Attitudes and opinions of dietetics professionals toward cost-benefit and cost-effectiveness analyses

Short-term effectiveness of an outcomes research training curriculum within a coordinated program

The fourth edition of the Commission on Accreditation for Dietetics Education Standards of Education mandated outcomes research training. Our objective was to determine the short-term effectiveness (<5 years) of the outcomes research training curriculum in the Coordinated Program in Dietetics (CP) at the University of Missouri-Columbia, which exceeds these minimum standards. Toward this end, a survey tool was administered to University of Missouri-Columbia CP graduates before the implementation of the fourth edition of Standards of Education and to University of Missouri-Columbia CP graduates with two semesters of outcomes research training; graduates of two other CPs from different universities from the same years were also surveyed. Graduates who went through CPs after implementation of the fourth edition of the Standards of Education showed notable improvement in attitudes, interest, and participation in most of the outcomes research skills queried, compared with those who completed their education under the earlier standards; knowledge was only slightly improved. Of these areas, only enhancements in attitudes and interest were consistently more pronounced in food and nutrition professionals trained using the University of Missouri-Columbia's outcomes research curriculum compared with other CP graduates. Both the Commission on Accreditation for Dietetics Education and program directors can use the findings described herein to further assess and develop the research competencies and/or to strengthen their programs.

Standards of professional practice: measuring the beliefs and realities of Consultant Dietitians in Health Care Facilities

A dietetic practice group of the American Dietetic Association (ADA), Consultant Dietitians in Health Care Facilities (CD-HCF), surveyed members (n = 5930) on agreement with the six standards of professional practice and frequency of completing indicators within each standard. Sampling approaches included placing a survey in the publication, The Consultant Dietitian, and disseminating at the following CD-HCF activities: the 1998 business meeting at ADA's Annual Meeting & Exhibition, a multi-state teleconference in December 1998, and conferences held between November 1998 to April 1999. Duplication was monitored using the RD or RD-eligible registration number. The final sample included 553 surveys and represented 10% of the membership. Of the survey responders, 50% were individual consultants and 43% were employees; 88% consulted to facilities providing skilled care (geriatrics/adults) and 48% consulted to intermediate care facilities. With the exception of one, all standards and indicators met acceptance criterion. The standard statement "participation in research to enhance practice" did not attain the validation criterion. Study findings indicated that consulting to a facility conducting nutrition research increased chances of agreement with the research participation standard. The Executive Committee approved all standards, indicators and outcomes as a document defining quality consultation and business services conduct for consultant dietitians in health care facilities.

A model for making outcomes research standard practice in clinical dietetics

In today's rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice.

Standards of practice for gerontological nutritionists: a mandate for action. The American Dietetic Association

Dietitians who had been members of the Gerontological Nutritionists dietetic practice group for more than 2 years were sent a questionnaire to determine demographics of members and to ascertain their level of agreement and compliance with 26 suggested criteria and supporting documentation for standards of practice. Standards of practice for gerontological nutritionists were based on the six Standards of Practice of The American Dietetic Association. Of the 1,571 questionnaires mailed, 415 were returned. Data were analyzed using the StatPac Gold statistical analysis package. All correlation analyses were positive with correlation coefficients in the range of 0.0 to 1.0. Correlation coefficients and mean scores were highest for the standards related to maintaining credentials and adhering to a code of ethics. Compliance was weakest for standards related to conducting research to justify reimbursement for nutrition services (correlation of 0.22) and advocating public policies to ensure quality nutrition care and dissemination of information (correlation of 0.25). Results indicate that to comply with the standards of practice, members need to be proactive in showing efficacy and cost-effectiveness of medical nutrition therapy; conduct, document, and apply outcome research to practice; and advocate public policies affecting older people.

Registered dietitian time requirements in the Modification of Diet in Renal Disease Study

OBJECTIVE

To assess time expended by registered dietitians to conduct clinical and research activities during the Modification of Diet in Renal Disease (MDRD) Study.

DESIGN

Two randomized, controlled clinical trials among persons with diminished levels of renal function using a factorial design to evaluate effects of dietary protein restriction and blood pressure control on progression of renal disease. In study A, subjects with moderate renal insufficiency were randomly assigned to a diet of usual protein (1.30 g/kg per day) or low protein (0.58 g/kg per day) and to either a usual or low blood pressure level. Study B involved subjects with advanced renal insufficiency who were randomly assigned to the low-protein diet or a very-low-protein prescription (0.28 g/kg per day) with a ketoacid-amino acid supplement (0.28 g/kg per day) and to either the usual or low blood pressure level. A time-log form designed by MDRD Study dietitians was completed for each participant at 36 monthly follow-up visits.

SETTING

Fifteen clinical centers throughout the continental United States.

SUBJECTS

Eight hundred forty adults aged 18 to 70 years with chronic renal diseases participated in the MDRD Study--585 in study A and 255 in study B.

STATISTICAL ANALYSES

One-way analyses of variance and t tests were used to evaluate significant time requirement differences by diet groups, diagnosis, and sociodemographics.

RESULTS

Mean total time for all participant visits declined from 183 +/- 1 minutes per visit during months 1 through 4 to 116 +/- 41 minutes per visit during months 25 through 36. Significantly more dietitian time was required for participants consuming the low-protein and very-low-protein diets than for those consuming the usual-protein diet. Age, gender, race, marital status, and renal diagnosis did not influence time requirements. A significant inverse association between education level and dietitian time was apparent.

APPLICATIONS

The MDRD Study time-log data should be useful when determining staffing patterns for nutrition management in clinical and research settings.