EAL

TN: Telenutrition Interventions by Registered Dietitians (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The purpose of this pilot study was to determine the effectiveness of a teleconferencing project that would assess the needs of children with complex feeding disorders referred from locations up to 3,500 miles away.

Inclusion Criteria:

Child with a feeding difficulty, as identified by a pediatric care provider
Informed consent provided by family.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment: Children were recruited from the University of Virginia Children's Hospital
Design: Pilot before-and-after study
Blinding used: Not applicable
Intervention: Children, families and health care professionals participated in teleconferences from a site close to their homes, with the remote team at Children's hospital. Remote sites varied from pediatric clinics to universities.
Statistical analysis: Not described.

Data Collection Summary:

Timing of Measurements

Preliminary planning for implementing the program was extensive as this involved conducting a site visit to the University of Virginia Medical Centers Telemedicine program, developing informed consent to make sure family members understood that the teleconference was observed by multiple team members, clarifying legal and medical record issues, pilot-testing equipment at the local facility, securing grant support to purchase and fund equipment, developing evaluation forms for families and Feed Team members, developing information packets to determine appropriate candidates and completing room preparation for optimal viewing on the receiving end.
15 patients participated in the 26-month project from September 2002 to October 2004.

Dependent Variables

Clinical outcomes were appropriateness of eating behavior and the range of foods accepted, increased jaw strength and swallowing ability, decreased in supplemental or tube feeding and decreased family burden as feeding behaviors and success improved
Reduced burden to families and costs of care.

Independent Variables

Children, families and health care professionals participated in teleconferences from a site close to their homes, with the remote team at Children's Hospital. Remote sites varied from pediatric clinics to universities.
The nurse practitioner, psychologist and dietitian conducted the clinical interview and observed the child feeding. The network administrator and case manager were also present.
Follow-up to the sessions was accomplished by phone and with a detailed letter to the child's treating health care provider, documenting findings and recommendations
Additional follow-up with the families participating in the teleconferencing was accomplished through administration of a questionnaire by phone or fax, according to family preference.

Description of Actual Data Sample:

Initial N: 15 children
Attrition (final N): 15 (six girls and nine boys)
Age: Range, eight months to 10 years old; 80% of the children were younger than five years old
Ethnicity: Not described
Other relevant demographics: Children, families and health care professionals participated in teleconferences from a site close to their homes, with the remote team at Children's Hospital. Remote sites varied from pediatrics clinics to universities.
Anthropometrics: Not described
Location: Children's Hospital, Richmond, VA.

Summary of Results:

Key Findings

The children seen resided in 11 states and one foreign country
Typical participants at the remote sites included the child patient, two parents or family members and the child's health care providers. In several cases, a speech therapist attended the session as well as the treating physician.
Participants, both families and health care providers reported a high level of satisfaction with the teleconferencing option for care. Costs were reduced dramatically for families, due to minimizing travel.
Half of the initial consultations resulted in recommendations that enabled the child to be treated effectively in their home community and six children were recommended to travel to the intensive day program at the Children's Hospital for an appropriate six-week stay. These included recommendations for additional tests (such as gastrointestinal studies, swallow studies), a specific therapeutic approach (such as Beckman oral motor exercises), behavioral
interventions or medication.
Other children demonstrated similar successes, with improvement in the age
appropriateness of their eating behavior and the range of foods accepted, increased jaw strength and swallowing ability, decreases in supplemental or tube feeding and decreased
family burden as feeding behaviors and success improved.
Children, families and health providers reported a high level of satisfaction with the teleconferencing program and costs were reduced dramatically for families due to minimizing travel. Cost savings were captured by using online travel search engines to identify the cost of pre-planned coach air travel for the child and one family member, as well as local per diems of $74 for one night of lodging and $64.50 per day for meals for two days. For participants in the United States, costs of travel to the program for transportation, food and lodging, alone averaged $917, as compared to less than $20 for a locally-based teleconferencing session. Missed work time was not included in these calculations. For many of the families, this cost differential made the difference between access and no access.

Author Conclusion:

The availability of a teleconferencing option for screening and follow-up care enables community-based pediatricians to provide comprehensive care and to maintain excellent communication and follow-up when treatment at a distant specialty program is required.

Funding Source:

University/Hospital:	Children's Hospital, Richmond, VA
Other:	Nordstrom

Reviewer Comments:

The authors did identify some technical difficulties with the teleconference connection. This resulted in at least brief interruptions in the flow of the conference, as the two sites had to be reconnected.

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)	Yes

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?	No
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	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?	Yes
	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?		No
	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.)	No
	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?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	No
	6.6.	Were extra or unplanned treatments described?	No
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	No
	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?		Yes
	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?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	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?	No
	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?	No
	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)?	No
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	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