Dietitian Referral Research Articles

Low Use of Medical Nutrition Therapy in Hyperllpedemic Patients with Coronary Artery Disease

LEARNING OUTCOME: To quantify the low use of medical nutrition therapy in hyperlipidemic patients with coronary artery disease in a mangaed care setting. The primary aim of this study was to assess the hypothesis that medical nutrition therapy (MNT) by registered dietitians is underutilized in hyperlipidemic patients with coronary artery disease (CAD). A secondary aim was to identify the characteristics of MNT referral. We conducted a retrospective analysis of 1,934 male veterans (62.1±8.8 years, mean ±SD) with CAD screened between 1991-93 using patient's medical, laboratory and pharmacy records. Hypercholesterolemia was initially present in 77% (n=1482) per National Cholesterol Education Program (NCEP I) criteria and 84% (n=1672) per NCEP II. At 22.2±10.5 months follow-up, 80% (n=1186) had received no dietitian visits (individual or class), 8% received one visit, 9% received 2 to 4 visits, 2% received 5-8 visits and 1% received ≥9 visits. Overall, only 12% received 2 or more dietitian visits (MNT group) with a mean of 3.8±2.4 visits and 88% did not receive MNT defined as 0 or one visit (non MNT group). The MNT group had a higher initial prevalence of: diabetes (55% vs 29%, p<.0001), obesity (63% vs 49%, p<.01), triglycerides (251.3±176.5 vs 223.1 ±189.0 mg/dl, p<.06) and lower high density lipoprotein cholesterol (37.8 ±9.0 vs 39.8 ±18.3 mg/dl (p<.02). Initial low density lipoprotein cholesterol (LDL-C) was equally elevated in both groups (152.7±38.0 vs 155.9 ±49.0 mg/dl, p=ns). Lipid lowering mediations were used equally in both groups (38% Vs 36%, p=ns). Although, the first and the second cholesterol treatment guidelines issued by the NCEP expect registered dietitians to play an important role, our data show that elevated LDL-C alone does not lead to dietitian referral. We conclude that most patients with elevated LDL-C and CAD do not receive MNT in the managed care setting. Barriers to this underutilization of medical nutrition therapy must be examined.

Pressure dependence of the Grüneisen parameter of sodium and potassium

UK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates.RICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing.Rates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease.PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5–7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028).Despite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.