Recommendations for phosphorus prove difficult for dietitians to implement
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Key takeaways:
- Dietitians found phosphorus guidelines from the Kidney Disease Outcomes Quality Initiative difficult to implement.
- Updated protocols could be a potential solution.
AUSTIN, Texas — Dietitians treating patients on dialysis identified the phosphorus recommendation from the 2020 Kidney Disease Outcome Quality Initiative difficult to implement among other recommendations, a presenter said.
“[Registered dietitian nutritionist] RDN care can help to minimize complications and improve patient outcomes by preventing and treating protein energy wasting, mineral and electrolyte disorders, and other metabolic comorbidities associated with CKD,” Gabriela V. Proaño, MS, RDN, senior research project manager at the Academy of Nutrition and Dietetics, told Healio at the National Kidney Foundation Spring Clinical Meetings. “Most recently, the Academy [of Nutrition and Dietetics] collaborated with the National Kidney Foundation to release updated clinical practice guidelines for nutrition care for patients with CKD. We wanted to evaluate the real-life implementation of these guideline recommendations and gather additional insight on what recommendations are being implemented or not and why that may be.”
In this analysis, 26 RDNs compared documented Nutrition Care Process-standardized Terminology (NCPT) from a subset of recommendations from the 2020 Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Nutrition in CKD to NCPT that would be expected in guideline congruent care. Recommendations analyzed included phosphorus, oral nutrition supplements, protein intake and energy intake.
Using natural language processing-based term matching, RDNs rated the recommendations at each patient visit with a score of 0 to 2 (not congruent), 2.5 to 3.5 (partially congruent), 4 to 5.5 (congruent) or 6 (fully congruent). RDNs treated 437 patients during a total of 784 visits.
“In our preliminary analysis, we found that after dietitians completed an assessment, they most often intervened to address dietary phosphorus intake (at about one in three patient visits) or to prescribe a trial of oral nutrition supplements (at about one in five patient visits),” Proaño said.
Analyses revealed RDNs scored the phosphorus recommendation as congruent or fully congruent for 36% of visits. This score was applied to oral nutritional supplements for 14% of visits, to protein intake for 12% of visits and energy intake for 4% of visits.
“We also looked at dietitian documentation to see if there was evidence that they were implementing the recommendation according to the guideline, and there were generally good indications that this was happening, with some variation across recommendations,” Proaño told Healio. “The phosphorus and oral nutrition supplement recommendations seemed to be the most challenging to fully implement, potentially indicating that dietitians need more systems support to implement those recommendations.”
Proaño said potential forms of support can come from organizations updating existing clinical protocols or the government changing its audit protocols to reflect the new recommendations.
“We have seen from previous guideline implementation research with other health professionals, that in order to have permanent and meaningful shifts in practice that align with evidence-based guidelines, there must be supports at various levels — clinician, facility, organizations, government or policy,” Proaño said. “These recommendations can come with their own barriers and unless there are facilitators in place to support this change in practice from a systems lens, it will be difficult to see a change and support the guideline recommendation implementation.”
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Proaño GV. et al. Poster 403. Presented at: National Kidney Foundation Spring Clinical Meetings; April 11-15, 2023; Austin, Texas.
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