Positive and negative deviance: Keys to elucidating thresholds of nutritional care

Abstract

• п Objective: To ascertain biochemical and clinical variables associated with positive deviance (low risk) and negative deviance (high risk for hospitalization with infection) as predicted by the Hemodialysis Prognostic Nutrition Index (HD-PNI). • п Design: Secondary, descriptive. • п Setting: Seven nonprofit, freestanding dialysis clinics. • п Patients: 402 hemodialysis patients (219 female, 154 with diabetic history). • п Intervention: Nonintervention study; routinely collected data were analyzed. • п Main outcome measure: Positive deviance indicators were those statistically different ( P < .05, Student's t tests/chi squared analysis) between the 25% in the low-risk group (HD-PNI) and those in the middle-risk group. Variables associated with negative deviance showed statistical difference between the 25% in the high risk group and those in the middle-risk group. • п Results: Diabetic patients showed negative deviance, with 16% classified as low risk and 30% as high risk ( P < .01). Only history of hospitalization (days, times), albumin (ALB) level, and white blood cell (WBC) count played roles in both positive and negative deviance. Negative deviance was characterized by an ALB level of 36 g/L (3.6 g/dL) or lower, a WBC count of 9.1 10 9/L (K/μL) or higher, a cholesterol level of 4.1 mmol/L (157 mg/dL) or lower, 88% usual weight or less, hospitalized 2.9 times, and hospitalized 18.9 days. Positive deviance indicators included absence of hospitalization and infection linked with a serum ALB level of 41 g/L (4.1 g/dL) or higher, a blood urea nitrogen level of 29.5 mmol/L (83 mg/dL) or higher, and a creatinine level of 1,123 μmol/L (12.7 mg/dL) or higher. • п Conclusion: Negative deviance indicators characterized a probable high-risk nutritional unwellness syndrome related to inadequate nutritional replacement. Likewise, variables associated with positive deviance enabled further conceptualization of nutritional wellness defined as minimal risk for hospitalization with infection.