Registered Dietitian Staffing in Dialysis: Impact on Quality Ratings in Mandate and Nonmandate States

Abstract

Objective: Texas is the only state to mandate a patient to full-time equivalent (FTE) registered dietitian (RD) ratio (,125 patients:FTE RD) in dialysis. Little research exists about the relationship between patient:FTE RD ratio and quality. Our objectives were to a) examine the effect of the mandate on patient:FTE RD ratios in Texas facilities compared to similar nonmandated facilities and b) examine the association between patient:FTE RD ratio and the patient rating of staff quality or star rating of the facility.Design and Methods: Using data from Dialysis Facility Annual Reports, we excluded facilities with less than 125 patients and matched based on region, chain/profit status, and number of patients, pairing each Texas facility with 2 non-Texas facilities. T-tests for difference of means and chi-square tests were performed to compare facility groups characteristics and assess mandate impact. We used correlation between patient:FTE RD ratio and staff quality linearized score, and ANOVA to compare patient:FTE RD ratios between the star rating levels.Results: The patient:FTE RD ratio was higher in non-Texas than Texas facilities (111.84 6 40.70 vs 90.80 6 24.02, P , .01). The Pearson correlation between patient:FTE RD ratio and linearized score rating of the dialysis center staff was essentially nonexistent (r 5 20.046). We found a trend of higher patient:FTE RD ratios in facilities with lower star ratings for quality and staff but no statistical significance. Conclusion:The mandate effectively lowered the patient:FTE RD ratio in Texas dialysis facilities with over 125 patients, indicating that states considering such a mandate may benefit from implementing it. We found no association between patient:FTE RD staffing and quality, either objectively or via patient assessment. Further research should examine whether dialysis facilities are trending toward smaller patient sizes to circumvent staffing mandates and examine the relationship between other professions' staffing ratios and quality.

Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease–stage 3 through maintenance dialysis

“…Using the 2012 Annual Facility Reports and excluding very small facilities whose ratios are skewed in administrative data, we estimated that the mean patient:FTE RDN ratio was 90 ± 34:1 (median 86:1) 42 . These ratios vary based on facility characteristics 41 but have not yet been demonstrated to have a relationship to outcomes 42 or patient satisfaction, 43 perhaps because staffing ratios do not necessarily directly equate to the time available for care.…”

“…While there is interest in California for mandated staffing ratios, and eight other states have some regulations related to dialysis staffing, 37,51 at the moment, there is no evidence to suggest that staffing ratios improve patient outcomes 42 or satisfaction, 43 and any ratios that could be recommended are expert consensus from over 20 years ago 4 . One recent study does suggest that dialysis facilities with significantly worse readmission rates have lower nurse staffing ratios that facilities with expected or better than expected readmission rates, but this analysis did not include RDNs or social workers in their composite staff measure 52 .…”

“…One recent study does suggest that dialysis facilities with significantly worse readmission rates have lower nurse staffing ratios that facilities with expected or better than expected readmission rates, but this analysis did not include RDNs or social workers in their composite staff measure 52 . Outcomes should be tracked before and after staffing mandates are imposed as there is potential for unintended consequences 53 such as a decrease in facility size 43 …”

Work Experiences of the Interdisciplinary Dialysis Workforce in the United States: A Cross-Sectional Survey

“…Physicians, along with PCTs, social workers, and particularly dietitians, were the least likely to report professional fulfillment, which may reflect suboptimal levels of autonomy and reduced intrinsic rewards for these workers. While previous studies of professional fulfillment among these workers are sparse, increasing caseloads and administrative burden may contribute [11,13,15,[27][28][29]. In fact, we found that workers with higher caseloads were more likely to report burnout (and less likely to report professional fulfillment).…”

“…One underexplored reason for poor dialysis clinic performance may be job quality and work environment issues including job dissatisfaction, work overload, burnout, high staff turnover, and inconsistent training [7][8][9]. Low ratings on job quality and work environment could reflect multiple issues, including administrative burden of dialysis care [2]; compassion fatigue and burnout [9][10][11]; inadequate staffing and high caseloads [12][13][14][15]; low or non-competitive pay [7]; perceptions of being undervalued by other team members [7]; and harassment or abuse from other team members, including those in leadership positions, or from patients [16,17]. The COVID-19 pandemic likely only exacerbated these issues [18].…”