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MNT: RDN in Medical Team (2015)

Citation:

Beck A, Andersen UT, Leedo E, Jensen LL, Martins K, Quvang M, Rask KØ, Vedelspang A, Rønholt F. Does Adding a Dietician to the Liaison Team After Discharge of Geriatric Patients Improve Nutritional Outcome: A Randomised Controlled Trial. Clinical Rehabilitation, 2014; Dec 31. Epub. ILL number: 37101937.
 

PubMed ID: 25552522
 
Study Design:
Randomized Controlled Trial
Class:
A - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:
To test whether adding a dietitian to the discharge Liaison-Team after discharge of geriatric patients improves nutritional status, muscle strength and patient relevant outcomes.
Inclusion Criteria:
  • Nutritional risk according to the level 2 screening in NRS2002 (a mandatory tool in Danish hospitals)
  • Received nutritional support via commercial oral nutritional supplements
  • Planned to be discharged to their private home assisted by the discharge Liaison-Team.
Exclusion Criteria:
  • Suffered from dementia or terminal disease
  • Impaired renal function
  • Unable to understand Danish language
  • Residing in nursing homes or rehabilitation homes
  • Incapable of performing hand-grip test
  • Planning a weight reducing diet
  • Unable or unwilling to give informed consent.
Description of Study Protocol:

Recruitment

All older (70 years or older) patients hospitalized at the Geriatric Medicine and Orthopaedic Surgery wards at Herlev Hospital were screened for nutritional risk and inclusion in the study.

Design

  • The study was designed as a 12-week RCT comparing standard discharge Liaison-Team (control) vs. discharge Liaison-Team in cooperation with a dietitian (intervention)
  • Simple randomization was used to allocate patients to groups
  • All included patients were followed home by a member of the discharge Liaison-Team, which consisted of a nurse, occupational therapist a physiotherapist
  • The agenda for the discharge Liaison-Team visit was as follows:
    • Testing and installation of aids (e.g., walking aids)
    • Reviewing of the discharge letter, medication list, prescriptions and use of medication
    • Contacting the discharging ward, home care and general practitioner, if relevant
    • Writing a discharge Liaison-team note in the Electronic Patient Journal and forwarding to the home care and general practitioner
    • Additional follow-up visits or contacts by telephone, if relevant.
  • Patients were followed for hospitalization and mortality for six months.

Blinding Used

Participants, dietitians, research assistants and the discharge Liaison-Team were not blinded to group assignment.

Intervention

  • For the intervention group, the dietitian joined the discharge Liaison-Team when the patient was discharged from the hospital
  • Before discharge, the dietitian prescribed oral nutritional supplements, if relevant
  • The dietitian performed a total of three home visits over a period of 12 weeks
    • The first visit took place on the day of discharge together with the discharge Liaison-Team in the patient’s home. During this visit, the dietitian performed an individual nutritional assessment focusing on dietary intake, activity level and weight of each participant as a basis for developing an individual nutrition care plan consistent with estimated nutritional requirements and nutritional rehabilitation goals.
    • The second and third visits, which were performed by the dietitian alone, took place approximately three and eight weeks after discharge, respectively. The aim of these visits was to implement the individual dietetic advice and optimize nutritional status by way of reviewing the nutrition care plan, dietary counseling, motivation and education, monitoring weight and ensuring that energy and protein requirements were achieved.
  • If relevant, the participant would receive a follow-up consultation by telephone by the dietitian in between home visits. 

Statistical Analysis

  • Power calculation estimated that 40 patients in each group (80 total) were required for a power of 80%
  • Analyses used intent to treat principles
  • Wilcoxon signed rank sum test, Mann-Whitney U-test, odds ratio, Pearson chi-square or Fisher’s Exact test of associations were used as appropriate.
Data Collection Summary:

Timing of Measurements

Just before discharge and 30 days, 12 weeks and six months after discharge.

Dependent Variables

  • Nutritional status
    • Weight
    • BMI
    • Energy and protein intake
    • Intake of supplements.
  • Muscle strength
    • Hand-grip strength (Hydraulic Hand Dynamometer)
    • Leg muscle strength (30-second chair stand).
  • Functional status
    • Mobility (Morton Mobility Index)
    • ADL (Barthel-Index-100).
  • Quality of life: EuroQol-5D-3L
  • Use of social services
  • Hospitalization
  • Mortality.

Independent Variables

Standard discharge Liaison-Team (control) vs. discharge Liaison-Team with dietitian (intervention).

Control Variables

  • Age
  • Gender
  • Diagnoses
  • Cumulated Ambulation Score (describes the patient’s independence with regard to three activities)
  • Mini-Mental State Examination
  • Oral vitamin D supplementation.
Description of Actual Data Sample:

Initial N
71 (23 male, 48 female)

  • Intervention Group: N=34 (12 male, 22 female)
  • Control Group: N=37 (11 male, 26 female).

Attrition (Final N)
63 (31 in the Intervention Group, 32 in the Control Group): 11% dropout rate.

Age
Median: 85 years.

Ethnicity
Not described.

Other Relevant Demographics
Not described.

Anthropometrics
The groups were similar in all baseline characteristics with the exception of the following:

  • 19% of the Control Group vs. 3% of the Intervention Group were discharged to day care with exercise (P=0.033)
  • 14% of the Control Group vs. 48% of the Intervention Group were prescribed oral nutritional supplements (P=0.001).

Location
Herlev, Denmark.

Summary of Results:

Key Findings

  • Data presented as median (95% CI)
  • Intervention had a positive effect on weight, energy intake and protein intake.
  Final Data Changes
Intervention Control P-Value Intervention Control P-Value
Weight, kg 66.1
(58.8; 70.7)
58.7
(56.5; 62.4)
0.041 0.5 (-1.0; 3.1) -0.9 (-3.2; 0.8) 0.025
Energy intake, MJ/d 7.9
(7.4; 9.1)
6.4
(5.9; 7.2)
0.002 1.4
(0.9; 3.0)
0.9
(-0.1; 1.2)
0.168
Protein intake, g/d 71
(59; 84)
52
(41; 57)
<0.001 19
(12; 26)
3
(-4; 15)
0.003
  • Total number of times hospitalized within six months after discharge was significantly lower in the Intervention Group: zero (0; 0) vs. zero (0; 2) (P=0.017)
  • The odds ratio for hospitalization with six months after discharge was 0.367 (0.129; 1.042). The odds ratio for mortality within six months was 0.323 (0.060; 1.724)
  • No differences between intervention and control were seen in functional status, quality of life and use of social services, however some positive tendencies in favor of the Intervention Group were observed in the prevalence who improved their ADL and quality of life.
Author Conclusion:
Adding a dietitian to the discharge Liaison-Team after discharge of geriatric patients can improve nutritional status and may reduce the number of times hospitalized within six months.
Funding Source:
Government: Danish Regions and the Danish Health Cartel
Reviewer Comments:
  • Low participation rate
  • Possibility of contamination between intervention and control groups.
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? Yes
  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? Yes
  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? Yes
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? Yes
  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.) Yes
  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? N/A
  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? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  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? Yes
  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? Yes
  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? Yes
  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)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? Yes
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