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Quality Improvement/Patient Safety: Primary & Subspecialty Outpatient Quality Improvement

QI 6: Primary & Subspecialty Outpatient QI Group 1

251 - Access to Nutrition Services for Children and Adolescents with Hypertension: A Quality Improvement Initiative

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 251
Publication Number: 251.452

James T. Nugent, Yale-New Haven Children's Hospital, New Haven, CT, United States; Jillian K.. Warejko, Yale School of Medicine, New Haven, CT, United States; Donna Caseria, Yale-New Haven Children's Hospital, New Haen, CT, United States; Sarah B. Kandil, Yale School of Medicine, New Haven, CT, United States

Presenting Author(s)

JN

James T. Nugent, MD, MPH

Pediatric Nephrology Fellow
Yale-New Haven Children's Hospital
New Haven, Connecticut, United States

Background: Clinical practice guidelines recommend lifestyle modification as the first-line treatment for most children with hypertension. Inadequate access to a nutritionist may reduce the effectiveness of dietary interventions for hypertension.

Objective: To improve access to nutrition services for children with hypertension seen in the pediatric nephrology clinic by increasing nutrition referrals for new patients from < 10% to 50% by 12/2022.

Design/Methods: The primary outcome was placement of a nutrition referral at an initial pediatric nephrology visit for hypertension or elevated blood pressure (BP). The secondary outcome was whether any patient with hypertension or elevated BP that was referred to the nutritionist by nephrology had seen nutrition within 6 months. We assembled a team of key stakeholders, including pediatric nephrologists, a dietitian, and a quality improvement specialist. Interventions consisted of nephrologist education, incorporation of smart phrases in note templates, and after-visit instructions for patients on scheduling a nutrition visit. We applied these interventions from 8/2021-12/2022. Because we observed low rates of scheduling nutrition visits among referred patients, we identified patients that were positive deviants for phone interviews to explore process factors associated with completing a nutrition visit.

Results: During the baseline period from 10/2018-7/2021, 13 of 135 (9.6%) new patients with hypertension or elevated BP were referred to nutrition (Table 1). During the intervention period, 33 of 126 (26.2%) new patients were referred to nutrition (Figure 1). Of 88 patients referred to nutrition at new or follow-up visits for hypertension or elevated BP, 7 (8.0%) had seen the nutritionist, 1 patient had scheduled a nutrition visit for a future date, and 80 patients had never scheduled a nutrition visit. Barriers to nutrition referral completion included lack of scheduling support for nutritionists, insurance that did not cover nutrition visits for hypertension or did not cover telehealth nutrition visits, and the time burden needed to complete nutrition visits separate from nephrology visits. Families that had followed up with the nutritionist were able to schedule the nutrition visit on the same day as another visit or saw the nutritionist as part of another specialty clinic.

Conclusion(s): Referral rates to nutrition improved during our study. Barriers to nutrition consultation include direct cost to families and the need to schedule separate nutrition appointments. Comprehensive patient-centered hypertension care may require embedding a nutritionist in nephrology clinic.