1
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Wong A, Huang Y, Banks MD, Sowa PM, Bauer JD. A Cost-Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition. Healthcare (Basel) 2024; 12:1041. [PMID: 38786451 PMCID: PMC11120964 DOI: 10.3390/healthcare12101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Malnutrition is a significant and prevalent issue in hospital settings, associated with increased morbidity and mortality, longer hospital stays, higher readmission rates, and greater healthcare costs. Despite the potential impact of nutritional interventions on patient outcomes, there is a paucity of research focusing on their economic evaluation in the hospital setting. This study aims to fill this gap by conducting a cost-consequence analysis (CCA) of nutritional interventions targeting malnutrition in the hospital setting. METHODS We performed a CCA using data from recent systematic reviews and meta-analyses, focusing on older adult patients with or at risk of malnutrition in the hospital setting. The analysis included outcomes such as 30-day, 6-month, and 12-month mortality; 30-day and 6-month readmissions; hospital complications; length of stay; and disability-adjusted life years (DALYs). Sensitivity analyses were conducted to evaluate the impact of varying success rates in treating malnutrition and the proportions of malnourished patients seen by dietitians in SingHealth institutions. RESULTS The CCA indicated that 28.15 DALYs were averted across three SingHealth institutions due to the successful treatment or prevention of malnutrition by dietitians from 1 April 2021 to 31 March 2022, for an estimated 45,000 patients. The sensitivity analyses showed that the total DALYs averted ranged from 21.98 (53% success rate) to 40.03 (100% of malnourished patients seen by dietitians). The cost of implementing a complex nutritional intervention was USD 218.72 (USD 104.59, USD 478.40) per patient during hospitalization, with additional costs of USD 814.27 (USD 397.69, USD 1212.74) when the intervention was extended for three months post-discharge and USD 638.77 (USD 602.05, USD 1185.90) for concurrent therapy or exercise interventions. CONCLUSION Nutritional interventions targeting malnutrition in hospital settings can have significant clinical and economic benefits. The CCA provides valuable insights into the costs and outcomes associated with these interventions, helping healthcare providers and policymakers to make informed decisions on resource allocation and intervention prioritization.
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Affiliation(s)
- Alvin Wong
- Department of Dietetics, Changi General Hospital, Singapore 529889, Singapore
- School of Human Movement and Nutrition Sciences, University of Queensland, St. Lucia, QLD 4072, Australia
| | - Yingxiao Huang
- Department of Dietetics, Changi General Hospital, Singapore 529889, Singapore
| | - Merrilyn D. Banks
- Department of Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia
| | - P. Marcin Sowa
- Centre for the Business and Economics of Health, University of Queensland, St Lucia, QLD 4067, Australia
| | - Judy D. Bauer
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, VIC 3168, Australia;
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2
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Roberts S, Nucera R, Dowd T, Turner K, Langston K, Keller H, Bell J, Angus RL. Prospective validation of the Global Leadership Initiative on Malnutrition criteria for identifying malnutrition in hospitals: A protocol and feasibility pilot study. Nutr Clin Pract 2024. [PMID: 38711239 DOI: 10.1002/ncp.11156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/03/2024] [Accepted: 04/07/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The aim of this study was to pilot a protocol for prospective validation of the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospital patients and evaluate its feasibility and patient acceptability. METHODS The validation protocol follows the GLIM consortium's rigorous methodological guidance. Protocol feasibility was assessed against criteria on recruitment (≥50%) and data collection completion (≥80%); protocol acceptability was assessed via patient satisfaction surveys and interviews. Adult inpatients in a tertiary hospital underwent four nutrition assessments (each by a different assessor); two Subjective Global Assessments (SGAs) and two GLIM assessments. All five GLIM criteria were assessed with bioelectrical impedance analysis used for muscle mass. Interrater reliability, criterion validity, and predictive validity were reported to detect trends. RESULTS All primary feasibility criteria were met (consent rate 76%; data for GLIM criterion validity collected on 83% participants). Of predictive outcome data, 100% of hospital-related data, 82% of 6-month mortality data, and 39% of 6-month health-related quality of life data were collected. The mean (SD) age of participants was 61.0 ± 16.2 years, and 51.5% were male. The median (interquartile range) length of stay and body mass index were 7 (4-15) days and 25.6 (24.2-33.0) kg/m2, respectively. GLIM criteria diagnosed 70% of the patients as malnourished vs 55% with SGA. Most patients found the data collection acceptable with minimal burden. CONCLUSION The methods outlined in this rigorous GLIM validation protocol are feasible to undertake in hospitals and acceptable to patients. This paper provides practical methodological guidance for future prospective GLIM validation studies.
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Affiliation(s)
- Shelley Roberts
- School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
- Allied Health Research, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Romina Nucera
- Nutrition and Food Services, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Tobias Dowd
- School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - Kyleigh Turner
- School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - Keanne Langston
- Nutrition and Food Services, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Heather Keller
- Schlegel-UW Research Institute for Aging, University of Waterloo, Ontario, Canada
- Department of Kinesiology and Health Sciences, University of Waterloo, Ontario, Canada
| | - Jack Bell
- Allied Health, The Prince Charles Hospital, Metro North Healthcare, Chermside, Queensland, Australia
| | - Rebecca L Angus
- Allied Health Research, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Nutrition and Food Services, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
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3
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Levy BE, Castle JT, Wilt WS, Fedder K, Riser J, Burke ED, Hourigan JS, Bhakta AS. Improving physician documentation for malnutrition: A sustainable quality improvement initiative. PLoS One 2023; 18:e0287124. [PMID: 37561733 PMCID: PMC10414681 DOI: 10.1371/journal.pone.0287124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/31/2023] [Indexed: 08/12/2023] Open
Abstract
This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.
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Affiliation(s)
- Brittany E. Levy
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Jennifer T. Castle
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Wesley S. Wilt
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Kelly Fedder
- Department of Clinical Nutrition, Center for Health Services Research, University of Kentucky College of Health Sciences, Lexington, Kentucky, United States of America
| | - Jeremy Riser
- Department of Clinical Nutrition, Center for Health Services Research, University of Kentucky College of Health Sciences, Lexington, Kentucky, United States of America
| | - Erin D. Burke
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Jon S. Hourigan
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
| | - Avinash S. Bhakta
- Division of Colorectal Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America
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4
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Busch RA, Stone S, Kudsk KA. A tale of two analyses: Administrative vs primary review of nutrition support team performance. Nutr Clin Pract 2023; 38:102-107. [PMID: 35499296 PMCID: PMC10084298 DOI: 10.1002/ncp.10856] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/11/2022] [Accepted: 04/03/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Our pharmacy department performed a medication-use evaluation using administrative data to assess prescription of parenteral nutrition (PN). They found that 31.6% (185 of 586) of nutrition support team (NST) patients received ≤5 days of PN, whereas 120 received ≤3 days. These results raised the question of NST prescribing practices given the incidence of short-duration PN. Since our NST evaluates all PN requests, the study prompted further review to identify reasons for short duration PN. METHODS Charts of patients receiving PN for ≤3 days in the initial study underwent an in-depth review focusing on indications, reasons for discontinuation, and protein-calorie malnutrition (PCM) at time of NST consultation. RESULTS A total 120 of 586 patients had PN ≤3 days. PN was clearly indicated in 94 cases: 27 patients received home PN but resolved the need for admission, 11 were admitted to later discharge on PN, 18 chose alternative/palliative care soon after starting PN, and 38 were nil per os for ≥6 days because of ileus, bowel obstruction, or contraindication to enteral feeding. Of the remaining 26 patients, 15 had PCM with poor intake for ≥ 3 days, warranting PN; only nine cases had unclear indications for PN and 11 could have potentially been avoided. CONCLUSION Administrative data implied inappropriate PN use, whereas in-depth review confirmed appropriate prescription in most patients. Reducing short-duration PN in the management of ileus or obstruction remains difficult because of variable time to symptom resolution. In-depth chart review remains the best method to assess appropriateness of PN use.
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Affiliation(s)
- Rebecca A Busch
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Susan Stone
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA.,Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Kenneth A Kudsk
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA.,Veterans Administration Surgical Services, William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
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5
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Barrocas A, Schwartz DB, Bistrian BR, Guenter P, Mueller C, Chernoff R, Hasse JM. Nutrition support teams: Institution, evolution, and innovation. Nutr Clin Pract 2023; 38:10-26. [PMID: 36440741 DOI: 10.1002/ncp.10931] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.
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Affiliation(s)
- Albert Barrocas
- Department of Surgery, Tulane University School of Medicine, Atlanta, Georgia, USA
| | - Denise Baird Schwartz
- Bioethics Committee, Providence Saint Joseph Medical Center, Burbank, California, USA
| | - Bruce R Bistrian
- Division of Clinical Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition (ASPEN), Moses Lake, Washington, USA
| | - Charles Mueller
- Department of Nutrition and Food Studies, New York University/Steinhardt, New York, New York, USA
| | - Ronni Chernoff
- Donald Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jeanette M Hasse
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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6
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Carvalho-Salemi J, Phillips W, Wong Vega M, Swanson J, Becker PJ, Salemi JL. Malnutrition among Hospitalized Children in the United States: A 2012-2019 Update of Annual Trends. J Acad Nutr Diet 2023; 123:109-116. [PMID: 35659540 DOI: 10.1016/j.jand.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/24/2022] [Accepted: 12/22/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malnutrition is associated with adverse clinical outcomes and increased health care utilization for hospitalized children. Yet pediatric malnutrition often goes undiagnosed and national prevalence research in this population is scarce. OBJECTIVE The aim was to assess change in the coded diagnosis of malnutrition (CDM) among US hospitalized children given increased awareness of the need for improved recognition and standardized diagnosis. DESIGN Retrospective, cross-sectional analysis using nationally representative data from the Nationwide Inpatient Sample. PARTICIPANTS/SETTING Our sample was 13.2 million hospitalizations from 2012 to 2019 among pediatric patients between age 1 month and 17 years. MAIN OUTCOME MEASURE CDM using International Classification of Diseases Ninth and 10th Revision-Clinical Modification diagnosis codes. STATISTICAL ANALYSES Descriptive statistics and sampling weights were used to estimate the national frequency and prevalence of CDM. Temporal trends in CDM overall and stratified by age, race/ethnicity, and hospital type were analyzed using joinpoint regression. RESULTS CDM prevalence increased from 3.9% in 2012 to 6.4% in 2019. During this period, failure to thrive decreased from 40.6% to 23.3% of all cases with concomitant increases in the diagnosis of protein-calorie malnutrition and children identified with more than one malnutrition subtype. Differences in CDM diagnoses are evident by hospital type, race/ethnicity, and age of the patient. CONCLUSIONS Although pediatric malnutrition continues to be underdiagnosed in hospital settings, this study demonstrates improvement over time. There continues to be a need for continued professional education regarding best practices for diagnosis to improve health care provider knowledge and self-efficacy on this topic, especially in nonteaching hospitals.
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Affiliation(s)
| | | | | | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, Florida
| | | | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, Florida
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7
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McCray S, Barsha L, Maunder K. Implementation of an electronic solution to improve malnutrition identification and support clinical best practice. J Hum Nutr Diet 2022; 35:1071-1078. [PMID: 35510388 DOI: 10.1111/jhn.13026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Routine malnutrition risk screening of patients is critical for optimal care and comprises part of the National Australian Hospital Standards. Identification of malnutrition also ensures reimbursement for hospitals to adequately treat these high-risk patients. However, timely, accurate screening, assessment and coding of malnutrition remains suboptimal. The present study aimed to investigate manual and digital interventions to overcome barriers to malnutrition identification for improvements in the hospital setting. METHODS Retrospective reporting on malnutrition identification processes was conducted through two stages: (1) manual auditing intervention and (2) development of a digital solution - the electronic malnutrition management solution (eMS). Repeated process audits were completed at approximately 6-monthly intervals through both stages between 2016 and 2019 and the results were analysed. In Stage 2, time investment and staff adoption of the digital solution were measured. RESULTS Overall, the combined effect of both regular auditing and use of the eMS resulted in statistically significant improvements across all six key measures: patients identified (97%-100%; p < 0.001), screened (68%-95%; p < 0.001), screened within 24 h (51%-89%; p < 0.001), assessed (72%-95%; p < 0.001), assessed within 24 h (66%-93%; p < 0.001) and coded (81%-100%; p = 0.017). The eMS demonstrated a reduction in screening time by over 60% with user adoption 100%. Data analytics enabled automated, real-time auditing with a 95% reduction in time taken to audit. CONCLUSIONS A single digital solution for management of malnutrition and automation of auditing demonstrated significant improvements where manual or combinations of manual and electronic systems continue to fall short.
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Affiliation(s)
- Sally McCray
- Dept of Dietetics and Foodservices, Mater Group, Raymond Terrace, South Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland Brisbane, QLD, Australia
| | - Laura Barsha
- Dept of Dietetics and Foodservices, Mater Group, Raymond Terrace, South Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland Brisbane, QLD, Australia
| | - Kirsty Maunder
- The CBORD Group, Sydney, NSW, Australia.,University of Wollongong, Faculty of Science, Medicine and Health, Wollongong, NSW, Australia
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8
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Mohamed Elfadil O, Velapati SR, Miller LD, Huiras MF, Stoecker EA, Warner M, Vanderveer L, Adkins A, Chargo C, Kueny K, Bailey MS, Hurt RT, Mundi MS. Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients. CAN J DIET PRACT RES 2022; 83:203-207. [PMID: 36004724 DOI: 10.3148/cjdpr-2022-016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Lisa D Miller
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Michael F Huiras
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Evan A Stoecker
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Morgan Warner
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Laura Vanderveer
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Ashley Adkins
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Christopher Chargo
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Katherine Kueny
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Molly S Bailey
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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9
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Mundi MS, Mechanick JI, Mohamed Elfadi O, Patel J, Bonnes SL, Blackmer AB, Christian VJ, Hennessy SA, Hurt RT, Jain A, Kaspar MB, Katz J, Labossiere R, Limketkai B, McCarthy PJ, Morrison CA, Newberry C, Pimiento JM, Rosenthal MD, Taylor B, McClave SA. Optimizing the Nutrition Support Care Model: Analysis of Survey Data. JPEN J Parenter Enteral Nutr 2022; 46:1709-1724. [PMID: 35040154 DOI: 10.1002/jpen.2326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/30/2021] [Accepted: 12/17/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Malnutrition is under-recognized and under-diagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low, despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p-value <0.0001). Most responding physicians (80.7%) reported being a member of NSTs, compared with 56.5% of dietitians. Of those not practicing in NSTs (N = 81, 34.4%), 12.3% reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (48.9%), followed by leadership (30.6%), and healthcare professional (HCP) interest (23.4%). A majority (73.6%) of all respondents wanted additional training in nutrition, but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION Core actions resulting from this survey focused on formalizing physician roles, increasing inter-disciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models. CLINICAL RELEVANCY STATEMENT Physician engagement in nutrition support continues to remain low despite the increasing prevalence of malnutrition. This problem, and the working solution, is in the context of decreased engagement of other healthcare professionals in nutrition support, as well as declining Nutrition Support Team utilization. To address these issues, the ASPEN Physician Engagement Committee (PEC) conducted a survey of healthcare professionals (HCPs) involved in nutrition support. Key findings include: (1) lack of financial support and physician champions with financial knowledge; (2) inadequate valuation of physicians and other nutrition support HCPs and NSTs, and their impact on clinical outcomes; and (3) significant barriers to primary and supplementary training for physicians in nutrition. Accordingly, the PEC recommends: (1) development of cost-effective screening and intervention for malnutrition; (2) expansion of nutrition support care models appropriately scaled to the available resources and expertise; and (3) development of a knowledge translation platform to foster transmission of novel breakthroughs while addressing research, knowledge, and practice gaps. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Jeffrey I Mechanick
- Kravis Center for Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Osman Mohamed Elfadi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Jayshil Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wi
| | - Sara L Bonnes
- General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Allison B Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Vikram J Christian
- Division of Pediatric Gastroenterology, University of Minnesota, Minneapolis, MN
| | - Sara A Hennessy
- Division of Burn, Trauma, Acute & Critical Care Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Ryan T Hurt
- General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ajay Jain
- Division of Pediatric Gastroenterology, Saint Louis University, Saint Louis, Missouri, USA
| | - Matthew B Kaspar
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jennifer Katz
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, New York, USA
| | | | - Berkeley Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA
| | - Paul J McCarthy
- Division of Cardiovascular Critical Care, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Chet A Morrison
- Division of Trauma and Critical Care, Central Michigan University College of Medicine
| | - Carolyn Newberry
- Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), Weill Cornell Medical Center, New York, NY
| | - Jose M Pimiento
- GI Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Martin D Rosenthal
- Division of Trauma and Acute Care Surgery, University of Florida, Gainesville, Florida
| | - Beth Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, School of Medicine, University of Louisville, Louisville, Kentucky, USA
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10
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House M, Gwaltney C. Malnutrition screening and diagnosis tools: Implications for practice. Nutr Clin Pract 2021; 37:12-22. [PMID: 34897800 DOI: 10.1002/ncp.10801] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Despite the prevalence of protein-calorie malnutrition (PCM) in acute-care hospitals and long-term care centers, a national and global consensus on nutrition screening and malnutrition diagnosis is lacking. PCM is associated with various acute and chronic complications, such as impaired wound healing, increased risk for infection, debility, and increased risk for rehospitalization. The consequences of PCM are also incredibly costly to both the patient and the healthcare facility. The purpose of this paper is to identify nutrition screening tools and malnutrition diagnosis tools currently being utilized in acute-care healthcare centers across the United States.
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Affiliation(s)
- Mary House
- Nutrition Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas, 75246, USA
| | - Caitlin Gwaltney
- Nutrition Services, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas, 75246, USA
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11
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Bernstein A, Moore R, Rhee L, Aronson D, Katz D. A digital dietary assessment tool may help identify malnutrition and nutritional deficiencies in hospitalized patients. RESEARCH IDEAS AND OUTCOMES 2021. [DOI: 10.3897/rio.7.e70642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Malnutrition is common among hospitalized patients and associated with longer hospital stays, higher rates of rehospitalization, and increased mortality. Validated questionnaires of varying sensitivity and specificity to help identify patients at risk of malnutrition have been developed, but none has been broadly adopted. Tools to identify patients at risk for malnutrition should be quick, inexpensive, easy to administer and use, not require specialized nutrition knowledge, and provide results which can be entered into an electronic medical record; ideally, the tool should be deployed within 24 hours of admission and repeated if warranted. We hypothesize that a novel digital nutrition assessment tool which uses the Diet Quality Photo Navigation (DQPN) method, can help triage hospitalized patients toward further evaluation of nutritional status. We further propose that micronutrient deficiencies may be identified at the same time as malnutrition and that the reimbursement and cost savings from DQPN will prove substantially greater than the combined costs of its use and triggered dietitian consult. Deploying DQPN upon admission will represent an addition to standard hospital intake procedure that is frictionless for patients and health professionals, and one which may be overseen by clerical rather than clinical staff. The digital format of DQPN, which can be integrated into electronic medical records, will facilitate easier tracking and management of nutritional status over the course of hospitalization and post-discharge. To evaluate the hypotheses, DQPN will be deployed in a hospital setting to a group of patients who will also be seen by a registered dietitian to assess the nutritional status of each patient. Receiver operating characteristic curves will determine the point, or criterion, at which maximal true positivity rate and least false positivity rate for a diagnosis of malnutrition and specific nutrient deficiencies align. The study cohort will also be compared to a matched historical cohort to compare total medical spend and reimbursement between the intervention cohort and matched control. Testing of these hypotheses will thus allow for insight into whether DQPN may be used to identify malnutrition and nutrient deficiencies in hospitalized patients and, in so doing, improve patient outcomes, reduce healthcare utilization, and bring financial benefit to hospitals.
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Academy of Nutrition and Dietetics Nutrition Research Network: Rationale and Protocol for a Study to Validate the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus-Derived Diagnostic Indicators For Adult And Pediatric Malnutrition and to Determine Optimal Registered Dietitian Nutritionist Staffing in Acute Care Hospital Settings. J Acad Nutr Diet 2021; 122:630-639. [PMID: 33962901 DOI: 10.1016/j.jand.2021.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/16/2021] [Accepted: 03/29/2021] [Indexed: 01/04/2023]
Abstract
No systematic, universally accepted method of diagnosing malnutrition in hospitalized patients exists, which may contribute to underdiagnosis, undertreatment, and poorer patient outcomes. To address this issue, the Academy of Nutrition and Dietetics is conducting a cohort study to: assess the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators for the diagnosis of adult and pediatric malnutrition in hospital settings; assess the interrater reliability of the indicators for the diagnosis of adult and pediatric malnutrition; and quantify the level of registered dietitian nutritionist care needed to improve patient outcomes. Up to 60 adult and 60 pediatric hospital sites will collect data to estimate level of registered dietitian nutritionist care, along with patient medical history and Malnutrition Screening Tool (adult) or STRONGkids (pediatric) results. A subset of 600 adult and 600 pediatric patients (∼1:1 screened as high- or low-risk for malnutrition) will be randomly selected for the indicators for the diagnosis of adult and pediatric malnutrition and Nutrition Focused Physical Exam data collection; 100 adult and 100 pediatric patients in this group will also undergo a bioelectrical impedance analysis measurement. Additional nutrition care and medical outcomes (eg, mortality and length of stay) will be collected for a 3-month period after the initial nutrition encounter. Multilevel linear, logistic, Poisson, or Cox regression models will be used to assess indicators for the diagnosis of adult and pediatric malnutrition validity and registered dietitian nutritionist staffing levels as appropriate for each medical outcome. Validation results will allow US clinicians to standardize the way they diagnose malnutrition in hospitalized patients, and the staffing data will support advocacy for available registered dietitian nutritionist-delivered malnutrition treatment to improve patient outcomes.
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Bomze L, Dehom S, Lao WP, Thompson J, Lee N, Cragoe A, Luceno C, Crawley B. Comorbid Dysphagia and Malnutrition in Elderly Hospitalized Patients. Laryngoscope 2021; 131:2441-2447. [PMID: 33493366 DOI: 10.1002/lary.29329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/01/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE/HYPOTHESIS Elderly individuals account for one-third of all hospitalizations. The goal of this study was to evaluate the prevalence of dysphagia in elderly patients admitted to a tertiary care center. It also sought to investigate how dysphagia is identified, how it covaries with malnutrition and other conditions, and how it impacts hospital stay. STUDY DESIGN Case Series. METHODS A retrospective chart review was performed. All patients >65 years admitted to a tertiary care center in January and February 2016 were included. Patients with primary psychiatric diagnoses and patients with upper aerodigestive tract malignancy or surgery were excluded. RESULTS A total of 655 patients were identified. Mean age was 76.6 years. Twenty-four percent (155 patients) had dysphagia while 43% (282 patients) had malnutrition. Thirteen percent (84 patients) had both dysphagia and malnutrition. Fifty percent of patients who had malnutrition were seen by speech language pathology (SLP). One hundred percent of malnourished patients that saw SLP were identified as having dysphagia. Three hundred and eighty-two patients (58%) were seen by the dietician but not by SLP. Multiple logistic regression indicated that the presence of dysphagia was positively associated with age, presence of malnutrition, admission to either cardiology or neurology service as compared to medicine service, and history of stroke. CONCLUSIONS One-quarter of elderly patients admitted to our tertiary care center had dysphagia. Dysphagia, especially when linked with malnutrition, has poorer outcomes and increased healthcare costs. Our data suggests a possible disconnect between malnutrition diagnosis and dysphagia identification. This is an important area of intervention that has the potential to improve the treatment and outcomes of these patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Laura Bomze
- Department of Otolaryngology - Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, U.S.A
| | - Salem Dehom
- School of Nursing, Loma Linda University, Loma Linda, California, U.S.A
| | - Wilson P Lao
- Department of Otolaryngology - Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, U.S.A
| | - Jordan Thompson
- School of Medicine, Loma Linda University, Loma Linda, California, U.S.A
| | - Nathan Lee
- School of Medicine, Loma Linda University, Loma Linda, California, U.S.A
| | - Andrea Cragoe
- School of Medicine, Loma Linda University, Loma Linda, California, U.S.A
| | - Cesar Luceno
- School of Medicine, Loma Linda University, Loma Linda, California, U.S.A
| | - Brianna Crawley
- Department of Otolaryngology - Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, U.S.A.,Voice and Swallowing Center, Loma Linda University, Redlands, California, U.S.A
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Limketkai BN, Mauldin K, Manitius N, Jalilian L, Salonen BR. The Age of Artificial Intelligence: Use of Digital Technology in Clinical Nutrition. CURRENT SURGERY REPORTS 2021; 9:20. [PMID: 34123579 PMCID: PMC8186363 DOI: 10.1007/s40137-021-00297-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW Computing advances over the decades have catalyzed the pervasive integration of digital technology in the medical industry, now followed by similar applications for clinical nutrition. This review discusses the implementation of such technologies for nutrition, ranging from the use of mobile apps and wearable technologies to the development of decision support tools for parenteral nutrition and use of telehealth for remote assessment of nutrition. RECENT FINDINGS Mobile applications and wearable technologies have provided opportunities for real-time collection of granular nutrition-related data. Machine learning has allowed for more complex analyses of the increasing volume of data collected. The combination of these tools has also translated into practical clinical applications, such as decision support tools, risk prediction, and diet optimization. SUMMARY The state of digital technology for clinical nutrition is still young, although there is much promise for growth and disruption in the future.
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Affiliation(s)
- Berkeley N. Limketkai
- Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, 100 UCLA Medical Plaza, Suite 345, Los Angeles, CA 90095 USA
| | - Kasuen Mauldin
- Department of Nutrition, Food Science, and Packaging, San José State University, San José, CA USA
| | - Natalie Manitius
- Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, 100 UCLA Medical Plaza, Suite 345, Los Angeles, CA 90095 USA
| | - Laleh Jalilian
- Department of Anesthesiology, UCLA School of Medicine, Los Angeles, CA USA
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Williams DGA, Villalta E, Aronson S, Murray S, Blitz J, Kosmos V, Wischmeyer PE. Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic. JPEN J Parenter Enteral Nutr 2020; 44:1185-1196. [PMID: 32232882 PMCID: PMC7540666 DOI: 10.1002/jpen.1824] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/25/2020] [Indexed: 12/29/2022]
Abstract
Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated—a true “silent epidemic” in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian–driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.
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Affiliation(s)
- David G A Williams
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Solomon Aronson
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sutton Murray
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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Bistrian BR, Mogensen KM, Christopher KB. Plea for Reapplication of Some of the Older Nutrition Assessment Techniques. JPEN J Parenter Enteral Nutr 2020; 44:391-394. [DOI: 10.1002/jpen.1808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
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Rogobete AF, Grintescu IM, Bratu T, Bedreag OH, Papurica M, Crainiceanu ZP, Popovici SE, Sandesc D. Assessment of Metabolic and Nutritional Imbalance in Mechanically Ventilated Multiple Trauma Patients: From Molecular to Clinical Outcomes. Diagnostics (Basel) 2019; 9:diagnostics9040171. [PMID: 31683927 PMCID: PMC6963656 DOI: 10.3390/diagnostics9040171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 12/26/2022] Open
Abstract
The critically ill polytrauma patient is characterized by a series of metabolic changes induced by inflammation, oxidative stress, sepsis, and primary trauma, as well as associated secondary injuries associated. Metabolic and nutritional dysfunction in the critically ill patient is a complex series of imbalances of biochemical and genetic pathways, as well as the interconnection between them. Therefore, the equation changes in comparison to other critical patients or to healthy individuals, in which cases, mathematical equations can be successfully used to predict the energy requirements. Recent studies have shown that indirect calorimetry is one of the most accurate methods for determining the energy requirements in intubated and mechanically ventilated patients. Current research is oriented towards an individualized therapy depending on the energy consumption (kcal/day) of each patient that also takes into account the clinical dynamics. By using indirect calorimetry, one can measure, in real time, both oxygen consumption and carbon dioxide production. Energy requirements (kcal/day) and the respiratory quotient (RQ) can be determined in real time by integrating these dynamic parameters into electronic algorithms. In this manner, nutritional therapy becomes personalized and caters to the patients’ individual needs, helping patients receive the energy substrates they need at each clinically specific time of treatment.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Ioana Marina Grintescu
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania.
| | - Tiberiu Bratu
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Marius Papurica
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | | | - Sonia Elena Popovici
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
| | - Dorel Sandesc
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu",300041 Timisoara 300723, Romania.
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