Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol

Abstract

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

Figure 1.

Selected recommendations from the chronic kidney disease (2020) evidence-based nutrition practice guideline.^,

Figure 1.

Selected recommendations from the chronic kidney disease (2020) evidence-based nutrition practice guideline.^,

Figure 1.

Selected recommendations from the chronic kidney disease (2020) evidence-based nutrition practice guideline.^,

Figure 2.

The Assessing Uptake and Impact of Guidelines for Clinical Practice in Renal Nutrition (AUGmeNt) study design. NCP/T, Academy of Nutrition and Dietetics’ Nutrition Care Process/Terminology; EAL, Academy of Nutrition and Dietetics’ Evidence Analysis Library; ANDHII, Academy of Nutrition and Dietetics Health Informatics Infrastructure; RDN, registered dietitian nutritionist; CKDG5D, chronic kidney disease grade 5 treated by dialysis; EBNPG, evidence-based nutrition practice guideline.

Figure 3.

Suggested terminology to document in the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) in the assessment step of the nutrition care process. *Denotes custom terms that were created for this project based on feedback from the Assessing Uptake and Impact of Guidelines for Clinical Practice in Renal Nutrition (AUGmeNt) study expert advisory group. Remaining terms are from the 2019 version of the Academy of Nutrition and Dietetics’ Nutrition Care Process Terminology.

Figure 4.

Guideline implementation fidelity framework (Adapted from the study by Carroll et al. 2007). The framework includes a main aspect of adherence, content congruence, as well as moderators that may impact adherence and patient outcomes. RDN, registered dietitian nutritionist; NCP, Academy of Nutrition and Dietetics’ Nutrition Care Process.

Figure 5.

Assessing Uptake and Impact of Guidelines for Clinical Practice in Renal Nutrition (AUGmeNt) study aim and outcome alignment. ^a Each documented RDN encounter assigned a congruence score using a natural language processing system that will compare RDN care documented into ANDHII and expected care plans developed from five recommendations included in the evidence-based nutrition practice guideline for chronic kidney disease.^{, b} A subset of documented care for each RDN will be scored for alignment with the NCP using a quality documentation audit tool called NCP Quality Evaluation and Standardization Tool or NCP-QUEST. ^c Denotes moderators that may impact adherence or outcomes as described in Figure 4 Guideline Implementation Fidelity Framework. ^d Nutrition-related patient outcomes from the NCPT may include subjective global assessment score, body weight, weight change, body mass index, protein intake, energy intake, oral nutrition supplement intake, phosphorus intake, and serum phosphorus. ^e Patient demographics from the NCPT may include sex, gender, age, race, ethnicity, preferred language, literacy, and education level. RDN, registered dietitian nutritionist; NCPT, Nutrition Care Process/Terminology.