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DLM: Self-Management and Individualized Counseling (2001)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The study purpose was to describe the physician-to-dietitian referral process and dietitian practice patterns and opinions related to adult outpatients with hypercholesterolemia.

Inclusion Criteria:
  • Minnesota RDs registered with the American Dietetic Association (ADA) 
  • Minnesota dietitians (RDs) working who treat adult outpatients referred by physicians for hypercholesterolemia.
Exclusion Criteria:

RDs who did not see any patients referred primarily for hypercholesterolemia (e.g., diabetics who were obese or had high serum cholesterol levels, but primarily referred for diabetes).

Description of Study Protocol:

Study Design

Cross-sectional survey by mail.

Instruments and Variables

  •  Nine-item Screener Survey: Basic demographics
    • Age
    • Educational degrees
    • Work status
    • Practice location
    • Types of patients seen
  • 36-item Survey: Practice patterns (data was collected on patients referred for hypercholesterolemia and then compared to patients referred for obesity or diabetes)
    • Demographics
    • Patterns related to dietitian visits with patients
    • Dietitians' opinions about the most effective nutritional intervention protocols for these patients and barriers to achieving them
    • Nature and mechanisms of information flow between physicians and dietitians
      • Quantitative instruction from the referring physician were defined as those with a clear quantitative value attached (e.g., 1800kcal American Diabetes Association, American Heart Association Step 1 or 1200 calorie reduction)
      • Background information from the referring physician was defined as information that was relevant to a patient's ability to modify his or her behavior, such as other medical problems, family or socio-economic factors and intellectual capacity
      • Follow-up was defined as dietitian-initiated rather than patient- or physician-initiated
    • Dietary assessment methods.

Data Analysis

  • Group comparisons for categorical data were assessed using chi-square tests
  • Continuous data were assessed with Student's T-test or ANOVA
  • Ordinal data and comparisons between continuous variables with non-normal distributions were assessed using the Friedman test for three or more variables and the Wilcoxon Signed Rank Test for two variables.
Data Collection Summary:

Recruitment

  • Participants were recruited in two stages: 
    • In the first stage, all Minnesota RDs who were registered with the American Dietetic Association (N=1,101) were sent a nine-item questionnaire to screen for the appropriate study population
    • In the second stage, a second survey (36-items) was mailed to all dietitians who, based on the first stage survey, saw adult outpatients with hypercholesterolemia who were referred by physicians
  • Follow-up: Reminder postcard and second mailing of 36-item survey were sent out  two and four weeks, respectively, after the first mailing.
Description of Actual Data Sample:

First Stage

  • 993 out of 1,101 RDs returned the survey (90% response rate)
    • 485 (49%) were practicing full-time
    • 325 (33%) part time
    • 178 (18%) not practicing
    • Of the 810 responding practicing dietitians:
      • 353 (44%) saw adult outpatients referred by physicians, including
      • 299 (37%) who saw outpatients with hypercholesterolemia.

Second Stage

  • 257 of 299 RD’s returned the questionnaire (86% response rate)
    • No deliverable address: N=1
    • Blank or incomplete survey: N=9
    • Indicated they did not meet eligibility requirements, despite saying so during the first stage survey: N=32
  • Final N: 216.

Description of Final Sample

 Respondents and non-respondents did not differ on age, education, work status or geographic practice distribution.

  • 47% of the RD’s were from the St. Paul/Minneapolis area
  • Mean age: 39.7±9.6 years
  • 99% Female
  • 69% earned Bachelors, 30% Masters
  • 50% employed full-time and 50% employed part-time
  • 67% consulted at the same location as referring physician (on site); 33% off-site
  • Mean number of referred adult outpatients per month: 31±35 (range=1 to 200, median 20)
  • Mean percent of patients seen primarily for:
    • Hypercholesterolemia 31±21
    • Diabetes 31±25
    • Obesity 24±18.
Summary of Results:

 

Variables Total On-site Off-site P-Value

Physician-to-Dietitian Information Transfer (mean ± standard deviation)

        
Percent time clinic chart available (%) 55±46 75±38 13±31 <0.0001

Percent time quantitative instructions provided by physician for:

  • hypercholesterolemia (%) 
  • diabetes (%) 
  • obesity (%) 
 15+25
30+32
19+26		 15+26
27+30
17+25		 14+24
38+33
24+28		 0.77
0.02
0.07

Percent time background information was provided by physician for:

  • hypercholesterolemia (%) 
  • diabetes (%) 
  • obesity (%) 
 37+37
37+37
32+36		 45+38
46+38
41+38		 20+27
19+27
14+23		 <0.0001
<0.0001
<0.0001
Physician-to-Dietian Communication Methods, Prefer this Method, % (Rank)        
     Written Consult from physician (%)  37 (1) 44 (1) 25 (3)  
     Oral Consult from physician (%)  26 (2) 21 (3) 36 (1)  
     Reviewing the chart (%)  20 (3) 24 (2) 9 (4)  
     Speaking with staff (%)  14 (4) 7 (4) 27 (2)  
     Speaking with the patient (%)  4 (5) 4 (5) 3 (5)  
Physician-to-Dietian Communication Methods, Use this Method Almost Always or Always, % (Rank)        
     Written Consult from physician (%)  53 (1) 61 (1) 37 (2)  
     Oral Consult from physician (%)  9 (5) 10 (5) 9 (4)  
     Reviewing the chart (%)  24 (3) 34 (2) 4 (5)  
     Speaking with staff (%)  28 (2) 18 (3) 49 (1)  
     Speaking with the patient (%)  19 (4) 13 (4) 31 (3)  
Dietitian Satisfaction, Absolute %        

Satisfaction with Information Provided:

  • Hypercholesterolemia (%) 
  • Diabetes (%) 
  • Obesity (%) 
 43
42
37		 56
52
49		 15
18
10		 <0.0001
<0.0001
<0.0001

Satisfaction with Physician Expertise:

  • Hypercholesterolemia (%) 
  • Diabetes (%) 
  • Obesity (%) 
 48
43
30		 53
47
32		 39
37
26		 0.19
0.39
0.38

Belief Physician Ignores Feedback when Making Medication Initiation:

  • Hypercholesterolemia (%) 
  • Diabetes (%) 
  • Obesity (%) 
 26
21
N/A		 20
15
N/A		 38
34
N/A		 0.03
0.04
N/A

Dissatisfied with Number of Return Visits:

  • Hypercholesterolemia (%)
  • Diabetes (%)
  • Obesity (%)
 42
51
59		 38
49
54		 50
53
67		 0.07
0.22
0.01

Information Transfer

  • Chart availability and background information from the physician varied by practice location with off-site dietitians having less access to patient charts and background information
  • Hypercholesterolemia Group vs. Diabetes and Obesity Groups: The physician was more likely to provide quantitative instructions for diabetes and obesity patients compared to patients seen for hypercholesterolemia (P<0.0001 and P=0.02, respectively). The physician was more likely to include background information for obesity patients compared to hypercholesterolemia patients (P=0.0002), but there was no difference between hypercholesterolemia and diabetes patients (P=0.76).

Communication Method

  • The communication method used most frequently and most valued overall was written communication from the referring physician
  • Dietitians preferred more oral consultation with referring physicians than they reported having
  • Speaking with the patient is the least preferred method for determining the reason for the visit.

Satisfaction

  • Dietitians' satisfaciton with the amount of information provided to them by referring physicians was directly related to how often that background information was provided, regardless of referral reason (r=0.5, P<0.0001). No relationship was found between satisfaction and how frequently quantitative instructions were provided.
  • About 1/4 of respondents perceived that physicians pay little or no attention to the dietitian's feedback, when deciding to begin a medication regimen for their patients with hypercholesterolemia or diabetes. Off-site dietitians were twice as likely as on-site dietitians to express this view.
  • Hypercholesterolemia Group vs. Diabetes and Obesity Groups: Dietitian satisfaction was higher for patients with hypercholesterolemia compared to patients with diabetes or obesity (P<0.0001 for all).

Follow-Up

  • The dietitian recommended at least one follow-up visit for 42% of hypercholesterolemia, 60% of diabetic and 70% of obese patients. The recommendations were bimodal with modes at both extremes (never and always recommending follow-up).
  • The number of follow-up sessions recommended by the dietitian was 2.0 for hypercholesterolemia, 3.5 for diabetes mellitus and 6.7 for obesity. The actual number of follow-up visits within six months was half or less of the number recommended by the dietitian.
  • Dietitians were more likely to recommend six-month maintenance visits (29±37% for hypercholesterolemia) more often than physicians (8±16%). Maintenance visits were more frequently recommended for diabetes and obesity groups compared to the hypercholesterolemia group by the physician and dietitian (P-values vary).

Diet Analysis

  • The dietitian calculated grams of fat intake of clients with hypercholesterolemia only 25±35% of the time, which was similar to 22±34% and 23±33% for diabetes and obesity groups, respectively 
  • Reasons for not calculating grams of fat intake were takes too much time (59.2%), not reimbursed (35.7%), not accurate (34.9%), physicians not interested (23.5%), patients not interested (12.2%) and not useful (10.4%).

 

Author Conclusion:
  • There is a low rate of transfer of important information between the referring physician and the dietitian, regardless of reason for referral. Dietitians were more satisfied when they had access to such information. Referring physicians depended on consulting dietitians to determine specific dietary treatment goals. The recommended and actual number of follow-up visits for patients with hypercholesterolemia was well below what would reasonably be expected to produce significant and sustained eating behavior change. Dietary fat content was generally not calculated by dietitians, not even for patients referred for hypercholesterolemia.
  • Authors recommend physicians communicate relevant patient background information to dietitians when referring adult outpatients, especially when the consultation will occur off-site. Barriers to initial and follow-up referrals for patients with hypercholesterolemia should be investigated.
Funding Source:
University/Hospital: Research Advisory Council, Department of Family Practice and Community Health, University of Minnesota
Reviewer Comments:

Limitations:

  • Self-reported data
  • Did not mention any statistical adjustments for multiple tests (e.g., family-wise error rate) which may lead to type II errors for significance
  • Generalizability limited to Minnesota RDs (a state with high rates of managed care)
  • Dietitians who saw diabetic and obesity patients, but did not see patients for high cholesterol were excluded, so the data on obesity and diabetes groups may be subject to bias
  • The data reflect RDs perspectives, not physician's actions
  • There may be other differences in practice environments that were not measured that may influence outcomes
  • Patient outcomes were not measured.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? No
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? No
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? No
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? No
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes