Incentive program to control interdialytic weight gains1, 2, 3

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THE CONTROL OF interdialytic weight gains (IDWG) is a challenging part of diet counseling for patients on hemodialysis. At the Vancouver Community Dialysis Unit (VCDU), recommended IDWG are 2.5 to 3.5 kg, based on body size. In April 1998, IDWG exceeded the recommendations in 36% of dialysis runs. At the same time, nutrition counseling resources were limited at the VCDU due to lack of funding, with only 20% of patients receiving nutrition assessment and one-to-one counseling with a renal dietitian. The remainder had access to a renal dietitian via the telephone for troubleshooting. The limited resources for nutrition counseling, the concerns of patients and staff, and the belief that external reinforcement may improve fluid control, gave birth to the incentive program as a continuous quality improvement project. There was a desire to try a new approach and to have fun in the dialysis unit during a period when patients were feeling discouraged because of long waits for kidney transplants. The Incentive Program started in October 1998 and continued until May 1999.

The Incentive Program consisted of two components. In the first component, the dietitian developed fluid control tips to be distributed by the clinical nurse specialist, one tip at a time, each time a patient dialyzed. These tips increased the opportunity for the nutrition education of patients and were found to be a good resource for staff education.

A second component of the Incentive Program consisted of a weekly and a monthly draw for lotto tickets. Each time patients did not exceed their recommended IDWG, they were eligible to enter a weekly draw. After 3 consecutive IDWG within the goal, patients were eligible to enter a monthly draw.

Patients were surveyed to assess their satisfaction with the Incentive Program in January and May 1999. Approximately 50% of patients replied to the surveys, responding as follows:

76% of respondents said that the nutrition tips increased their nutrition knowledge.

58% said that they were eating less salty foods since the Incentive Program began.

48% said they used the nutrition tips to make better food choices.

52% said they limited fluid intake to participate in the lotto draw.

30% felt the Incentive Program had improved their relationship with the health care team.

When patients were asked about their preferred style of nutrition tip, responses varied as follows:

44% said they liked ones that simply stated a food was high in sodium.

33% wanted to know the actual amount of sodium in the food.

13% liked tips that gave the percentage of sodium in the food in comparison to the daily limit for sodium.

Although in January, 86% of responders wanted the Incentive program to continue, only 57% desired it in May. These results may reflect the changing population in the unit over the months and the fact that no nutrition tips had been distributed since the end of March 1999 because of the ever-increasing workload of the dietitian and the resignation of the clinical nurse leader.

A generalized estimating equations model was used to check the effect of the nutrition tips and lottery ticket draw on patients achieving their recommended IDWG. The lottery ticket draw did not have a statistically significant effect on patients achieving their recommended IDWG (P value .33). During the periods when no nutrition tips were given, patients were 0.76 times as likely to have success in controlling their IDWG than when nutrition tips were given (P value .053).

Despite these findings, the nutrition tips may not have been the only factor responsible for the improved fluid control. Patients were well aware of the expectations for improved fluid control when this program began, however, their motivation may have decreased as time progressed. If there were such a Hawthorne effect at the beginning of the program, it suggests that we as renal dietitians need to change our approach from time to time to assist our patients in achieving nutrition goals.

As a result of the Incentive Program trial, we are continuing to distribute nutrition education tips in the community dialysis unit to increase patient knowledge and reinforce the instruction they have previously received. The lotto ticket draw has been discontinued because it was not effective. For an incentive program to work, the expertise of a psychologist is required. Commitment from patients, staff, and an effective reinforcer is essential.

As renal dietitians, we need to be innovative in providing nutrition education to our clients. We need to try a variety of approaches to deliver our message: one-to-one counseling, group counseling, involvement in patient and family support groups, cooking classes, recipes with food samples, posters, videos, quizzes, friendly competitions, newsletters, and report cards. Nutrition tips are another effective way of providing a practical nutrition education message in a simple format, where patients can make one small change at a time in their food choices. The following nutrition tips may be a useful addition to your nutrition education armamentarium.

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a St. Paul’s Hospital, 1081 Burrard St, Vancouver BC, Canada V6Z1Y6

Submitted by anice Berg, MS, RDN, St. Paul’s Hospital, 1081 Burrard St, Vancouver BC, Canada V6Z1Y6

1 Column Editor: Beth McQuiston, MS, RD, LD

2 This Patient Information Forum may be photocopied for the purpose of distribution to patients only, but not for any other purposes, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale.

3 Professional review and adaptation before patient use is encouraged.

PII: S1051-2276(03)00181-X

doi:10.1053/j.jrn.2003.10.002

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