comparable to data from the Australia28 and US29-31 studies as well the 34% use noted in a Canadian acute care center.44 Given renal RD’s support for having a standardized process to assess nutrition status and a tool to direct the process, it may be beneficial to include a brief discussion during SGA training about the validation and reliability studies in the CKD population.9,10,12,14 Having background knowledge of how a tool has been validated may support a renal RD’s understanding of and ability to discuss the tool and how it contributes to a standardized process and ultimately patient care. Barriers to using SGA reported in the literature included insufficient training, lack of privacy,30 time, skill, and
self-efficacy.28,45 Similar barriers were identified in this study—lack of privacy including what a patient is wearing, confidence in skill level specific to physical assessment, and limited time to allow for completion of the SGA. Insufficient training was not a common theme from the focus groups. However, it does appear that training quality may be important given results suggest that including hands-on in addition to theory training may promote SGA use in practice (Fig. 1). Of those renal RDs who ‘‘do not’’ or ‘‘do not always’’ use SGA, 40% do not include a physical component in their nutritional assessment. Also of note, 50% of renal RDs surveyed had concerns regarding their confidence in performing physical assessment and it acted as a barrier to their use of SGA. Studies have shown that alterations in muscle and fat mass are the most common finding in identifying PEW18,14 and that muscle wasting is associated with mortality in hemodialysis patients.46 Given its role in whole body homeostasis, preservation of muscle mass is a vital goal of treating PEW.4 This also suggests the need for continuing education opportunities for renal RDs focused on hands-on techniques of physical examination. A lack of time was a limitation to the use of SGA for 81% of renal RDs working in a clinic environment. The PG-SGA tool has been shown to have high sensitivity (83%) and specificity (92%) at predicting SGA category and may help triage patients.16 It is important to note that the PG-SGA may have limitations with patients or caregivers who are unable to complete the tool due to cognitive impairment or language barriers. SGA requires a practitioner to utilize clinical judgment; however, in this study, renal RDs often feel their judgment alone is as valuable as SGA in confirming malnutrition. This response is supported by Polanyi’s description of ‘‘tacit knowledge’’ where professionals act on their knowledge without having to articulate their actions.47 This may be an efficient process, but the limited ability to explain what one knows can create a lack of credibility.47 Given renal RDs feel SGA promotes a positive educational experience for patients and interns, it is helpful to have a tool to support their judgment. A quick screening tool may also help validate renal RDs’ judgment while decreasing work load of performing SGA on every patient. The Geriatric Nutritional Risk Index has shown promise as a screening tool.48,49 However, further discussion and validation would be required for this tool to be used in other demographics. A considerable number (76%) of participants noted difficulty in interpreting the ‘‘B’’ category of SGA. The validated CANUSA version of 7-point SGA12 provides an opportunity for clarity, but may have an impact on the overall reliability of the tool given its measure of inter-observer reliability (weighted kappa 5 0.52).15 Cooper et al.10 showed the original SGA version to have a moderate inter-observer reliability as well, but with a
PERCEPTIONS OF SUBJECTIVE GLOBAL ASSESSMENT
slightly higher weighted kappa (0.60). Steenson et al.50 showed improvements in IRR with increasing clinical experience of administering the A/B/C version of SGA, supporting the need for initial and on-going training to maintain a high IRR for users of the SGA tool. Responsiveness is a measure of a tool’s ability to detect change in its construct and is determined using effect size or standardized response mean.51,52 In the case of the SGA, the construct is nutritional status. Limited studies have been performed in regard to SGA and its responsiveness. This may be related to the fact that the SGA is multi-dimensional and each component of SGA has a different measurement scale (categorical or continuous). Campbell et al.8 address the debate of whether it is appropriate or not to report the total SGA score as a true continuous variable. The challenge with the 1-7 rating is the inability to report half value scores (i.e., 3.5/7). Furthermore, measures with limited number of categories, as in the SGA A/B/C, tend not to be responsive given a large change is required to change a category.53,54 It could be argued that this suggests that SGA is better used as a tool to describe the nutritional status of a patient or client at a distinct point in time but not to determine a change in nutrition status over time.54 Of the survey participants, 39% used SGA often or occasionally to determine a change in nutrition status of their patient/ clients over time which suggests the need to discuss how the SGA tool is used in practice. The majority of study participants wanted to see more objective measures to help assess the functional component of SGA. Hand grip strength (HGS) is an objective measure that may meet this need. In an observational study, Matos et al.55 reported a higher risk of death in male patients on hemodialysis for those with lower HGS (HR 3.35, 95% CI 1.67-6.73 for men; HR 1.10, 95% CI 0.49-2.46 for women) after taking into consideration covariates. Although limitations exist, HGS may be a useful adjunct to SGA and further investigation into its use to assess nutritional and functional status in dialysis patients is needed.56,57 In the interim, it may be useful for practitioners to know that the Detsky et al.58 version of SGA does not differentiate between a decline in functional capacity due to nutritional or non-nutritional changes. As well, functional capacity has less of a weighting on the end SGA score compared to weight loss, dietary intake, and fat/muscle loss.58 Concerns were expressed about how the results of SGA are used by administration. Although there is currently no policy linking the use of SGA scores to support RD time, concerns were expressed that it may be used for this purpose in the future. During focus group conversations, there were fears noted that only patients with SGA B or C rating would have supported time with a renal RD. As noted by participant comments, it is possible for a patient to have an SGA rating of A, but still require nutrition
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intervention. In contrast, a patient may be an SGA C but have limited intervention by the renal RD given the circumstances. Participants questioned how these types of issues are addressed by administration and feel that SGA scores should be considered in conjunction with the whole nutrition assessment including interventions. It may be helpful for nutrition managers and educators to communicate the application of SGA statistics with renal RDs and to share how SGA statistics are used to support renal RD time. Limitations of this study include having only 2 focus groups—additional focus groups may have provided further saturation of themes. As well, a more evenly distributed proportion of participants geographically and years of experience may have contributed different results. The longer survey length of 40 questions may have influenced participant responses. Finally, more than one peer debriefer may have enhanced study credibility. Despite these limitations, this was the first study to assess in-depth renal RDs’ perspectives on SGA and its use in clinical practice. Ideally, these views will provide background to support renal RDs in their daily clinical practice assessing nutrition status and to improve overall patient care in CKD clients.
Practical Application In order for a validated nutrition tool to be used by clinicians it needs to be practical and appropriate for the clinical practice area. In some situations, different versions of SGA or a validated screening tool, despite its limitations, may improve rates of standardized documentation of nutrition status or risk by renal RDs. Findings of this study support the need to provide education to SGA users on (1) the value of using a valid, reliable, responsive tool; (2) hands-on physical assessment practice; and (3) how SGA results are compiled and used by administration.
Acknowledgment The authors would like to thank Dr. K. Campbell, PhD, for the discussion and input regarding the responsiveness of the SGA tool. The authors would also like to thank the Fraser Health dietitians involved in piloting the focus group and survey questions as well as the Department of Evaluation and Research Services in Fraser Health for supporting the revision of this manuscript.
Supplementary Data
Supplementary data associated with this article can be found in the online version at https://doi.org/10.1053/j. jrn.2019.04.004.
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