Differences in Occupational Burnout Among Primary Care Professionals.

BACKGROUND: Occupational burnout is a major concern for personal well-being and patient care. We examined burnout among primary care providers (PCPs), medical residents, behavioral health providers (BHPs), nurses, and other clinical and nonclinical primary care team members. METHODS: This was a cross-sectional study, nested within a larger randomized trial. Participants completed a validated 9-item burnout measure with 3 domains: depersonalization, emotional exhaustion, and personal accomplishment. Multivariable multilevel linear regression with a random intercept for each practice was used to determine mean differences in burnout across professional roles. RESULTS: Overall burnout rates varied by professional role: PCPs 70%, medical residents 89%, BHPs 59%, nurses 66%, other clinicians 68%, and nonclinical professionals 70%. Compared with nonclinical professionals, residents experienced more burnout in more domains, followed by PCPs. PCPs, residents, and nurses reported significantly worse depersonalization and exhaustion scores. Nonclinical professionals had worse accomplishment scores than all clinical professionals except for residents. This study revealed moderate-to-high levels of burnout among primary care professionals. DISCUSSION: Clinicians may be experiencing aspects of burnout more intensely than their nonclinical colleagues, and this may be most true for residents and PCPs. Based on these variations, interventions to mitigate burnout may need to be tailored by professional role.

Persistent Hypertension in Children and Adolescents: A 6-Year Cohort Study.

OBJECTIVES: To determine the natural history of pediatric hypertension. METHODS: We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared. RESULTS: Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or <3 hypertensive blood pressure levels, and 29% (542) had ≥3 hypertensive blood pressure levels. Of 2144 patients with elevated blood pressure in the first 36 months, 70% (1492) had no abnormal blood pressure levels, 18% (378) had persistent elevated blood pressure levels, and 13% (274) developed hypertension in the second 36-months. Among the 7775 patients with abnormal blood pressure levels in the first 36-months, only 52% (4025) had ≥3 blood pressure levels recorded during the second 36-months. CONCLUSIONS: In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.

Usefulness of Assessment of Stool Form by the Modified Bristol Stool Form Scale in Primary Care Pediatrics.

PURPOSE: Rome criteria are considered the gold standard for diagnosing functional constipation. The modified Bristol stool form scale (m-BSFS) was validated to measure stool form in children. However, neither the potential use of the m-BSFS as a tool to facilitate the diagnosis of potential constipation, nor the agreement between m-BSFS and stool consistency by Rome has been studied. Our objective is to determine if m-BSFS is a reliable tool to facilitat detection of constipation; and the agreement between stool form by m-BSFS and hard stool criteria in Rome. METHODS: A survey tool with the Rome III criteria and the m-BSFS was developed. A Likert-scale addressed frequency of each stool form on the m-BSFS. Responses to Rome III and m-BSFS were compared. RESULTS: The sensitivity and specificity of the m-BSFS was 79.2% and 66.0% respectively; and in children <4 years. improved to 81.2% and 75.0% respectively. There was poor agreement between hard stools by m-BSFS and the painful or hard bowel movement question of Rome Criteria. CONCLUSION: The potential utility of m-BSFS as a reasonably good tool to facilitate the diagnosis of potential constipation in children is shown. The poor agreement between painful or hard stool question in Rome III, and ratings for hard stool on the m-BSFS illustrates that one's perception may differ between a question and a picture. A useful pictorial tool to appraise stool form may, thus, be a favorable complement in the process of enquiry about bowel habits in well-child care.

Comparison of the Availability and Cost of Foods Compatible With a Renal Diet Versus an Unrestricted Diet Using the Nutrition Environment Measures Survey.

OBJECTIVE: Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey. DESIGN: Cross-sectional study. SETTING: Twelve grocery stores in Northeast Ohio. MAIN OUTCOME MEASURE: Availability and cost of food items in 12 categories. RESULTS: The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74). CONCLUSION: The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases.

Diagnosis and Medication Treatment of Pediatric Hypertension: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: Pediatric hypertension predisposes children to adult hypertension and early markers of cardiovascular disease. No large-scale studies have examined diagnosis and initial medication management of pediatric hypertension and prehypertension. The objective of this study was to evaluate diagnosis and initial medication management of pediatric hypertension and prehypertension in primary care. METHODS: Retrospective cohort study aggregating electronic health record data on >1.2 million pediatric patients from 196 ambulatory clinics across 27 states. Demographic, diagnosis, blood pressure (BP), height, weight, and medication prescription data extracted. Main outcome measures include proportion of pediatric patients with ≥3 visits with abnormal BPs, documented hypertension and prehypertension diagnoses, and prescribed antihypertensive medications. Marginal standardization via logistic regression produced adjusted diagnosis rates. RESULTS: Three hundred ninety-eight thousand seventy-nine patients, ages 3 to 18, had ≥3 visits with BP measurements (48.9% girls, 58.6% <10 years old). Of these, 3.3% met criteria for hypertension and 10.1% for prehypertension. Among practices with ≥50 eligible patients, 2813 of 12 138 patients with hypertension (23.2%; 95% confidence interval, 18.2%-28.2%) and 3990 of 38 874 prehypertensive patients (10.2%; 95% confidence interval, 8.2%-12.2%) were diagnosed. Age, weight, height, sex, and number and magnitude of abnormal BPs were associated with diagnosis rates. Of 2813 diagnosed, persistently hypertensive patients, 158 (5.6%) were prescribed antihypertensive medication within 12 months of diagnosis (angiotensin-converting enzyme inhibitors/angiotensin receptive blockers [35%], diuretics [22%], calcium channel blockers [17%], and ß-blockers [10%]). CONCLUSIONS: Hypertension and prehypertension were infrequently diagnosed among pediatric patients. Guidelines for diagnosis and initial medication management of abnormal BP in pediatric patients are not routinely followed.

Direct messaging to parents/guardians to improve adolescent immunizations.

PURPOSE: To study the impact on adolescent immunization rates of direct messages to parents/guardians. METHODS: Electronic health record rules identified adolescents needing an immunization. Parents/guardians of adolescents were messaged via a single vendor using automated text, prerecorded voice, and/or postcard. RESULTS: Parents/guardians of 3,393 patients, ages 11-18 years, with one or more primary care visits in the prior 2 years, identified as needing (average of 2.04 years) a vaccination (meningococcal conjugate, human papillomavirus, or tetanus, diphtheria, and pertussis vaccines) were messaged (mean age, 14 years; 50% male; 38% African-American; 23% white; 19% Hispanic; and 79% public health insurance). A total of 7,094 messages were sent: 3,334 automated voice (47%), 2,631 texts (37%), and 1,129 postcards (16%). After the first message, 865 adolescents (25.5%) received at least one vaccine. Within 24 weeks of messaging 1,324 vaccines (745 human papillomavirus; 403 meningococcal conjugate; and 176 tetanus, diphtheria, and pertussis vaccines) occurred in 959 visits (83.8% physician visits and 16.2% nurse visits). Average visits generated $204 gross reimbursement for $1.77 in messaging expenses per vaccine given. No differences in immunization completion rates occurred by age, gender, race/ethnicity, or insurance type. At 24 weeks, one message was more effective than two or three messages (35.6%, 19.4%, and 24.1% effectiveness, respectively; p < .0001). Texts and postcards correlated with more vaccination visits (38.8% and 40.1%, respectively) than phone calls (31.5%; p = .04). More vaccines due led to increasing message effectiveness. CONCLUSIONS: Automated texts, voice messages, and postcards had a significant positive effect on vaccination rates in adolescents needing vaccination and required minimal financial expenditure.

If we build it, we will come: a model for community-led change to transform neighborhood conditions to support healthy eating and active living.

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb. To address this disparity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship to develop a strategic community engagement process to establish a Healthy Eating & Active Living (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, engaging the community in establishing HEAL options and culture. Residents used the model to identify a shared vision for HEAL and collaborated with community partners to create and sustain innovative HEAL opportunities. This community-led, collaborative model produced high engagement levels (15% of targeted 12 000 residents) and tangible improvements in the neighborhood's physical, resource, and social environments.

Using a web-based nutrition algorithm in hemodialysis patients.

OBJECTIVES: The purpose of this study was to test the ability of a newly developed nutrition algorithm on (1) clinical utility and (2) ability to capture patient outcomes. RESEARCH DESIGN: This was a prospective observational study, using a practice based research network structure, involving renal dietitians and hemodialysis [HD] patients. SETTING: This study took place in HD outpatient units in five different countries. SUBJECTS: Hundred chronic HD patients were included in this study. To select subjects, dietitians screened and consented patients in their facilities until 4 patients "at nutrition risk" based on the algorithm screening tool were identified. Inclusion criteria were patients aged older than 19 years, not on hospice or equivalent, able to read the informed consent and ask questions, and receiving HD. MAIN OUTCOME MEASURE: The ability of the algorithm screening tool is to identify patients at nutrition risk, to guide clinicians in logical renal-modified nutrition care process chains including follow-up on relevant parameters, and capture change in outcomes over 3 months. Statistics were performed using SPSS version 20.0 and significance was set at P < .05. RESULTS: One hundred patients on HD, enrolled by 29 dietitians, were included in this analysis. The average number of out-of-range screening parameters per patient was 3.7 (standard deviation 1.5, range 1-7), and the most prevalent risk factors were elevated parathyroid hormone (PTH; 62.8%) and low serum cholesterol (56.5%). At the initial screening step, 8 of the 14 factors led to chains with nonrandom selection patterns (by χ(2) test with P < .05). In the subsequent diagnosis step, patients diagnosed within the insufficient protein group (n = 38), increased protein intake by 0.11 g/kg/day (P = .022). In patients with a diagnosis in the high PTH group, PTH decreased by a mean of 176.85 pg/mL (n = 19, P = .011) and in those with a diagnosis in the high phosphorous group, serum phosphorous decreased by a mean of 0.91 mg/dL (n = 33, P = .006). Finally, the relative likelihood of each assessment being completed after making the related diagnosis at the previous visit compared with those for whom that diagnosis was not made was assessed, including the likelihood of a patient's protein intake assessed after a diagnosis in the insufficient protein group was made (odds ratio = 4.08, P < .05). CONCLUSIONS: This study demonstrates the clinical utility of a web-based HD-specific nutrition algorithm, including the ability to track changes in outcomes over time. There is potential for future research to use this tool and investigate the comparative impact of nutrition interventions.

The prevalence of phosphorus-containing food additives in top-selling foods in grocery stores.

OBJECTIVE: The objective of this study was to determine the prevalence of phosphorus-containing food additives in best-selling processed grocery products and to compare the phosphorus content of a subset of top-selling foods with and without phosphorus additives. DESIGN: The labels of 2394 best-selling branded grocery products in northeast Ohio were reviewed for phosphorus additives. The top 5 best-selling products containing phosphorus additives from each food category were matched with similar products without phosphorus additives and analyzed for phosphorus content. Four days of sample meals consisting of foods with and without phosphorus additives were created, and daily phosphorus and pricing differentials were computed. MAIN OUTCOME MEASURES: Presence of phosphorus-containing food additives, phosphorus content. RESULTS: Forty-four percent of the best-selling grocery items contained phosphorus additives. The additives were particularly common in prepared frozen foods (72%), dry food mixes (70%), packaged meat (65%), bread and baked goods (57%), soup (54%), and yogurt (51%) categories. Phosphorus additive-containing foods averaged 67 mg phosphorus/100 g more than matched nonadditive-containing foods (P = .03). Sample meals comprised mostly of phosphorus additive-containing foods had 736 mg more phosphorus per day compared with meals consisting of only additive-free foods. Phosphorus additive-free meals cost an average of $2.00 more per day. CONCLUSION: Phosphorus additives are common in best-selling processed groceries and contribute significantly to their phosphorus content. Moreover, phosphorus additive foods are less costly than phosphorus additive-free foods. As a result, persons with chronic kidney disease may purchase these popular low-cost groceries and unknowingly increase their intake of highly bioavailable phosphorus.

The adequacy of phosphorus binder prescriptions among American hemodialysis patients.

Because hemodialysis treatment has a limited ability to remove phosphorus, dialysis patients must restrict dietary phosphorus intake and use phosphorus binding medication. Among patients with restricted dietary phosphorus intake (1000 mg/d), phosphorus binders must bind about 250 mg of excess phosphorus per day and among patients with more typical phosphorus intake (1500 mg/d), binders must bind about 750 mg/d. To determine the phosphorus binding capacity of binder prescriptions among American hemodialysis patients, we undertook a cross-sectional study of a random sample of in-center chronic hemodialysis patients. We obtained data for one randomly selected patient from 244 facilities nationwide. About one-third of the patients had hyperphosphatemia (serum phosphorus level > 5.5 mg/dL). Among the 224 patients prescribed binders, the mean phosphorus binding capacity was 256 mg/d [standard deviation (SD) 143]. A total of 59% of prescriptions had insufficient binding capacity for restricted dietary phosphorus intake, and 100% had insufficient binding capacity for typical dietary phosphorus intake. Patients using two binders had a higher binding capacity than patients using one binder (451 vs. 236 mg/d, p < 0.001). A majority of binder prescriptions have insufficient binding capacity to maintain phosphorus balance. Use of two binders results in higher binder capacity. Further work is needed to understand the impact of binder prescriptions on mineral balance and metabolism and to determine the value of substantially increasing binder prescriptions.

Impact of navigators on completion of steps in the kidney transplant process: a randomized, controlled trial.

BACKGROUND AND OBJECTIVES: Many patients with ESRD, particularly minorities and women, face barriers in completing the steps required to obtain a transplant. These eight sequential steps are as follows: medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on completion of steps. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Cluster randomized, controlled trial at 23 Ohio hemodialysis facilities. One hundred sixty-seven patients were recruited between January 2009 and August 2009 and were followed for up to 24 months or until study end in February 2011. Trained kidney transplant recipients met monthly with intervention participants (n=92), determined their step in the transplant process, and provided tailored information and assistance in completing the step. Control participants (n=75) continued to receive usual care. The primary outcome was the number of transplant process steps completed. RESULTS: Starting step did not significantly differ between the two groups. By the end of the trial, intervention participants completed more than twice as many steps as control participants (3.5 versus 1.6 steps; difference, 1.9 steps; 95% confidence interval, 1.3-2.5 steps). The effect of the intervention on step completion was similar across race and sex subgroups. CONCLUSIONS: Use of trained transplant recipients as navigators resulted in increased completion of transplant process steps.

Effect of an iPod video intervention on consent to donate organs: a randomized trial.

BACKGROUND: The gap between the supply of organs available for transplantation and demand is growing, especially among ethnic groups. OBJECTIVE: To evaluate the effect of a video designed to address concerns of ethnic groups about organ donation. DESIGN: Cluster randomized, controlled trial. Randomization was performed by using a random-number table with centralized allocation concealment. Participants and investigators assessing outcomes were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00870506) SETTING: Twelve branches of the Ohio Bureau of Motor Vehicles in northeastern Ohio. PARTICIPANTS: 952 participants aged 15 to 66 years. INTERVENTION: Video (intervention; n = 443) or usual Bureau of Motor Vehicles license practices (control; n = 509). MEASUREMENTS: The primary outcome was the proportion of participants who provided consent for organ donation on a newly acquired driver's license, learner's permit, or state identification card. Secondary outcomes included willingness to make a living kidney donation to a family member in need and personal beliefs about donation. RESULTS: More participants who viewed the video consented to donate organs than control participants (84% vs. 72%; difference, 12 percentage points [95% CI, 6 to 17 percentage points]). The video was effective among black participants (76% vs. 54%; difference, 22 percentage points [CI, 9 to 35 percentage points]) and white participants (88% vs. 77%; difference, 11 percentage points [CI, 5 to 15 percentage points]). At the end of the trial, fewer intervention than control participants reported having insufficient information about organ donation (34% vs. 44%; difference, -10 percentage points [CI, -16 to -4 percentage points]), wanting to be buried with all of their organs (14% vs. 25%; difference, -11 percentage points [CI, -16 to -6 percentage points]), and having conflicts with organ donation (7% vs. 11%; difference, -4 percentage points [CI, -8 to -2 percentage points]). LIMITATION: How the observed increases in consent to donate organs might translate into a greater organ supply in the region is unclear. CONCLUSION: Exposure to a brief video addressing concerns that ethnic groups have about organ donation just before obtaining a license, permit, or identification card increased consent to donate organs among white and black participants. PRIMARY FUNDING SOURCE: National Institutes of Health and the Robert Wood Johnson Foundation.

A preliminary report on the functioning and data collection capabilities of a web-based nutrition algorithm for patients with chronic kidney disease.

OBJECTIVE: The purpose of this study was to test the functional and data collection capabilities of an online nutrition algorithm for patients with chronic kidney disease by comparing dietitian-selected nutrition diagnoses, etiologies, and interventions in hemodialysis (HD) patients with and without diabetes mellitus (DM). DESIGN: Data were collected using an online nutrition screening tool and algorithm for HD patients based on the American Dietetic Association's Nutrition Care Process. SETTING: Data were collected by dietitians in the United States, New Zealand, Australia, and Brazil. PATIENTS: Patients undergoing HD under the care of a participating dietitian and who were deemed at nutrition risk at visit 1 were eligible to participate. Other inclusion criteria included age >19 years, able to speak and write English, and not receiving hospice care or the international equivalent. Data were available on 26 patients (50% males, 39% with DM). Mean baseline values were as follows: age, 56.3 years; body mass index, 28.2 kg/m(2); and serum albumin (bromocresol green), 36.8 g/L (3.68 g/dL). There were no statistically significant differences between DM and non-DM patients except in mean hemoglobin A1C. MAIN OUTCOME MEASURE: Differences in the frequency of selection of diagnoses, etiology, and intervention categories were compared. RESULTS: The algorithm is under continuous development using input from participating dietitians, but its use was generally considered feasible. The initial data analysis showed that the algorithm is an effective method for collecting data on HD patients. In this small cohort, patients with and without DM had similar dietitian-selected nutrition diagnoses and etiologies, but had statistically significant differences in the dietitian-selected nutrition interventions that were selected most frequently. Health Care Team Referral was selected more often in DM patients (P < .003) and Recommendation of Specific Foods was selected more often in non-DM patients (P < .0170). CONCLUSION: This preliminary analysis shows that the algorithm can be used as both a clinical and a data collection tool. The test analysis, although small in sample size, showed interesting differences in the care of DM and non-DM HD patients.

Effect of food additives on hyperphosphatemia among patients with end-stage renal disease: a randomized controlled trial.

CONTEXT: High dietary phosphorus intake has deleterious consequences for renal patients and is possibly harmful for the general public as well. To prevent hyperphosphatemia, patients with end-stage renal disease limit their intake of foods that are naturally high in phosphorus. However, phosphorus-containing additives are increasingly being added to processed and fast foods. The effect of such additives on serum phosphorus levels is unclear. OBJECTIVE: To determine the effect of limiting the intake of phosphorus-containing food additives on serum phosphorus levels among patients with end-stage renal disease. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial at 14 long-term hemodialysis facilities in northeast Ohio. Two hundred seventy-nine patients with elevated baseline serum phosphorus levels (>5.5 mg/dL) were recruited between May and October 2007. Two shifts at each of 12 large facilities and 1 shift at each of 2 small facilities were randomly assigned to an intervention or control group. INTERVENTION: Intervention participants (n=145) received education on avoiding foods with phosphorus additives when purchasing groceries or visiting fast food restaurants. Control participants (n=134) continued to receive usual care. MAIN OUTCOME MEASURE: Change in serum phosphorus level after 3 months. RESULTS: At baseline, there was no significant difference in serum phosphorus levels between the 2 groups. After 3 months, the decline in serum phosphorus levels was 0.6 mg/dL larger among intervention vs control participants (95% confidence interval, -1.0 to -0.1 mg/dL). Intervention participants also had statistically significant increases in reading ingredient lists (P<.001) and nutrition facts labels (P = .04) but no significant increase in food knowledge scores (P = .13). CONCLUSION: Educating end-stage renal disease patients to avoid phosphorus-containing food additives resulted in modest improvements in hyperphosphatemia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00583570.

Fast food, phosphorus-containing additives, and the renal diet.

OBJECTIVE: Fast food is commonly consumed by hemodialysis patients, but many menu items are not compatible with renal diets because of their sodium, potassium, or phosphorus content. Moreover, the phosphorus content of fast foods is difficult for patients to estimate, because phosphorus-containing additives are commonly added to many fast foods. We sought to determine how many fast-food entrees and side dishes are compatible with renal diets. METHODS: We examined nutrition-facts labels and ingredient lists provided by 15 fast-food chains. Each entree and side dish was first assessed according to traditional criteria (limited sodium, potassium, and naturally occurring phosphorus content), and then according to the presence of a phosphorus -containing additive. RESULTS: Of 804 total entrees across all restaurants, 415 (52%) were acceptable according to traditional criteria, but only 128 (16%) were also free of phosphorus-containing additives. Of 163 total side dishes, 37 (23%) were acceptable according to traditional criteria, and 27 (17%) were also free of phosphorus-containing additives. There were no acceptable entrees at 3 chains, and no acceptable side dishes at 5 chains. CONCLUSION: Only a small proportion of fast-food entrees and side dishes are compatible with renal diets. The widespread use of phosphorus-containing additives is a major impediment to the availability of acceptable fast-food choices for hemodialysis patients. We recommend limiting the use of phosphorus-containing additives, and including phosphorus content in nutrition-facts labels.

Public health approach to addressing hyperphosphatemia among dialysis patients.

Elevated serum phosphorus levels are a major source of morbidity and mortality for the 350,000 Americans receiving chronic dialysis treatment. Despite the widespread application of medical and behavioral interventions, the prevalence of hyperphosphatemia remains exceedingly high. At first glance, a public health perspective may seem inappropriate for addressing a disorder of mineral metabolism among patients receiving a life-sustaining treatment. However, we analyzed this topic from a public health perspective and identified many opportunities to improve the management of hyperphosphatemia, including (1) media and cultural messages about food, (2) the availability of appropriate foods and medications, (3) physical structures such as the location of products in grocery stores, and (4) social structures such as food-labeling laws.

Multicenter study of the validity and reliability of subjective global assessment in the hemodialysis population.

OBJECTIVE: Subjective Global Assessment (SGA) is a nutrition assessment tool recommended by the 2000 NKF K/DOQI Nutrition Guidelines. However, the validity and reliability of this tool have not been established in hemodialysis (HD) patients. The purpose of this observational study was to determine the reliability and validity of SGA in the HD population. Renal dietitians (RD) were recruited to perform SGA (7-point scale version) and collect data on demographics, clinical status, biochemistries, dietary intake, and quality of life (Medical Outcomes Short Form-36) on 3 HD patients at baseline and 6 months later. DESIGN: The 54 participating RDs were trained to perform SGA and collect data via a website created for this study. Interrater reliability for SGA was tested in a subset of 76 patients, via an SGA performed by a second RD at baseline, while intrarater reliability was assessed by the original RD repeating the SGA at 1 month. Data collection occurred at HD facilities in the United States (109 patients), Canada (35 patients), and New Zealand (9 patients). RESULTS: Of the 153 patients, 46% were female, 64% were Caucasian, 6% were Hispanic, 21% were African American, and 6% were Asian. The primary etiologies were hypertension (33%), type 2 diabetes mellitus (DM) (27%), type 1 DM (10%), and glomerular nephritis (10%); 59% had cardiovascular disease. The mean age, body mass index (BMI), serum albumin, and duration on HD were 64 +/- 14 years (mean +/- SD), 28 +/- 7 kg/m(2), 3.7 +/- 0.4 mg/dL, and 41 +/- 34 months, respectively. SGA scores were well nourished (7)-30%; mildly malnourished (MN 6)-41%; moderately MN 5-21%, 4-7%, and 3-2%; and severely MN (2 and 1)-0%. SGA training via the Internet achieved fair interrater reliability (weighted Kappa = 0.5, Spearman's Rho = 0.7) and substantial intrarater reliability (weighted Kappa = 0.7, Spearman's Rho = 0.8) (P < .001). Validity was demonstrated through statistically significant differences in mean BMI and serum albumin across the 5 categories of SGA (7-28 +/- 7, 6-29 +/- 7, 5-28 +/- 8, 4-21 +/- 4, 3-24 +/- 2, P < .05; and 7-3.8 +/- 0.3, 6-3.8 +/- 0.4, 5-37 +/- 0.05, 4-3.4 +/- 0.07, 3-2.9 +/- 1.2, P < .001, respectively). Nutritional status varied by age (P < .05), but not ethnicity or nationality. CONCLUSION: We conclude that the 7-point scale SGA is a reliable and valid tool for nutritional assessment in adults on HD.

Phosphorus-containing food additives and the accuracy of nutrient databases: implications for renal patients.

OBJECTIVE: Phosphorus-containing additives are increasingly being added to food products. We sought to determine the potential impact of these additives. We focused on chicken products as an example. METHODS: We purchased a variety of chicken products, prepared them according to package directions, and performed laboratory analyses to determine their actual phosphorus content. We used ESHA Food Processor SQL Software (version 9.8, ESHA Research, Salem, OR) to determine the expected phosphorus content of each product. RESULTS: Of 38 chicken products, 35 (92%) had phosphorus-containing additives listed among their ingredients. For every category of chicken products containing additives, the actual phosphorus content was greater than the content expected from nutrient database. For example, actual phosphorus content exceeded expected phosphorus content by an average of 84 mg/100 g for breaded breast strips. There was also a great deal of variation within each category. For example, the difference between actual and expected phosphorus content ranged from 59-165 mg/100 g for breast patties. Two 100-g servings of additive-containing products contained, on average, 440 mg of phosphorus, or about half the total daily recommended intake for dialysis patients. CONCLUSIONS: Phosphorus-containing additives significantly increase the amount of phosphorus in chicken products. Available nutrient databases do not reflect this higher phosphorus content, and the variation between similar products makes it impossible for patients and dietitians to accurately estimate phosphorus content. We recommend that dialysis patients limit their intake of additive-containing products, and that the phosphorus content of food products be included on nutrition facts labels.

The prevalence and nutritional implications of fast food consumption among patients receiving hemodialysis.

BACKGROUND: Fast food consumption has increased dramatically in the general population over the last 25 years. However, little is known about the prevalence and nutritional implications of fast food consumption among patients receiving hemodialysis. METHODS: By using a cross-sectional study design, we obtained data on fast food consumption and nutrient intake (from four separate 24-hour dietary recalls) and nutritional parameters (from chart abstraction) for 194 randomly selected patients from 44 hemodialysis facilities in northeast Ohio. RESULTS: Eighty-one subjects (42%) reported consuming at least one fast food meal or snack in 4 days. Subjects who consumed more fast food had higher kilocalorie, carbohydrate, total fat, saturated fat, and sodium intakes. For example, kilocalorie per kilogram intake per day increased from 18.9 to 26.1 with higher frequencies of fast food consumption (P = .003). Subjects who consumed more fast food also had higher serum phosphorus levels and interdialytic weight gains. CONCLUSION: Fast food is commonly consumed by patients receiving hemodialysis and is associated with a higher intake of kilocalories, carbohydrates, fats, and sodium and adverse changes in phosphorus and fluid balance. Further work is needed to understand the long-term benefits and risks of fast food consumption among patients receiving hemodialysis.

Job satisfaction among renal dietitians.

OBJECTIVE: Little is known about job satisfaction among renal dietitians. We sought to determine overall job satisfaction and specific domains of job satisfaction among renal dietitians. DESIGN: Cross-sectional study. SETTING: A total of 46 outpatient hemodialysis facilities in northeast Ohio. PARTICIPANTS: A group of 40 renal dietitians. INTERVENTION: Structured questionnaire. MAIN OUTCOME MEASURE: Overall job satisfaction; specific domains of job satisfaction, workload, and suggestions for improving job satisfaction. RESULTS: Of all responding dietitians, 78% expressed overall satisfaction with their job. Dietitians were least satisfied with opportunities for advancement (13%), supervisors' handling of employees (50%), the chance to be somebody in the community (53%), praise received for doing a good job (55%), and amount of work assigned (58%). Dietitians were most satisfied with the chance to do things for others (98%). A higher patient-to-renal dietitian ratio was associated with lower overall job satisfaction and a reduced likelihood that renal dietitians would recommend their career to others. The most common suggestions for improving job satisfaction consisted of reducing paperwork (named by 28% of dietitians), spending more time with patients (23%), and increasing time for creative projects (18%). CONCLUSIONS: Although renal dietitians generally expressed overall satisfaction with their jobs, almost all were dissatisfied with opportunities for advancement, and nearly half were dissatisfied with other specific aspects of their work. We urge local and national associations of renal dietitians to collaborate with dialysis facilities, chains, and regulatory agencies to improve job satisfaction. Further research is needed to determine the impact of job satisfaction of renal dietitians on patient outcomes.