MNT: RDN in Medical Team (2015)

Jhagroo R, Nakada S, Penniston K. Shared medical appointments for patients with kidney stones new to medical management decrease appointment wait time and increase patient knowledge. The Journal of Urology. 2013; 190: 1778-1784. PubMed ID: 23707453
Study Design:
Before-After Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To test whether shared medical appointments (SMAs) could be suitably adapted to our multi-disciplinary kidney stone clinic
  • To:
    • Reduce wait times for new patient appointments (from six to three months or less)
    • Improve physician productivity
    • Expand the number of new patients exposed to nutrition
    • Assess patient satisfaction with SMAs.
  • To focus on new patient visits, as these are generally ones in which standard information is provided and because it would impact our goal of initiating prevention close to a recent event.
Inclusion Criteria:
Not described.
Exclusion Criteria:
Not described.
Description of Study Protocol:


SMA was offered to patients via scheduler; if accepted, they were routed into the study.


Before-and-after study.



  • Vitals would be taken but no physical examinations were done
  • Learning objectives and a curriculum were developed for a visit, which was to last no longer than 90 minutes
  • A consent form for participation and sharing of medical information in a group setting was designed by our institution
  • After collecting patient consent forms, each visit began with a presentation introducing them to the SMA and providing general background information. This included epidemiology, renal physiology, pathophysiology and risk factors, all presented by the urologist or nephrologist.
  • This was followed by a focused diet assessment of each patient, conducted by the RD, who then gathered individual medical histories and reviewed each patient’s 24-hour urine study, which was projected at the front of the room
  • Next, clinical decisions regarding medical and nutritional management were discussed with patients in the group setting. Each patient was provided a checklist that identified his or her specific risk factors.
  • Finally, nutrition education was provided, including practical strategies to address common risk factors. Patients were reminded to focus especially on therapies for individual risk factors, which had been identified during individual rounds. At the end of the visit, the RD left and the MA returned to administer a patient satisfaction survey and two brief tests to determine patient understanding of core nutrition concepts.
  • At checkout, patients received follow-up information and scheduled their next appointment.
Data Collection Summary:

Timing of Measurements

Questionnaires and surveys completed upon exiting SMAs.

Dependent Variables

  • Nutrition knowledge (urinary Ca and diet)
  • Patient satisfaction
  • Appointment wait time.

Independent Variables

Attending SMA.

Control Variables

SMA visit.

Description of Actual Data Sample:
  • Initial N: N=112 patients seen in 27 SMAs (55% female) in 14 months
  • Attrition (final N): N=112 (0% attrition)
  • Age: 51±14 years (19 years to 87 years)
  • Ethnicity: 94% Caucasian
  • Location: Madison, Wisconsin, US.


Summary of Results:

Key Findings

Appointment wait time decreased steadily from 180±77 days before shared medical appointments to 84±39 days. The number of patients seen per month increased by 43%. The number of new clinic patients, which includes those seen in shared medical appointments and in individual appointments, who received nutrition education and intervention increased from approximately 50% before shared medical appointments to nearly 75%. Patients who attended a shared medical appointment overwhelmingly (87%) rated their satisfaction as excellent or very good; 90% of patients said they would recommend this kind of visit to others. Post-tests revealed that patients in shared medical appointments had superior knowledge regarding urinary Ca and diet (P<0.02) compared to controls.

Author Conclusion:
Shared medical appointments can be an efficient way to evaluate and manage new patients for urolithiasis prevention. Patient satisfaction was high and knowledge about prevention was higher than that of patients seen in individual appointments.
Funding Source:
University/Hospital: University of Wisconsin Health Ambulatory Care Innovation Grant Program
Reviewer Comments:
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? ???
  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? ???
3. Were study groups comparable? ???
  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? ???
  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? No
  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? ???
  4.1. Were follow-up methods described and the same for all groups? No
  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%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  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? Yes
  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? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? ???
  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? 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? 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? ???
  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? ???
  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? ???
  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)? N/A
  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? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
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