Diet in the management of non-dialysis dependent chronic kidney disease: perceptions and practices of health professionals.

BACKGROUND: Therapeutic strategies, including dietary intervention, to target non-dialysis dependent Chronic Kidney Disease (CKD) progression have been at the forefront of recent renal research. Nephrologists and other renal health professionals are key stakeholders in the dietary management of patients with non-dialysis dependent CKD and referrals to dietetic services. The aims of this study were to explore (i) health professional perceptions regarding the role of diet in managing non-dialysis dependent CKD, and (ii) health professional practices regarding the provision of dietary advice and referrals to dietetic services. METHODS: A 31-item online survey was emailed to members of professional renal networks and associations in Australia and New Zealand. Data was analysed descriptively. Categorical variables were assessed to determine associations between referral frequency, demographic variables, health professional role (non-dietetic versus dietetic) and perceptions of the role of diet. RESULTS: Overall, 189 health professionals completed the survey. Nephrologists (42%), renal nurses (29%) and renal dietitians (24%) were the most common respondents. Non-dietetic health professionals rated the importance of diet in the management of non-dialysis dependent CKD significantly lower than renal dietitians (73% versus 98% ranked as very-extremely important, p = 0.002). Fifty percent of non-dietetic health professionals referred patients to renal dietetic services never or 0-25% of the time. Reasons for not referring included perceptions there is a lack of evidence that diet reduces CKD progression, perceptions that patients will not adhere to dietary recommendations, and a desire to reduce visit burden for patients. Barriers to accessing dietetic services were perceived to be significant and include lengthy wait times and inadequate dietetic staffing. CONCLUSION: Inconsistencies exist between non-dietetic health professionals and dietitians regarding the importance of diet in non-dialysis dependent CKD. Referral practices appear to be influenced by beliefs about the evidence base and perceptions regarding the ability of dietitians to meet referral demand. Raising awareness for non-dietetic health professionals working in nephrology regarding the evidence on diet and CKD progression is needed. An improved understanding of this evidence base may improve knowledge and referral patterns. Further, an increase in renal dietetic staffing is recommended to enhance patient access to services.

Health Service Costs for a Predialysis Dietetic Clinic: A Retrospective Cost Analysis Study.

OBJECTIVES: Effect of dietetic consultation (DC) on clinical outcomes is an under-researched component of predialysis education. Predialysis DC has been associated with a 7.5-month delay in requiring dialysis commencement, having potential cost implications for health services. Limited studies have evaluated the possible impact of predialysis DC on health service costs. This study aimed to investigate the hospital health service costs associated for patients attending a predialysis dietetic clinic. METHODS: A cost analysis comparing hospital health service costs over 4 years in a cohort of predialysis patients with and without DC. Retrospective study data were used (n = 246) along with outpatient renal clinic visits, hospital admissions records to estimate total hospital service costs. A generalized linear model evaluated associations between total cost and the marginal effects of DC and other variables on total costs. RESULTS: Mean total cost for patients (outpatient visits, admissions, and dialysis) was AUD$178,913 (95% confidence interval = $158,735-$199,090) or $185/day (95% confidence interval = $12-$161). The DC group total costs/day were lower than the no-DC group with a mean difference of $51/day ($155 vs. $206; P = .03). Patients in the DC group had less admissions compared to the no-DC group (6.32 vs. 8.06; P = .02). The highest marginal costs estimated for the entire cohort were lower estimated glomerular filtration rate at admission ($123,511, P = .001), inpatient admissions ($189,333, P < .001), commencing dialysis ($581,812, P < .001), having diabetes ($94,590, P = .014), and cerebrovascular disease ($177,080, P = .01). DC advice did not influence total costs. CONCLUSIONS: Patients who received DC had lower total health services costs/day compared to those who did not receive DC. Marginal cost analysis indicates the cost difference to be attributed to less time on dialysis and fewer hospital admissions in this retrospective observational cohort. An assessment of dietetic staffing in predialysis renal services is warranted.

Renal supportive care programs: An observational study assessing impact on hospitalization and survival outcomes.

AIM: Renal supportive care (RSC) programs are used to manage non-dialysis end-stage kidney disease (ESKD) patients. The aim of this study was to analyse the impact of RSC programs on hospitalization and survival outcomes in these patients. METHODS: A retrospective, single-centre observational cohort study of non-dialysis ESKD patients was undertaken. Hospitalizations and survival from eGFR≤15 ml/min was compared between patients managed in an RSC program (RSC group) and patients receiving standard conservative therapy (non-RSC group). Local databases, physician letters and electronic medical records were used for data collection. Prevalent patients from 2013 to 2017 with eGFR ≤15 ml/min were included. Cox proportion hazard testing and generalized linear modelling was undertaken to adjust for confounders. RESULTS: A total of 172 patients were included (95 RSC; 75 non-RSC). The median age was 82 years [IQR 78-85], 46% were male, the median Charlson-comorbidity Index was 5 [IQR 4-7]. The RSC group had significantly lowered haemoglobin level (102 g/L vs. 111 g/L) and fewer English-speakers (34% vs. 44%). RSC was associated with the decreased number of days in hospital per year (estimated means 46.6 days [95% CI 21-67] vs. 83.2 days [95%CI 60.5-105.8]; p = .01) and decreased number of hospital admissions per year (estimated means 5.4 [95%CI 2.1-8.8] vs. 12.3 [95%CI 8.2-16.4]; p = .01) compared with non-RSC. Median overall survival from eGFR≤15 in the entire cohort was 735 days, with no significant difference between RSC and non-RSC groups (p = .9), both unadjusted and adjusted for confounders. CONCLUSION: RSC programs can significantly decrease the number and length of hospitalizations in conservatively managed ESKD patients.

Implementation of a peer review program using the validated DIET-COMMS tool to assess dietitians' communication skills in the workplace.

AIMS: Communication is the main method used by dietitians to conduct their practice. Yet, few evidence-based tools are available to assess dietitians' communication skills to guide skill development. Further, workplace peer review programs for assessment of communication skills are not standard practice. DIET-COMMS is a validated tool to assess dietitians' communication skills in patient consultations. The aims of this study were to implement a workplace peer review program using the DIET-COMMS tool, assess dietitians' communication skills, evaluate inter-rater reliability and dietitian satisfaction. METHODS: Single site study within Australian hospital dietetics department. Training for DIET-COMMS usage was undertaken with assessors (senior dietitians) and dietitians being assessed using an online training package and face-to-face group sessions. The peer review process consisted of two rounds, occurring four to six months apart. The first round was undertaken with two assessors to evaluate inter-rater reliability. An online survey was conducted to evaluate dietitian satisfaction. RESULTS: Seventeen dietitians completed the program. In the first round, 13 of 17 dietitians scored 76% to 100% on the DIET-COMMS tool (median = 85%, interquartile range [IQR] = 77-93). All dietitians scored 76-100% (median = 98%, IQR = 94-100) in the second round, with significantly higher scores compared to the first (98% vs 85%; P-value <.001). The intra-class correlation coefficient was 0.86 (95% confidence interval = 0.64-0.95), indicating good-excellent inter-rater reliability. All dietitians reported the tool measured the nutrition care process adequately and was applicable to practice. CONCLUSIONS: The peer review program using DIET-COMMS was successfully implemented within a workplace environment. Widespread implementation of peer review programs using DIET-COMMS is recommended as a standard practice for the profession.

Factors that influence adherence to aspirin therapy in the prevention of preeclampsia amongst high-risk pregnant women: A mixed method analysis.

BACKGROUND: Non-adherence with medications in pregnancy is increasingly recognized and often results in a higher rate of preventable maternal and fetal morbidity and mortality. Non-adherence with prophylactic aspirin amongst high-risk pregnant women is associated with higher incidence of preeclampsia, preterm delivery and intrauterine growth restriction. Yet, the factors that influences adherence with aspirin in pregnancy, from the women's perspective, remains poorly understood. OBJECTIVE: The study is aimed at understanding the factors, from the women's perspective, that influenced adherence with prophylactic aspirin in their pregnancy. STUDY DESIGN: A sequential-exploratory designed mixed methods quantitative (n = 122) and qualitative (n = 6) survey of women with recent high-risk pregnancy necessitating antenatal prophylactic aspirin was utilized. Women recruited underwent their antenatal care in one of three high-risk pregnancy clinics within the South Western Sydney Local Health District, Australia. The quantitative study was done through an electronic anonymous survey and the qualitative study was conducted through a face-to-face interview. Data obtained was analysed against women's adherence with aspirin utilizing phi correlation (φ) with significance set at <0.05. RESULTS: Two key themes, from the women's perspective, that influenced their adherence with aspirin in pregnancy were identified; (1) pill burden and non-intention omission (2) communication and relationship with health care provider (HCP). Pill burden and its associated non-intentional omission, both strongly corelated with reduced adherence (Φ = 0.8, p = 0.02, Φ = 0.8, p<0.01) whilst the use of reminder strategies minimized accidental omission and improved adherence (Φ = 0.9, p<0.01). Consistent communication between HCPs and a good patient-HCP relationship was strongly associated with improved adherence (Φ = 0.7, p = 0.04, Φ = 0.9, p = <0.01) and more importantly was found to play an important role in alleviating factors that had potentials to negatively influence adherence with aspirin in pregnancy. CONCLUSION: This study identified factors that both positively and negatively influenced adherence with aspirin amongst high-risk pregnant women. Is highlights the importance in recognizing the impact of pill burden in pregnancy and the need to counsel women on the utility of reminder strategies to minimize non-intentional omission. Importantly, it emphasizes on the importance of a positive patient-HCP relationship through effective and consistent communication to achieve the desired maternal and fetal outcomes.

The association between dietetic consultation and time to dialysis for patients attending a pre-dialysis clinic: A retrospective cohort study.

AIM: A multidisciplinary approach, including dietetics, is considered the optimal model of care for dialysis preparation. Dietetic consultation (DC) focuses on symptom management and dietary changes to delay time to dialysis. Evidence of the effectiveness of DC on time to dialysis is limited. This study aimed to investigate the impact of DC on time to dialysis for patients attending a pre-dialysis clinic. METHODS: A retrospective cohort study was designed to include all patients attending outpatient pre-dialysis clinics at a large metropolitan renal service between January 2014 and March 2018. Time to dialysis (days) was compared between patients that received DC and those who did not. Cox proportional hazards analysis allowing for adjustment of differences and confounders was undertaken. RESULTS: A cohort of 246 patients was identified. Median estimated glomerular filtration rate was 16mL/min per 1.73 m2 (interquartile range = 13-20) at initial pre-dialysis clinic visit and 63% commenced dialysis during the study period. Only 41% of patients received dietetic consultation. Significantly fewer patients needed to commence dialysis in the DC group compared to the no-DC group (hazards ratio 0.63; 95% confidence interval (CI) 0.45-0.89; P = 0.008 Cox proportion hazard). The DC group commenced dialysis significantly later than the no-DC group; 933 days (95% CI 832-1034) versus 710 days (95% CI 630-790) respectively, after the initial pre-dialysis clinic visit; log-rank 0.005. CONCLUSION: DC provided to patients attending a pre-dialysis clinic was associated with a delayed time to dialysis. Standardised referral pathways to improve patient access to renal dietetic services are recommended to optimise care.

A qualitative analysis of eating behaviour change for patients with diabetes and non-dialysis dependent chronic kidney disease stages 4-5.

BACKGROUND: Dietary changes recommended for chronic kidney disease (CKD) stages 4-5 and concurrent diabetes are difficult to follow given the multitude of food and fluid restrictions aimed at reducing the rate of CKD progression. Reduced adherence is commonplace and there is limited literature on patients' experiences with dietary changes and potential strategies to overcome this. OBJECTIVES: Examine patients' experiences when adopting dietary changes recommended for CKD Stages 4-5 (pre-dialysis) and diabetes, and their perceptions of dietetic services and how they can be improved to assist them with dietary change. METHODS: An exploratory qualitative study was undertaken using a purposive sampling method from a dietetic pre-dialysis clinic. Participants were interviewed using a semi-structured interview style. Data were analysed using an inductive thematic analysis from a constructivist perspective. RESULTS: Three themes were identified: (1) Negative motivation to change eating behaviour to avoid dialysis; (2) sustaining motivation for change is challenging due to a sense of loss and confusion to incorporate the dietary changes recommended and (3) support is needed for eating behaviour change. CONCLUSION: These findings have implications for dietitians to enhance their understanding of the patient experience and improve their skills in motivational counselling. Development of dietitian-specific communication and nutrition counselling programmes are recommended to equip dietitians with skills to better support patients. CKD Stage 3 nutrition education programmes could be beneficial to promote earlier access to dietetic services and dietary recommendations.

Nutrition in Renal Supportive Care: Patient-driven and flexible.

Renal Supportive Care is an alternative treatment pathway in advanced chronic kidney disease that is being increasingly adopted, particularly in the elderly. Renal Supportive Care uses principles of palliative care and has been developed to enhance the care for dialysis patients with a high symptom burden and those being managed on a non-dialysis pathway. Nutrition management is often an under-recognized component of care and can play an important role in improving patients' quality of life to reduce symptom burden, support physical function and independence and provide appropriate counselling to patients and their families to ensure the goals of Renal Supportive Care are met. Nutrition interventions need to target patient and treatment goals, with frequent monitoring to ensure patient needs are being met. This review outlines available literature on this topic and suggests some practical ways in which nutrition can be enhanced for these patients.