Improving malnutrition documentation enhances reimbursement

Malnutrition and Associated Factors in Acute and Subacute Stroke Patients with Dysphagia

Most patients with stroke suffer from complications and these include dysphagia. Dysphagia can cause malnutrition, and malnutrition affects prognosis and recovery. However, there is a lack of accurate studies on the nutritional status of stroke patients with dysphagia and its associated factors in different phases of stroke. This study retrospectively investigated 620 stroke patients who underwent a videofluoroscopic swallowing study (VFSS) due to dysphagia, from March 2018 to February 2021. The study aimed to evaluate the nutritional state and associated factors of malnutrition in acute and subacute stroke patients with dysphagia. Serum albumin and percentage of current weight to ideal weight were used to determine nutritional status. Malnutrition was observed in 58.9 and 78.9% of acute and subacute stroke patients. Exact logistic regression analysis revealed that old age and high penetration-aspiration scale score were significantly associated factors for malnutrition in patients with acute stroke. Old age, stroke history, bilateral hemiplegia, high modified Rankin score, low Korean Mini-Mental State Examination, pneumonia, and high functional dysphagia score were significantly associated factors for malnutrition in patients with subacute stroke. Patients with these associated factors in each phase of stroke require active nutritional assessment and care to decrease the risk of malnutrition.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative

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.

The role of malnutrition universal screening tool in predicting outcomes after radical cystectomy

PURPOSE

The Malnutrition Universal Screening Tool integrates body mass index, unintentional weight loss and present illness to assess risk for malnutrition. The predictive role of 'MUST' among patients undergoing radical cystectomy is unknown. We investigated the role of 'MUST' in predicting postoperative outcomes and prognosis among patients after RC.

MATERIALS AND METHODS

We conducted a multicenter retrospective analysis of 291 patients who underwent radical cystectomy in 6 medical centers between 2015 and 2019. Patients were stratified to risk groups according to the 'MUST' score [low risk (n = 242) vs. medium-to-high risk (n = 49)]. Baseline characteristics were compared between groups. Endpoints were 30-day postoperative complications rate, cancer-specific-survival and overall survival. Kaplan-Meier curves and Cox-regression analyses were used to evaluate survival and identify predictors of outcomes.

RESULTS

Median age of the study cohort was 69 years (IQR 63-74). Median duration of follow up for survivors was 33 months (IQR 20-43). Thirty-day major postoperative complications rate was 17%. Baseline characteristics were not different between the 'MUST' groups, and there was no difference in early post-operative complication rates. CSS and OS were significantly lower (p ≤ 0.02) in the medium-to-high-risk group ('MUST' score≥1) with estimated 3-year CSS and OS rates of 60% and 50% compared to 76% and 71% in the low-risk group, respectively. On multivariable analysis, 'MUST'≥1 was an independent predictor of overall- (HR = 1.95, p = 0.006) and cancer-specific-mortality (HR = 1.74, p = 0.05).

CONCLUSIONS

High 'MUST' scores are associated with decreased survival in patients after radical cystectomy. Thus, the 'MUST' score may serve as a preoperative tool for patient selection and nutritional intervention.

Impact of malnutrition and nutrition support in hospitalised patients with inflammatory bowel disease

BACKGROUND

Malnutrition is prevalent in patients with inflammatory bowel disease (IBD) and has been associated with worse clinical outcomes.

AIMS

This observational study examines trends in protein-calorie malnutrition (PCM) amongst hospitalised IBD and non-IBD patients, and the association between (1) malnutrition and (2) nutrition support and hospitalisation outcomes.

METHODS

We queried the Nationwide Readmissions Database from 2010 to 2018 for hospitalisations with and without IBD. Amongst patients with IBD and concurrent PCM, we identified those who received nutrition support. Multivariable Cox proportional hazards and Kaplan-Meier analyses evaluated the associations between PCM and nutrition support and readmission and mortality. Multiple linear regression described the association between compared variables and length of stay (LOS) and total hospitalisation costs.

RESULTS

This study included 1,216,033 patients (1,820,023 hospitalisations) with Crohn's disease (CD), 832,931 patients (1,089,853 hospitalizations) with ulcerative colitis (UC) and 240,488,656 patients (321,220,427 hospitalisations) without IBD. Admitted IBD patients were 2.9-3.1 times more likely to have PCM than non-IBD patients. IBD patients with PCM had a higher risk of readmission and mortality, as well as longer LOS and higher hospitalisation costs. Nutrition support (parenteral and enteral) was associated with a reduced risk of readmission, but higher mortality increased LOS and higher total hospitalisation costs.

CONCLUSIONS

Malnutrition in hospitalised IBD patients remains an important contributor to readmission, mortality, LOS and healthcare costs. Providing nutrition support to IBD patients may reduce the risk of readmission. Further studies are needed to evaluate the role of nutrition support amongst hospitalised IBD patients to optimise disease and healthcare outcomes.

A digital dietary assessment tool may help identify malnutrition and nutritional deficiencies in hospitalized patients

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.

Target Calorie Intake Achievements for Patients Treated in the Surgical Intensive Care Unit

Adequate nutritional support in critically ill patients is important, however, sometimes it has been neglected in perioperative period of patients at surgical intensive care units (SICU). The aim of this study was to investigate whether approaching target calorie intake of surgical patients influences on their clinical outcomes. A total of 279 patients who admitted at SICU in perioperative period from August 2014 to July 2016 at our hospital were analyzed. Demographics, supplied calorie amount and its method, lengths of SICU and hospital stay, and mortality of study population were collected. Among 279 patients, 103 patietns (36.9%) approached target calorie intake during SICU stay. Patients who approached target calorie intake had significantly decreased length of stay in SICU (10.78 ± 11.5 vs. 15.3 ± 9.9, p = 0.001) and hospital (54.52 ± 40.6 vs. 77.72±62.2, p < 0.001), than those did not, however there was no significant difference of mortality (9.7% vs. 8.5%, p = 0.829). Enteral feeding was a significant factor for target calorie achievement (odd ratio [OR], 2.029; 95% confidence interval [CI], 1.096–3.758; p = 0.024) and especially in patients with ≤ 7 days of SICU stay (OR, 4.13; 95% CI, 1.505–11.328; p = 0.006). Target calorie achievement in surgical patients improves clinical outcomes and enteral feeding, especially in early postoperative period would be an effective route of nutrition.

Impact of Nutrition Care Process Documentation in Obese Children and Adolescents with Metabolic Syndrome and/or Non-Alcoholic Fatty Liver Disease

This study evaluated the Nutrition Care Process documentation used by dietitians for obese pediatric patients diagnosed with metabolic syndrome (MetS) and/or non-alcoholic fatty liver disease (NAFLD) and its impact on the achievement of nutritional goals. This retrospective cohort study utilized data retrieved from three tertiary care hospitals in Riyadh. A total of 142 obese pediatric patients aged 8–18 years diagnosed with NAFLD and/or MetS were evaluated. Data on weight, height, blood pressure (BP), lipid profile, and liver enzymes were collected. A validated audit was used to assess the documentation quality. Twenty-seven (46.6%) dietitian notes received a high score, 21 (36.2%) received a medium score, and 10 (17.2%) received a low score. There was no significant effect of dietitian audit scores on nutritional outcomes, however, the change in body mass index from 6 to 12 months follow-up period was inversely correlated with the audit score (r = −0.761, p = 0.007), and alkaline phosphatase was inversely correlated with the audit score (r = −0.819, p = 0.013). In conclusion, there was a clear variation in the quality of dietitians’ documentation and the impact of documentation scores on nutritional outcomes.

Does malnutrition influence hospital reimbursement? A call for malnutrition diagnosis and coding

OBJECTIVES

The aim of this study was to determine how diagnosing and coding of malnutrition in an internal medicine ward setting influences potential hospital reimbursement.

METHODS

Patients admitted to the internal medicine ward of Centro Hospitalar do Médio Ave between April 24 and May 22, 2018 were screened by Nutritional Risk Screening 2002, and patients classified as at "risk for malnutrition" were assessed by the Patient-Generated Subjective Global Assessment (PG-SGA). For each patient, medical coders simulated coding, taking into account the malnutrition diagnosis by PG-SGA, and compared it with the real coding as retrieved from the medical records. For the coding, the Diagnosis-Related Group and Severity of Illness were determined, allowing the calculation of hospitalization cost (HC) according to Portuguese Ministerial Directive number 207/2017. The increase of HC in this subsample was extrapolated to the number of patients admitted during 2018, to obtain the estimated unreported annual HC.

RESULTS

Of the 71% (92/129) participants having malnutrition risk according to Nutritional Risk Screening 2002, 86% were malnourished. Including malnutrition diagnosis in the coding of malnourished patients increased the level of Severity of Illness in 39% of cases and increased HC for this subsample, resulting in €52 000. Extrapolating for the annual HC, total HC reached €1.3 million.

CONCLUSIONS

Identifying malnourished patients and including this highly prevalent diagnosis in medical records allows malnutrition coding and consequent increase of HC. This can improve the potential hospital reimbursement, which could contribute to the quality of patient care and economic sustainability of hospitals.

The continuous downgrading of malnutrition in the German DRG system: possible effects on the treatment of patients at risk for malnutrition

It has been internationally recognized that malnutrition is an independent risk factor for patients' clinical outcome. A new mandatory fixed price payment system based on diagnosis-related groups (G-DRG) went into effect in 2004. The aim of our study was to demonstrate the importance of carefully coding the secondary diagnosis of "malnutrition" in the G-DRG system and to highlight how the economic relevance of malnutrition in the G-DRG system has changed from 2014 to 2016. 1372 inpatients at the Berufsgenossenschaftliche Unfallklinik (Trauma Center) in Tübingen were screened for the risk of malnutrition using Nutritional Risk Screening (NRS-2002). Patient data were compared with the NRS values collected during the study and a case simulation was carried out separately for each year. We used the codes E44.0 for NRS = 3 and E43.0 for NRS > 3. The ICD codes were entered as an additional secondary diagnosis in the internal hospital accounting system DIACOS to determine possible changes in the effective weight. In 2014 the highest additional revenue by far was calculated by coding malnutrition. For the 638 patients enrolled in the study in 2014, we were able to calculate an average additional revenue per patient coded with malnourishment of €107. In 2016, we were unable to calculate any additional revenue for the 149 patients enrolled. Although it is well known that malnutrition is an independent risk factor for poor patient outcomes, nationwide screening for a risk of malnutrition when patients are admitted to a hospital is still not required. For this reason, malnutrition in German hospitals continues to be insufficiently documented. Due to the continuous downgrading of diagnosis-related severity (CCL) of malnutrition in the G-DRG system in trauma surgery patients, it is no longer possible to refinance the costs incurred by malnourished patients through the conscientious coding of malnutrition. We assume that the indirect positive effects of nutritional interventions will have to be taken into account more in the costing calculations and possibly lead to indirect cost compensation.

Large regional disparities in prevalence, management and reimbursement of hospital undernutrition

BACKGROUND/OBJECTIVES

Undernutrition is a frequent condition among hospitalized patients, with a significant impact on patient's outcome and hospital costs. Whether undernutrition is reported similarly at the national level has seldom been assessed. We aimed to (1) assess regional differences within Switzerland regarding undernutrition prevalence, management, and cost reimbursement and (2) identify the factors associated with reporting of undernutrition status and its management.

SUBJECTS/METHODS

Observational cross-sectional study including routine statistics from the Swiss hospital discharge databases for years 2013 and 2014 (seven administrative regions). All adults aged ≥20 with length of hospital stay of at least 1 day was included. Reported undernutrition was defined based on the International Classification of Diseases (ICD)-10 codes. Nutritional management and "reimbursable" undernutrition codes were also assessed.

RESULTS

Of the initial 1,784,855 hospitalizations, 3.6% had reported undernutrition, the prevalence ranging between 1.8% (Ticino) and 4.6% (Mittelland). Use of different undernutrition-related ICD-10 codes also varied considerably across regions. Multivariable analysis showed a twofold variation in reported undernutrition: multivariable-adjusted odds ratio and 95% confidence interval relative to Eastern Switzerland: 2.31 (2.23, 2.38) for Mittelland and 0.74 (0.70, 0.79) for Ticino. Over half (59.6%) of hospitalizations with reported undernutrition also included information on undernutrition management, ranging between 28.6% (Ticino) and 67.2% (Zürich). Only one third (36.8%) of undernutrition-related codes were reimbursable, ranging between 8.3% (Ticino) and 50.7% (Zürich).

CONCLUSIONS

In Switzerland, there is considerable regional variation regarding reporting of undernutrition prevalence, management, and cost reimbursement. Undernutrition appears to be insufficiently managed and valued.

The Use of Technology in Identifying Hospital Malnutrition: Scoping Review

Background

Malnutrition is a condition most commonly arising from the inadequate consumption of nutrients necessary to maintain physiological health and is associated with the development of cardiovascular disease, osteoporosis, and sarcopenia. Malnutrition occurring in the hospital setting is caused by insufficient monitoring, identification, and assessment efforts. Furthermore, the ability of health care workers to identify and recognize malnourished patients is suboptimal. Therefore, interventions focusing on the identification and treatment of malnutrition are valuable, as they reduce the risks and rates of malnutrition within hospitals. Technology may be a particularly useful ally in identifying malnutrition due to scalability, timeliness, and effectiveness. In an effort to explore the issue, this scoping review synthesized the availability of technological tools to detect and identify hospital malnutrition.

Objective

Our objective was to conduct a scoping review of the different forms of technology used in addressing malnutrition among adults admitted to hospital to (1) identify the extent of the published literature on this topic, (2) describe key findings, and (3) identify outcomes.

Methods

We designed and implemented a search strategy in 3 databases (PubMed, Scopus, and CINAHL). We completed a descriptive numerical summary and analyzed study characteristics. One reviewer independently extracted data from the databases.

Results

We retrieved and reviewed a total of 21 articles. We categorized articles by the computerized tool or app type: malnutrition assessment (n=15), food intake monitoring (n=5), or both (n=1). Within those categories, we subcategorized the different technologies as either hardware (n=4), software (n=13), or both (n=4). An additional subcategory under software was cloud-based apps (n=1). Malnutrition in the acute hospital setting was largely an unrecognized problem, owing to insufficient monitoring, identification, and initial assessments of identifying both patients who are already malnourished and those who are at risk of malnourishment. Studies went on to examine the effectiveness of health care workers (nurses and doctors) with a knowledge base focused on clinical care and their ability to accurately and consistently identify malnourished geriatric patients within that setting.

Conclusions

Most articles reported effectiveness in accurately increasing malnutrition detection and awareness. Computerized tools and apps may also help reduce health care workers’ workload and time spent assessing patients for malnutrition. Hospitals may also benefit from implementing malnutrition technology through observing decreased length of stay, along with decreased foregone costs related to missing malnutrition diagnoses. It is beneficial to study the impact of these technologies to examine possible areas of improvement. A future systematic review would further contribute to the evidence and effectiveness of the use of technologies in assessing and monitoring hospital malnutrition.

Undernutrition is associated with increased financial losses in hospitals

BACKGROUND & AIMS

Undernutrition is associated with increased hospital costs. Whether these increased costs are totally compensated by third payer systems has not been assessed. We aimed to assess the differences between actual and reimbursed hospital costs according to presence/absence of nutritional risk, defined by a Nutritional risk screening-2002 (NRS-2002) score ≥3.

METHODS

Retrospective study. Administrative data for years 2013 and 2014 of the department of internal medicine of the Lausanne university hospital. The data included total and specific costs (i.e. clinical biology, treatments, pathology). Reimbursed costs were based on the Swiss Diagnosis Related Group (DRG) system.

RESULTS

2200 admissions with NRS-2002 data were included (mean age 76 years, 53.9% women), 1398 (63.6%) of which were considered nutritionally 'at-risk'. After multivariate adjustment, patients nutritionally 'at-risk' had higher costs (multivariate-adjusted difference ± standard error: 34,206 ± 1246 vs. 22,214 ± 1666 CHF, p < 0.001) and higher reimbursements (26,376 ± 1105 vs. 17,783 ± 1477 CHF, p < 0.001). Still, the latter failed to cover the costs, leading to a deficit between costs and reimbursements of 7831 ± 660 CHF in patients 'at-risk' vs. 4431 ± 881 in patients 'not at-risk' (p < 0.003). Being nutritionally 'at-risk' also led to a lower likelihood of complete coverage of costs: multivariate-adjusted odds ratio and 95% confidence interval 0.77 (0.62-0.97). Patients 'at-risk' had lower percentage of total costs in medical interventions, food, imaging and "other", but the absolute differences were less than 2%.

CONCLUSION

Hospital costs of patients nutritionally 'at-risk' are less well reimbursed than of patients 'not at-risk'. Better reporting of undernutrition in medical records and better reimbursement of undernourished patients is needed.

Efficiency, cost-effectiveness and need of inversion in nutritional therapy. Importance of detecting and documenting undernutrition

Disease Related Malnutrition (DRM) is highly prevalent in Spanish hospitals. WHO estimates that 20-40% of health-associated expenses are lost due to inefficiency. Demonstration that DRM is a component of inefficiency and hiring a specialist physician for its detection and treatment is cost-effective.

MATERIAL AND METHODS

Comparison between nutritional diagnosis and procedures detected and encoded at discharge using McNemar test. Recoding of 162 discharge reports including nutritional diagnoses and procedures. Determine changes on Case-Mix Index (IC), cost of procedure and cost procedure/DRG index. Comparison using T-student paired test.

RESULTS

Only 10 of 162 diagnoses of malnutrition were coded in delivery statements (p < 0.001). After right codification, IC increased in 103,3 DRG points (p < 0.001). Consequently, procedure cost/DRG index was reduced in 978.81 € (p < 0.001).

CONCLUSIONS

DRM is underdiagnosed in our hospital. DRM and nutritional procedures detection by a doctor specialist in clinical nutrition led to a reduction in cost procedure/DRG index of 16.8% of officially established by the Health System. Loss of 16.8% of health expenses, estimated in 424.785,15 € was described. Proper codification would have justified 343.291,2 € reimbursement just for nutritional diagnoses and processes. Both expenses were lost due to system's inefficiency. Those amounts are much higher than cost associated of hiring a specialist in clinical nutrition.

Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition

The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.

Prealbumin levels as a useful marker for predicting infectious complications after gastric surgery

BACKGROUND/OBJECTIVES

Preoperative nutritional status is associated with postoperative complications. Prealbumin, a visceral protein, is sensitive to protein malnutrition. The objective of this study is to evaluate the role of preoperative prealbumin levels as a marker for predicting complications after gastric surgery.

METHODS

An observational study was performed on 183 patients who underwent gastric surgery due to benign or malignant gastric disease at Seoul National University Hospital (SNUH) between August 2009 and October 2010. Preoperative prealbumin levels were also measured. Nutritional variables such as prealbumin (cutoff value, 18 mg/dL), albumin, body mass index (BMI), and clinicopathologic data were collected. Postoperative hospital stay, 30-day complications and mortality rate were obtained to investigate outcomes.

RESULTS

The complication rate was 52% in the abnormal prealbumin group (n = 23) and 24% in the normal prealbumin group (n = 160; p = 0.005). The complication rate was higher in patients with low preoperative albumin levels (<3.5 g/dL) and abnormal BMI (<18.5 kg/m(2)), but the differences were not statistically significant. Comorbidity of diabetes mellitus (DM), resection extent, combined resection, TNM stage and prealbumin levels were associated with complications. In multivariate analysis, DM and combined resection were significantly correlated with complications (p = 0.001 for each). In subgroup analysis, resection extent, approach, combined resection, TNM stage, and prealbumin levels were significantly associated with infectious complications. Multivariate analysis identified combined resection (p = 0.001) and prealbumin levels (p = 0.032) as independent variables.

CONCLUSIONS

Preoperative prealbumin levels could be a useful marker for predicting complications, especially infectious complications, after gastric surgery.

Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

Malnutrition screening in hospitalised patients and its implication on reimbursement

BACKGROUND

Several studies have cited the incidence of malnutrition in hospitals, which is correlated to negative clinical outcomes, to be up to 60%. Data in Singapore, however, are scarce. Its impact on casemix funding is not known.

AIMS

The aims of the present study were to determine the prevalence of malnutrition, the predisposing risk factors and the impact of documentation and coding of malnutrition on casemix funding in a local population in Singapore.

METHODS

Patients admitted to selected wards over a 1-month period were screened for malnutrition. Those at risk were further assessed using subjective global assessment. Logistic regression was used to ascertain the impact of identified factors on malnutrition. Financial impact analysis of coding of malnutrition as a comorbidity was carried out and tested with Wilcoxon signed rank tests.

RESULTS

Six hundred and fifty-eight patients were eligible for screening. The overall prevalence of malnutrition in the selected wards was 14.7% (95% confidence interval (CI): 12.0-17.4%). Old age, the occurrence of cancer and the admitting unit were statistically significant in explaining the occurrence of malnutrition. Coding of malnutrition was found to significantly increase the complexity of 24 of 105 episodes (22.9%) of patient care as measured by expected cost weights (P < 0.001) and expected lengths of stay (P < 0.001). As a result, the expected financing for these 24 patients increased by 59.7%.

CONCLUSIONS

Malnutrition is prevalent in hospitalised medical and surgical patients. Certain clinical factors should heighten awareness and prompt detection for malnutrition. Coding for malnutrition impacts favourably on casemix funding for a subset of malnourished patients.

Medicare medical nutrition therapy: legislative process and product

The new Medicare benefit, medical nutrition therapy (MNT), came into effect January 2002-the product of a lengthy legislative process. Over several years, evidence-based advocacy by groups such as the American Diabetic Association and the National Kidney Foundation led to a legislative product that was introduced and passed by Congress. More recently, the legislation entered an implementation process, including the most recent Coverage Determination phase. The definition of MNT and the scientific evidence supporting it are presented. Evidence-based nutrition now enters a new phase of implementation and additional analysis.

Preadmission nutrition screening: expanding hospital-based nutrition services by implementing earlier nutrition intervention

The need to screen patients earlier than within the first 24 hours of hospital admission has resulted in the development of preadmission nutrition screening. At Providence Saint Joseph Medical Center (PSJMC), a 455-bed acute-care facility, this procedure has been used since 1994. The preadmission screening method was developed because of the use of critical pathways for patients in specific diagnosis-related groups. Critical pathways specified that registered dietitians must assess these patients within 24 hours of admission at PSJMC. However, at that time there was minimal data in the chart from which to assess the patient's nutritional status and the ability to interview the patient was often limited as a result of intubation or postoperative pain. Family members were not always available at the hospital to discuss a patient's preadmission nutritional status. To address this problem, we developed a system to call people at home before their admission to the hospital to obtain specific nutrition information. To analyze the effectiveness of the procedure, the Food and Nutrition Services Department developed a process to assess this method of screening and to improve the system. Patients were enrolled in a study over a 1-month period, demographics were identified for this sample population, and patient satisfaction was determined via an interview conducted by a dietetic technician after the patient was admitted. Most patients found this to be a very helpful process and an example is presented here on the role of preadmission nutrition screening in improving patient outcome. To better define the population of the case study presented, additional information was gathered on a second study group of patients screened before admission who were admitted for hip and knee surgery, one of the specific diagnosis-related groups with a critical pathway. Our findings indicate that preadmission nutrition screening has the potential to improve patient outcomes by increasing nutrient intake before their hospital admission, reducing hospitalization length, and enhancing patient satisfaction during their hospital stay.

Casemix: the allied health response

Casemix has given allied health professionals the opportunity to review their approaches to patient care, contribute to reducing inpatient costs and improve quality of care. The National Allied Health Casemix Committee was formed in 1993 to advance allied health participation in casemix. The Committee has taken the first step in establishing cost weights for allied health through the Australian Allied Health Activity Classification, which defines allied health inputs in terms of clinical care, clinical service management, teaching and training, and research. Work is being done on generic classification of allied health inputs, and studies are examining what allied health activities are accounted for by DRGs and ICD-9-CM. Allied health has taken up the challenge of casemix, but better access to information technology will enhance its continued contribution.

A comparison of dressings in the management of surgical abdominal wounds

This prospective randomised trial compared the performance of three dressing protocols in the management of 36 dehisced surgical abdominal wounds: a standard alginate; a gauze moistened with sodium hypochlorite (0.05%); and a combine dressing pad. Outcomes assessed were: healing time (cm2 per day and cm3 per day), patient comfort (pain and satisfaction) and cost. There were no statistically significant differences in healing rates between the three groups but there was a trend for the combine dressing pad protocol to produce a greater reduction in wound area. The combine dressing pad protocol performed well when compared with the calcium alginate in terms of healing time, patient comfort and cost. Maximum pain was significantly greater (p = 0.011) and satisfaction significantly lower among patients who received the sodium hypochlorite protocol. Costs during the in-patient phase were also substantially higher for the sodium hypochlorite protocol. Trial results support the view that sodium hypochlorite dressing protocols for surgical wounds should be abandoned.

Improved detection of malnutrition by medical housestaff following focused-teaching intervention

We examined the influence of a brief, small group teaching intervention, which used current patients as examples, on the detection of malnutrition by medical housestaff. We reviewed 100 consecutive patient admissions before and 61 admissions 1 month after the intervention for any mention of malnutrition in admitting, progress, or discharge notes and compared the result with the number of patients diagnosed as malnourished by dietitians. Before the intervention, interns correctly identified 4 (14%) of 28 malnourished patients. After the intervention, the same interns correctly identified 15 (94%) of 16 malnourished patients (p = .0004). We conclude that this brief teaching intervention was effective in increasing the awareness and detection of malnutrition by interns.

Standards of practice for gerontological nutritionists: a mandate for action. The American Dietetic Association

Dietitians who had been members of the Gerontological Nutritionists dietetic practice group for more than 2 years were sent a questionnaire to determine demographics of members and to ascertain their level of agreement and compliance with 26 suggested criteria and supporting documentation for standards of practice. Standards of practice for gerontological nutritionists were based on the six Standards of Practice of The American Dietetic Association. Of the 1,571 questionnaires mailed, 415 were returned. Data were analyzed using the StatPac Gold statistical analysis package. All correlation analyses were positive with correlation coefficients in the range of 0.0 to 1.0. Correlation coefficients and mean scores were highest for the standards related to maintaining credentials and adhering to a code of ethics. Compliance was weakest for standards related to conducting research to justify reimbursement for nutrition services (correlation of 0.22) and advocating public policies to ensure quality nutrition care and dissemination of information (correlation of 0.25). Results indicate that to comply with the standards of practice, members need to be proactive in showing efficacy and cost-effectiveness of medical nutrition therapy; conduct, document, and apply outcome research to practice; and advocate public policies affecting older people.