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Outcome Measures in Nutrition Support

Jacklyn Jones, PENG Clinical Lead Research and Audit, and Carole-Anne Fleming, PENG Education Officer

In 2010 the Department of Health (DH) published their white paper ‘Equity and Excellence: Liberating the NHS’. This set out an ambition for world-class healthcare outcomes with the NHS being held accountable against clinically credible and evidence-based outcome measures¹. Whilst this document does not apply to all the countries within the UK, improving the quality of care in the NHS is a priority across the UK and the principles are therefore relevant to all. The use of outcome measures enables service providers to demonstrate that the service they provide is clinically effective and of high quality whilst providing a means to identify how the quality of a healthcare service or treatment can be improved². It is therefore essential that all healthcare practitioners utilise outcomes as part of routine practice and dietitians are no exception to this. To help support dietitians in this, the British Dietetic Association (BDA) have produced a Model for Dietetic Outcomes³ and have embedded the use of outcomes into the Model and Process for Nutrition and Dietetic Practice⁴ (Figure 1). This process can be applied to individuals, groups and populations⁴.

Figure 1: Process for nutrition and dietetic practice⁴

This process requires dietitians to set outcomes as part of the planning stage of a nutrition and dietetic intervention. Although a range of outcome measures are available for patient care it has been acknowledged that dietetic specific outcome measures may not be readily available.² This is particularly true of nutrition support where nutritional care is provided using different feeding routes, as different modalities and across a wide spectrum of clinical conditions. It has therefore been suggested that outcome measures can be divided into four categories as outlined below⁵:

1. Direct nutrition outcomes (e.g. change in knowledge, behavioural change)
2. Clinical and health status outcomes (e.g. anthropometric and biological measurements)
3. Patient value based care outcomes (e.g. patient reported outcome measures (PROMs)
4. Healthcare utilisation and cost savings (e.g. changes in medication use, hospital readmission rates benefit of nutritional interventions).

Whatever outcome is chosen to demonstrate that a treatment is effective it must be specific, measurable, achievable, realistic and timebound (SMART)⁶. Whether set outcomes are quantitative or qualitative it is important that when set dietitians have a means to measure them, e.g. if measuring confidence in setting up an enteral feeding pump is stated as an outcome there must be a means to measure this.

Setting appropriate outcomes is however only the start of the process as any set outcome should then be monitored and reviewed to ensure that the intervention is both effective and meets the patients needs. This concept is not new, with Florence Nightingale purportedly using a simple healthcare measure for her patients which constituted care being evaluated as either relieved, unrelieved or dead⁷. Whilst nobody would suggest that this is appropriate in today’s NHS, it could be argued that a similar three point system could be used when reviewing outcome measures which have been set. Reviewing outcome measures as achieved, partially achieved not achieved clearly demonstrates that outcomes are monitored and reviewed. Where outcomes are only partially achieved or not achieved the reasons for this should be documented and a review of either the intervention or the outcome, as appropriate, should take place.

The final stage of the process is for outcome measures to be evaluated and it is this evaluation which enables practitioners to demonstrate the quality of the service they provide. There is however little point in setting, monitoring and evaluating outcome measures if the data from this is not analysed and results of this analysis responded to. Sharing and disseminating the results of the analysis of this data should be encouraged as it is this sharing of practice which encourages and enables other dietitians to develop their practice utilising outcome measures.

At an individual level deciding which outcome or outcomes are appropriate for monitoring and evaluating dietetic interventions is relatively straightforward. However to demonstrate effectiveness it is the collective evaluation of outcomes which is of greatest use. In view of this, many dietetic departments and specialist groups have been working on developing outcome measures. Many examples of these can be found on the BDA website: www.bda.uk.com/professional/practice/Outcomes.

In terms of nutrition support developing generic outcome measures which can be utilised across departments, whilst being specific enough to provide evidence to demonstrate the clinical effectiveness and the quality of that service, is challenging. However, in line with PENG’s research and audit strategy, it is anticipated that work will begin to develop outcome measures for areas of practice related to nutrition support in the near future. If you are interested in being involved in this exciting development, please contact: Jacklyn Jones, PENG Clinical Lead for Research and Audit: jjones@qmu.ac.uk