The History, Attitudes, and Barriers of Primary

Care Providers Practicing in the Northeast in

Referring Patients to Registered Dietitian
Nutritionists for Chronic Diseases.
LAURA E. NIEDERER | MARYWOOD UNIVERSITY
PROJECT GOALS

Integrative Preventative Fill the gap in

health care healthcare research
PURPOSE
Problem Statement. The purpose of this study is to assess the history, attitudes,
and barriers to primary care providers practicing in the Northeastern region of the
United States in referring patients to registered dietitian nutritionists for chronic
diseases.
Sub-problem 1. What is the referral history of PCPs to RDNs for chronic
diseases?
Sub-problem 2. What are the attitudes of PCPs in referring patients to RDNs for
chronic diseases?
Sub-problem 3. What are the perceived barriers of PCPs in referring patients to
RDNs for chronic diseases?
METHODS

Primary care provider

>18 years of age
Practice in one or more states in the Northeastern region of the US
MD, DO, NP, PA-C
Patient population of 50% or greater of adults (18 years)
 METHODS

Rhode Island Society of Osteopathic Physicians

Connecticut Osteopathic Medical Society
Massachusetts Osteopathic Society
New York State Association of Family Physicians
New Hampshire Nurse Practitioner Association
ProHealth Physicians Inc. in Connecticut
METHODS
Statistical Analysis
Online survey (5-10 mins.)
Descriptive statistics
Reviewed by a professional in the field, REDCap
Frequency distributions
Direct Email, E-Newsletter, Website Newsfeed
Independent samples t-test
Collection time: 3 months
ANOVA with Bonferroni
post hoc
Pearson Correlation
SPSS Version 24
p < .05
 Have you Obesity Daily
For a Weekly
ever referred T2D
a pt. to an chronic HTN
Bi-weekly
disease? Monthly
RDN? HLD Bi-monthly

#1 I feel comfortable providing nutrition counseling/ education to patients with the following chronic diseases

#2 Referring an adult patient to an RDN for MNT is a significant component of the tx/management of the
following chronic diseases

#3 In the next year, what is your likelihood of referring an adult patient to an RD/RDN for MNT for the
tx/management of the following chronic diseases

#4 Currently, what would be your most likely reason for referral of an adult pt. to an RDN for MNT regarding
the prevention and/or tx/ management of the following chronic diseases?
Prevention,Tx/Management, Both, Neither

#5 I feel that MNT provided by an RD/RDN is more effective in the tx/management of chronic diseases than
nutrition counseling provided by myself.
 Table 1 - Participant Demographics

RESULTS Characteristic
Gender
n %

Male 11 44
Female 14 56
Race
Caucasian 23 95.8
American Indian/Alaskan Native 1 4.2
n = 25 Credential
MD 12 48
DO 5 20
PA-C 1 4
NP 7 28
Area of Practice
Urban 1 4.5
Suburban 16 72.7
Rural 4 18.2
Other 1 4.5
Percentages are out of total study participants, n=25
 Table 2

Chronic Disease Referral History

n %
RESULTS HISTORY Have referred to an
RDN
Yes 23 92.0
Most (92%) have referred to an No 2 8.0
RDN Have referred for
Most common referral were Obesity
Obesity and T2D (n=23) Yes 23 100
No 0 0.0
Overweight and Pre-Diabetes T2D
were most common other Yes 23 100
referrals No 0 0.0
HTN
Least common referral was HTN Yes 8 34.8
No 15 65.2
HLD
Yes 16 69.8
No 7 30.4
 RESULTS ATTITUDES RDN Score

Table 17

RDN Scores by Gender, Credential and Area of Practice

n Mean SD
Total 25 48.68 8.15
Gender
Male 11 48.27 7.12
Female 14 49.00 9.13
Credential
MD 12 46.08 9.62
DO 5 53.60 3.29
NP 7 48.86 7.08
Area of Practice
Suburban 16 48.81 9.40
Rural 4 47.75 3.69
 RESULTS ATTITUDES
Level of comfort in providing nutrition counseling/ education to patients
Referrals indicate a lesser comfort with providing education.
PCPs who have previously referred for HTN are significantly less comfortable in providing
nutrition education to pts.
Level of agreement with MNT provided by an RDN being a significant
component of the treatment/management of a disease.
PCPs who have previously referred for HTN were in significantly more agreement
DOs were in significantly more agreement with the importance than MDs to refer for HTN
and HLD
Likelihood of referring a patient to an RDN for MNT based upon a previous
referral
PCPs who have previously referred for HTN or HLD are significantly more likely to refer in
the future
DOs were significantly more likely than MDs to refer for HLD
RESULTS BARRIERS
64% - There are a limited number RD/RDNs in my geographic area of practice to
refer my patients.
60% - I know RD/RDN services will not be covered under my patients' medical
insurance.
48% - Patients are resistant to me referring them to an RD/RDN.
24% - I assume RD/RDN services will not be covered under my patients' medical
insurance.
RESULTS BARRIERS
I worry about what my patients are being told. What kind of training does the RD
get, who sponsors their education, what do they know about food politics, big ag, etc.
I am well read on these topics and feel confidant [confident] in doing my own
counseling when time allows
RD's are in great shortage in my area. I would refer much more if there was
access!
I didn't realize this service was available
In military PCMH, RDs are often part of the team, and are of tremendous value to
our military retirees.

Insurance coverage Inadequate number of RDNs

 DISCUSSION
28 PCPs in the U.S. n = 25
There are no current
79% of PCPs have referred a pt. to RDN 92% research in the United
Most frequent reasons for referring States that specifically
Special conditions, complicated dietary needs
evaluated the PCPs
likelihood to refer
Diabetes (94.2%) 92%
patients to an RD for
Obesity(90.7%) 92% treatment and
HLD (88.9%) 64% prevention of chronic
HTN (80.6%) 32% diseases
Emina, S. (2012). Barriers to Providing Nutrition Counseling by Primary Care Physicians: Opportunities for
(Emina, 2012 pg. 45).
Registered Dietitians (Doctoral dissertation, The Ohio State University).
 Strategic Marketing Interdisciplinary Care
DISCUSSION
One referral, future referrals Encouraging PCP, RDN relationship
Obesity, T2D In-patient, Out-patient (job growth)
DO > MD, PA-C Medical School education

Clinical Implications

Promote Practice Insurance Reimbursement

Education & Training Further coverage
Food Police Preventative health-care
We are the professionals
DISCUSSION
Limitations
Lack of measured reliability and validity of surveying instruments
Low response rate, convenience sample
Reliability of the administrators to distribute the surveys to PCPs
5 out of 9 states in the Northeast Region
Future Research
Larger sample size
More ethnically diverse
Representative of the entire U.S. population
CONCLUSION
Contributed to filling the gap in research.
This research aims to build a foundation to support interdisciplinary health
care in an out-patient setting.
Model for future investigation of interdisciplinary health care.
It the responsibility of the RDN to truly capitalize upon these opportunities,
along with the cooperation of other health professionals such as PCPs,
nutrition policies and insurance coverages.
RDNs must advocate and capitalize on these opportunities!
QUESTIONS?