Targeting malnutrition: Nutrition programs yield cost savings for hospitalized patients

Prospective validation of the Global Leadership Initiative on Malnutrition criteria for identifying malnutrition in hospitals: A protocol and feasibility pilot study

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.

Health economic value of postacute oral nutritional supplementation in older adult medical patients at risk for malnutrition: a US-based modelling approach

OBJECTIVE

To estimate the health economic value of postdischarge oral nutrition supplement (ONS) consumption among elderly adults who were malnourished during hospitalisation.

DESIGN

A cost-effectiveness model was developed from a US payer perspective based on a recent meta-analysis of randomised trials of nutritional support following hospital discharge and studies of US hospital mortality, readmission rates and costs.

PARTICIPANTS AND SETTING

The target population of this study was postacute care US patients aged ≥65 years who were identified as malnourished during hospitalisation.

INTERVENTION AND OUTCOME MEASURES

A decision-tree model was used to evaluate the impact of postacute care daily consumption of ONS compared with no ONS. Outcomes were evaluated over a 1-year time interval. Clinical outcomes of interest included readmission and mortality rates. Economic value of ONS was quantified using three different metrics: cost per death averted, cost per readmission avoided and direct cost savings resulting from changes in postacute mortality and readmission rates. The economic value of ONS was also measured by gains in quality-adjusted life-years.

RESULTS

Compared with patients not receiving ONS after hospital discharge, use of ONS during the postacute phase reduced mortality by 36.3% and readmissions by 11.0%. Reductions in readmissions resulted in annual savings of US$1113 per person. When extrapolating the results to the estimated 1 693 034 hospitalised elderly US adults at risk of malnutrition, the use of ONS after hospital discharge would prevent 67 747 deaths and 116 570 hospital readmissions per year. With the estimated cost of nutritional support at US$175 per patient per month corresponding to two servings ONS per day, the ONS cost per death and readmission avoided was estimated at US$4380 and US$2546, respectively.

CONCLUSIONS

Postdischarge use of ONS among patients at risk for malnutrition is highly cost-effective with important reductions in mortality and readmission rates.

Implementation of nutritional care in hospitals: A qualitative study of barriers and facilitators using implementation theory

BACKGROUND

Disease-related malnutrition is prevalent among hospitalised patients, but not all patients achieve the needed nutritional care. At a Danish University Hospital, focus has been on implementing nutritional practices based on clinical guidelines, but there is continuously variation between the wards regarding the quality of nutritional care.

AIM

The aim of this study was to identify the potential barriers and facilitators for implementation of the clinical guidelines for nutritional practices and to recommend suggestions for development of nutritional practices, using a theoretical implementation strategy.

METHOD

The design was a qualitative interview study of employees at a Danish University Hospital, using a semi-structured interview guide. The participants were nurses, nurse's assistant, nurse nutrition expert, head nurse and dieticians. We recruited 11 employees, representing eight different wards.

FINDINGS

The analysis identified six themes: (1) clear allocation of responsibilities and committed management enhances nutrition practices, (2) leadership support is essential, (3) physical settings and tools affect possibilities for action, (4) selection of equivalent staff is core, (5) teaching promotes the knowledge and skills and (6) a dietitian in the ward facilitates implementation of nutritional care. Barriers and facilitators among the themes were identified and has led to suggestions to strengthen nutritional care, based on implementation theory.

CONCLUSION

Various factors were identified as having impact on the implementation of nutrition practices and different suggestions have emerged to accommodate those factors, as well as to apply an implementation strategy to facilitate change in practice.

Patient-Led, Technology-Assisted Malnutrition Risk Screening in Hospital: A Feasibility Study

Malnutrition risk screening is crucial to identify at-risk patients in hospitals; however, screening rates can be suboptimal. This study evaluated the feasibility, acceptability, and potential cost-effectiveness of patient-led, technology-assisted malnutrition risk screening. A prospective multi-methods study was conducted in a 750-bed public hospital in Australia. Patients were recruited from seven wards and asked to complete an electronic version of the Malnutrition Screening Tool (e-MST) on bedside computer screens. Data were collected on feasibility, acceptability, and cost. Feasibility data were compared to pre-determined criteria on recruitment (≥50% recruitment rate) and e-MST completion (≥75% completion rate). Quantitative acceptability (survey) data were analyzed descriptively. Patient interview data were analyzed thematically. The economic evaluation was from the perspective of the health service using a decision tree analytic model. Both feasibility criteria were met; the recruitment rate was 78% and all 121 participants (52% male, median age 59 [IQR 48-69] years) completed the e-MST. Patient acceptability was high. Patient-led e-MST was modeled to save $3.23 AUD per patient and yield 6.5 more true malnutrition cases (per 121 patients) with an incremental cost saving per additional malnutrition case of 0.50 AUD. Patient-led, technology-assisted malnutrition risk screening was found to be feasible, acceptable to patients, and cost-effective (higher malnutrition yield and less costly) compared to current practice at this hospital.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

Impact of a specialized oral nutritional supplement on quality of life in older adults following hospitalization: Post-hoc analysis of the NOURISH trial

BACKGROUND & AIMS

Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality in malnourished older adults. In a post-hoc analysis of data from hospitalized older adults with malnutrition risk, we sought to determine whether consuming a specialized ONS (S-ONS) containing high protein and beta-hydroxy-beta-methylbutyrate (HMB) can also improve Quality of Life (QoL).

METHODS

We analyzed data from the NOURISH trial-a randomized, placebo-controlled, multi-center, double-blind study conducted in patients with congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Patients received standard care + S-ONS or placebo beverage (target 2 servings/day) during hospitalization and for 90 days post-discharge. SF-36 and EQ-5D QoL outcomes were assessed at 0-, 30-, 60-, and 90-days post-discharge. To account for the missing QoL observations (27.7%) due to patient dropout, we used multiple imputation. Data represent differences between least squares mean (LSM) values with 95% Confidence Intervals for groups receiving S-ONS or placebo treatments.

RESULTS

The study population consisted of 622 patients of mean age ±standard deviation: 77.9 ± 8.4 years and of whom 52.1% were females. Patients consuming placebo had lower (worse) QoL domain scores than did those consuming S-ONS. Specifically for the SF-36 health domain scores, group differences (placebo vs S-ONS) in LSM were significant for the mental component summary at day 90 (-4.23 [-7.75, -0.71]; p = 0.019), the domains of mental health at days 60 (-3.76 [-7.40, -0.12]; p = 0.043) and 90 (-4.88 [-8.41, -1.34]; p = 0.007), vitality at day 90 (-3.33 [-6.65, -0.01]; p = 0.049) and social functioning at day 90 (-4.02 [-7.48,-0.55]; p = 0.023). Compared to placebo, differences in LSM values for the SF-36 general health domain were significant with improvement in the S-ONS group at hospital discharge and beyond: day 0 (-2.72 [-5.33, -0.11]; p = 0.041), day 30 (-3.08 [-6.09, -0.08]; p = 0.044), day 60 (-3.95 [-7.13, -0.76]; p = 0.015), and day 90 (-4.56 [-7.74, -1.38]; p = 0.005).

CONCLUSIONS

In hospitalized older adults with cardiopulmonary diseases and evidence of poor nutritional status, daily intake of S-ONS compared to placebo improved post-discharge QoL scores for mental health/cognition, vitality, social functioning, and general health. These QoL benefits complement survival benefits found in the original NOURISH trial analysis.

CLINICAL TRIAL REGISTRATION

NCT01626742.

"More2Eat" in patients at nutritional risk during hospital stay lowers the risk of three-month mortality

BACKGROUND & AIMS

Malnutrition is a common problem among hospitalized patients due to increased nutrient requirements and reduced food intake or uptake of nutrients. The aim of this prospective cohort study was to investigate the association of nutritional risk status (at or not at risk by NRS-2002) as well as energy and protein intake, use of oral nutritional supplements (ONS) and snack meals in at risk patients during hospitalization and adverse outcomes (length of stay (LOS), readmissions and mortality) at three-months follow-up.

METHODS

Data were collected at baseline and at three-months follow-up in patients hospitalized at 31 units at a Danish University Hospital. Diet records were performed at baseline by using the nurses' quartile nutrition recording methods. Data about disease and clinical outcomes were collected from electronic medical records at baseline and three-months follow-up.

RESULTS

A total of 318 patients were included. Patients at nutritional risk (n = 149, 47%) had higher risk of longer LOS (≥20 days (OR = 4.24 [1.81;9.95] and ≥30 days OR = 2.50 [1.22;5.14])), having one readmission (OR = 1.86 [1.15;3.01]) and death (OR = 2.56 [1.27;5.20]) compared to patients not at nutritional risk (n = 169, 53%). A longer LOS was associated with patients who achieved ≥75% of energy and protein requirements, consumed snack meals incl. and excl. oral nutritional supplements. Readmissions in patients at nutritional risk during the three-months were not associated with food intake during the index hospitalization. Mortality was observed in 43 of the 318 (13.5%) hospitalized patients. A lower mortality was associated with increased energy and protein intake in patients at nutritional risk.

CONCLUSIONS

The results of this study indicate a longer LOS, higher readmission rate and increased mortality in patients at nutritional risk compared to patients not at risk. Patients at nutritional risk had lower risk of three-month mortality and longer LOS during index hospitalization with increased energy and protein intake. Readmissions in patients at nutritional risk were not affected by food intake. The association of nutritional risk with poorer outcomes indicates that good nutritional care including constant attention to food-intake during hospitalization can be beneficial regarding mortality.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Scaling up health technology assessment capacities in selected African countries - A conceivable route ahead

BACKGROUND

This study aimed to provide a structured description of the commonalities and differences in healthcare structures across Africa to establish a reliable basis for the health technology assessment (HTA) of nutrition and nutrition interventions. A ranking of current nutrition conditions in the general population of the participating countries was included to gain a better understanding of the factors influencing hospital malnutrition (HMN), which will inform future multi-country research.

METHOD

A questionnaire on the structure of the health systems was distributed among ten African countries. Subsections were included that inquired about the drivers or barriers to using principles of HTA to assess nutritional care. Analysis and ranking of malnutrition data were based on data from the Global Hunger Index report and two poverty indicators used by the World Bank.

RESULTS

The health system structure of each country was identified and described, whereas questions about HTA could not always be analyzed due to a lack of adequate in-depth knowledge and skills in most countries. Early experience from some countries demonstrates a conceivable route ahead for African countries in strengthening the capacity for and implementing HTA in accordance with distinct national healthcare contexts and social determinants of health.

CONCLUSION

Problems related to nutritional care represent one of the major priorities in the surveyed countries. A future HMN multi-country study will provide valuable insight into the potential of low-cost primary prevention orientations.

Implementation of an electronic solution to improve malnutrition identification and support clinical best practice

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.

Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits

OBJECTIVES

We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia.

METHODS

The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation.

RESULTS

Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82.

CONCLUSIONS

For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.

Preoperative nutritional evaluation of prostate cancer patients undergoing laparoscopic radical prostatectomy

Background and objective

Prostate cancer (PCa) is one of the most common malignant tumors in men. Geriatric Nutritional Risk Index (GNRI) is an objective index for evaluating nutritional status of elderly people over 65 years old. The aim of the current study was to explore the correlation and predictive value between GNRI and postoperative recovery and complications in PCa patients undergoing laparoscopic radical prostatectomy (LRP).

Methods

Taking 98 as the GNRI boundary value, 96 PCa patients (aged≥65 y) undergoing LRP in the Department of Urology, Affiliated Hospital of North Sichuan Medical College from January 2018 to December 2020 were grouped into malnutrition group (MNg, 34 patients, 35.4%) and normal nutrition group (NNg, 62 patients, 64.6%). Basic information, laboratory examination indexes, operation conditions, postoperative complications and postoperative recovery indexes of patients were recorded and retrospectively analyzed. Clavien-Dindo Classification System (CDCS) was used to assess postoperative complications. T-test was used to analyze differences between the two groups. ROC curve was generated to determine the predictive value of GNRI for postoperative complications.

Results

Percentage of complications was significantly higher in MNg group compared with that in NNg group (P < 0.01). The average grade based on CDCS was significantly lower in NNg group compared with that in MNg group (P < 0.01). Body weight, Body Mass Index (BMI), preoperative hemoglobin value (HGB), serum albumin (ALB) values of MNg and NNg were significantly positively correlated with GNRI (P<0.01). Incidence and severity of postoperative complications of MNg patients were significantly higher compared with those of NNg patients (P<0.05). Average hospitalization cost of MNg patients was higher in MNg patients compared with that of NNg patients (P<0.05). Duration of post-anesthesia care unit (PACU), duration of antibiotic use and duration of indwelling drainage tube were longer in MNg patients compared with those in NNg patients (P<0.05). Furthermore, volume of indwelling drainage tube was higher in MNg patients compared with that in NNg patients (P<0.05).

Conclusion

GNRI is an effective and reliable tool for evaluation of preoperative nutritional status of prostate cancer patients. The findings showed that GNRI is correlated with postoperative recovery and complications, and is an effective predictive marker.

Healthcare professionals' experiences with practice for managing disease-related malnutrition in general practice and proposals for improvement: A qualitative study

BACKGROUND & AIM

Disease-related malnutrition is prevalent in all healthcare settings, including general practice, and is associated with negative consequences for the individual and the community. The aim of this study was to investigate general practitioners and general practice nurses' perceptions of how they manage disease-related malnutrition, and their view on introducing an early intervention against disease-related malnutrition.

METHODS

Content analysis was used to analyse individual semi-structured interviews with the general practitioners (n = 9) and five focus group interviews with the general practice nurses (n = 21) from five general practices in Denmark.

RESULTS

General practice has no tradition for detection of disease-related malnutrition and find that they rarely see patients with unintended weight loss. Nutritional guidance is to a low degree and only randomly performed. Furthermore, most of the health professionals do not have access to nutritional guidance material for patients and lack information about patients' nutrition, when patients when patients receive treatment in the hospital. Suggestions for improvement were handouts with pictures and including nutritional status as a standard in the communication from hospital to general practice. An early intervention against unintended weight loss in specific groups was found feasible. Barriers and facilitators were seen as lack of time, lack of educational opportunities and skills. A financial incentive from the health authorities, and interventions adapted to the individual general practice were among suggested facilitators.

CONCLUSION

Disease-related malnutrition was rarely recognised and managed in general practice. The health professionals found they lacked means to perform nutritional guidance to patients with unintended weight loss. However, the health professionals had suggestions for improvement for an early intervention including handouts for patients. Further research on implementation of early intervention against unintended weight loss in general practice is needed.

Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials

BACKGROUND AND AIMS

Nutritional support improves clinical outcomes during hospitalisation as well as after discharge. Recently, a systematic review of 27 randomised, controlled trials showed that nutritional support was associated with lower rates of hospital readmissions and improved survival. In the present economic modelling study, we sought to determine whether in-hospital nutritional support would also return economic benefits.

METHODS

The current economic model applied cost estimates to the outcome results from our recent systematic review of hospitalised patients. In the underlying meta-analysis, a total of 27 trials (n=6803 patients) were included. To calculate the economic impact of nutritional support, a Markov model was developed using transitions between relevant health states. Costs were estimated accounting for length of stay in a general hospital ward, hospital-acquired infections, readmissions and nutritional support. Six-month mortality was also considered. The estimated daily per-patient cost for in-hospital nutrition was US$6.23.

RESULTS

Overall costs of care within the model timeframe of 6 months averaged US$63 227 per patient in the intervention group versus US$66 045 in the control group, which corresponds to per patient cost savings of US$2818. These cost savings were mainly due to reduced infection rate and shorter lengths of stay. We also calculated the costs to prevent a hospital-acquired infection and a non-elective readmission, that is, US$820 and US$733, respectively. The incremental cost per life-day gained was -US$1149 with 2.53 additional days. The sensitivity analyses for cost per quality-adjusted life day provided support for the original findings.

CONCLUSIONS

For medical inpatients who are malnourished or at nutritional risk, our findings showed that in-hospital nutritional support is a cost-effective way to reduce risk for readmissions, lower the frequency of hospital-associated infections, and improve survival rates.

Identifying patients with malnutrition and improving use of nutrition interventions: A quality study in four US hospitals

OBJECTIVE

This study investigated how specific nutrition interventions were implemented at four US hospitals, compared rates of malnutrition diagnosis and assessment between physicians and registered dietitian nutritionists (RDNs), and examined how these differences affected the nutrition intervention received during patients' hospital stay.

METHODS

Data on patients' nutrition status and nutrition interventions were collected from 16 669 hospital inpatient records. Data on intervention utilization for patients with differing nutrition assessments and diagnoses from different health care practitioners were compared using descriptive statistics and χ² tests.

RESULTS

The study found high levels of agreement between physician diagnosis and RDN assessment of malnutrition (88%). Much of this agreement related to patients identified as not malnourished. Of patients identified as malnourished by either physician diagnosis or RDN assessment, agreement was reached in 55.5% of patients. Less than half (46.3%) of patients identified as malnourished had a documented nutrition intervention. Oral nutritional supplements (ONS) were the most commonly used intervention, with 5.1% of patients receiving them. Patients identified as malnourished by physician diagnosis, but not by RDN assessment, were more likely to receive enteral and parenteral nutrition. Patients identified as malnourished by RDN assessment, but not by physician diagnosis, were more likely to have received ONS, meals and snacks, counseling, and food/nutrition-related medication management.

CONCLUSION

The high level of agreement on assessment and malnutrition diagnosis suggests positive levels of malnutrition care coordination at the study hospitals. However, significant room for improvement exists in providing interventions to inpatients diagnosed with malnourishment. Differences in interventions may reflect dissimilar approaches commonly used by different practitioners and should be a topic of future study.

Critical analysis of factors affecting the efficiency of nutrition therapy teams

BACKGROUND

Nutrition therapy (NT), defined as the provision of oral, enteral, or parenteral nutrition, should be considered a part of the holistic approach to patient care, while quality assessment of its practices is crucial. The present study aimed to identify variables capable of explaining the reason behind compliance of NTTs with the regulatory requirements.

METHODS

A cross-sectional study focused on assessing the quality of nutritional therapy practices among NTTs who previously stated to be able to comply with requirements of the Brazilian law versus those who were not able to meet these demands. Hospitals were classified as A (teams that had previously reported to be able to meet the requirements) and B (those unable to comply with them). The study was approved by the ethics committees of all participant institutions.

RESULTS

Twenty six hospitals met the inclusion criteria. The main hospital features, such as size, classification, service type, and percentage of hospitals providing NT were similar. Hospitals differed on the median number of patients undergoing NT per week: in group B (41.0; IR = 28.0-58.0) and group A (11.0; IR = 5.0-48.0) (p < 0.05), but there were no differences regarding personnel expertise. Both hospital groups had low quality control of the NT processes.

CONCLUSION

Lack of quality assurance is responsible for the inadequate services in both type of institutions.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Oral nutritional supplements, physical activity, and sarcopenia in cancer

PURPOSE OF REVIEW

Sarcopenia is prevalent in cancer patients and can occur as a result of cancer as well as cancer-related therapies. It is related to high postoperative complications, long hospitalization, slow recovery as well as low tolerance to chemotherapy. Patients with sarcopenia also have poor oncological outcomes. Oral nutritional supplements (ONS) and physical activity have shown great potentials in managing this debilitating condition. We summarized the recent developments in the assessment of sarcopenia and its management with ONS and physical activity.

RECENT FINDINGS

Many methods were developed to evaluate sarcopenia including muscle quality/quantity measurement and functional tests. Recent studies have shown that ONS and physical training can be used in managing sarcopenia, especially when used together as part of a multimodal intervention. However, barriers such as low awareness and lack of training and support for both patients and healthcare workers still exist and need attention.

SUMMARY

Recent findings highlighted the benefits of identifying sarcopenia and managing those at risk. The details of a multimodal protocol, such as components of nutritional substrates, the intensity of physical exercise, and the use of medication need to be further looked into for an optimum approach. Education and training programs need to be developed to overcome the barriers in managing sarcopenia.

Impact of Malnutrition in Patients With Infective Endocarditis

BACKGROUND

Effects of malnutrition on patients with infective endocarditis (IE) have not been fully studied. Because malnutrition is associated with poor health, we hypothesized that among patients with IE, those with malnutrition would have more negative in-hospital outcomes.

METHODS

The National Inpatient Sample was used to identify adults ≥18 years old with IE. We compared outcomes of in-hospital mortality, morbidity, valvular interventions, and utilization of resources between individuals with and without malnutrition.

RESULTS

11,939 adults ≥18 years were hospitalized with IE, 2035 had a secondary diagnosis for malnutrition. There were no significant differences in age (mean age ± SEM: 55.6 ± 1.0 vs 54.3 ± 0.4 years, P = .21) or sex (female: 36.7%; 743/2,035 vs 37.5%; 3,717/9,904, P = .69) in patients with and without malnutrition. Patients with malnutrition had more comorbidities (Charlson comorbidity score ≥3: 36%; 732/2,035 vs 30.7%; 3,040/9,904, P = .04). Despite similar adjusted in-hospital mortality (adjusted odds ratio [aOR], 1.4; 95% CI, 0.8-1.5; P = .23), malnourished patients were more likely to develop sepsis (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) and had higher odds of mitral-valve (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) repairs/replacements. Patients with malnutrition also had increased lengths of stay (adjusted mean difference [aMD], 4.7 days; 95% CI, 2.9-6.5 days; P < .01) and hospital charges (aMD, $36,052; 95% CI, $14,935-$57,168; P < .01).

CONCLUSIONS

Patients with malnutrition and IE are at risk for high morbidity, valvular repairs/replacements, and use of hospital resources.

Hospital nutrition care informs potential cost-savings for healthcare: A budget impact analysis

BACKGROUND AND AIM

In Mexico, about half of hospitalized patients are malnourished or at risk of malnutrition upon hospital admission, while many others experience deterioration of their nutritional status while in the hospital. Such patients often experience poor health outcomes and have increased hospital costs. The aim of our budget-impact analysis was to estimate potential savings associated with the implementation of a Mexican hospital-based program of nutrition care for patients at malnutrition risk or malnourished.

METHODS

The budget-impact model was based on data published previously. Our model compared patients assigned to receive individualized early nutrition therapy (initiated within 24-48 h of hospital admission) with those who received standard delayed nutrition therapy (not initiated early). Outcomes included length of stay, infectious complications, and 30-day readmissions. We modeled a 30-day time-horizon, estimated event probabilities on the basis of published data, and projected costs in 2020 US dollars.

RESULTS

Average total healthcare costs over 30-days were $3527 for patients with early nutrition therapy vs $6032 for patients with standard nutrition therapy-a savings of $2505 per early nutrition-treated patient (41.5% lower). Cost differences between the groups were $2336 vs $3065 for hospital-associated costs (23.8% lower), $262 vs $780 for 30-day readmissions (66.4% lower) and $1348 for malnutrition-associated infections. Applying these potential savings from individualized early nutrition care to a one-year estimate of 3.22 million Mexican hospital patients with malnutrition or its risk, the total overall savings for public health expenditures was equivalent to $8.1 billion per year or 32.1% of total healthcare expenditures.

CONCLUSIONS

The results demonstrated the potential for hospital-based nutrition care programs to reduce costs of patient hospitalizations. These notable findings provide a rationale for Mexican healthcare institutions to implement programs of comprehensive nutrition-focused care for inpatients with malnutrition or its risk. To this end, we advise implementation of professional programs for education and training in order to increase awareness of patients' nutritional needs and to better prepare clinical personnel to identify, treat, and monitor patients at-risk/malnourished.

Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients

BACKGROUND

Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients.

METHODS

This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed.

RESULTS

Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes.

CONCLUSION

Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.

Comorbid Dysphagia and Malnutrition in Elderly Hospitalized Patients

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.

Nutrition Therapy Cost‐Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health Systems

Background

Method

Results

Conclusion