The cost associated with disease-related malnutrition in Ireland

Institutional Factors Associated with Residents' Malnutrition in Nursing Homes: A Cross-Sectional Study

OBJECTIVES

Malnutrition is frequent in older adults, associated with increased morbidity, mortality, and higher costs. Nursing home residents are especially affected, and evidence on institutional factors associated with malnutrition is limited. We calculated the prevalence of malnutrition in Swiss nursing home residents and investigated which structure and process indicators of nursing homes are associated with residents' malnutrition.

DESIGN

Subanalysis of the Swiss Nursing Homes Human Resources Project 2018, a multicenter, cross-sectional study conducted from 2018 to 2019 in Switzerland.

SETTING AND PARTICIPANTS

This study included 76 nursing homes with a total of 5047 residents.

METHODS

Malnutrition was defined as a loss of bodyweight of ≥5% in the last 30 days or ≥10% in the last 180 days. Binomial generalized estimating equations (GEE) were applied to examine the association between malnutrition and structural (staffing ratio, grade mix, presence of a dietician, malnutrition guideline, support during mealtimes) and process indicators (awareness of malnutrition, food administration process). GEE models were adjusted for institutional (profit status, facility size) and specific resident characteristics.

RESULTS

The prevalence of residents with malnutrition was 5%. A higher percentage of units per nursing home having a guideline on prevention and treatment of malnutrition was significantly associated with more residents with weight loss (OR 2.47, 95% CI 1.31-4.66, P = .005). Not having a dietician in a nursing home was significantly associated with a higher rate of residents with weight loss (OR 1.60, 95% CI 1.09-2.35, P = .016).

CONCLUSIONS AND IMPLICATIONS

Having a dietician as part of a multidisciplinary team in a nursing home is an important step to address the problem of residents' malnutrition. Further research is needed to clarify the role of a guideline on prevention and treatment of malnutrition to improve the quality of care in nursing homes.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

Starving for knowledge. Addressing the place of clinical nutrition within undergraduate and postgraduate clinical training: A national survey of practicing clinicians

INTRODUCTION

Clinical Nutrition is finding its place within medical training. In response to IrSPEN's objectives and ESPEN's manifesto, IrSPEN distributed an electronic survey investigating attitudes to Clinical Nutrition and unmet educational needs.

METHODS

A 35-part questionnaire was designed and distributed to clinicians in Ireland. Questions elicited clinician demographics, education history and experience assessing and managing malnutrition. Descriptive statistics were reported, comparisons analysed using Chi-squared test and correlation between experience and confidence analysed with Spearman correlation coefficient.

RESULTS

Of 168 respondents, 41% (n = 58) were male and most practice medicine in an academic centre (87.5%). Fifty-eight (34.7%) were regularly involved in nutrition support. Despite 20% (n = 33) of respondents regularly managing patients on parenteral nutrition (PN) and a fifth (n = 34) regularly managing complications of obesity, few had confidence in assessment for artificial nutrition (15.7% (n = 26), enteral nutrition; 8% (n = 13), PN). Trainees were less confident than attending staff in assessing and managing artificial enteral feeding (p = 0.022) and complications of PN (p = 0.01). Over 70% respondents reported they received <2 h clinical nutrition education. Only 32% (n = 52) received any formal training within postgraduate training (PGT), more often GI trainees (p = 0.01). A striking 98% felt additional focus on nutrition education in PGT is required.

CONCLUSION

This survey elicits physician attitudes on nutrition education in undergraduate and postgraduate curricula in Ireland. Practicing physicians identify the need to increase clinical nutrition education. IrSPEN are actively engaging with Irish medical schools and training bodies to address these deficits with multidisciplinary engagement from expert physicians and allied dietetic colleagues.

Advances in knowledge of screening practices and their use in clinical practice to prevent malnutrition

Malnutrition is common among older adults and is associated with a progressive decline in overall health and increased mortality. With a rapidly ageing population, the detection, prevention and management of malnutrition require urgent attention within health service planning and delivery. Routine screening for malnutrition among older adults in community settings, which addresses aetiological as well as phenotypic factors, is considered an important step for prevention and early intervention. The aim of this review is to summarise current malnutrition screening literature and highlight research that seeks to understand and address community-based approaches to malnutrition screening and management. Key healthcare professionals (HCPs) that encounter community-dwelling older adults include general practitioners (GPs), community-based nurses, community pharmacists and a range of other health and social care professionals including dietitians, physiotherapists, speech and language therapists, and occupational therapists. The key barriers to implementing screening in primary care include lack of knowledge about malnutrition among non-dietetic HCPs, lack of resources allocated to managing malnutrition, lack of access to dietetic services, and poor GP knowledge about oral nutritional supplement prescribing. In addition, older adults have poor insight into the clinical condition and the associated negative health implications. Investment in education among HCPs and public awareness is required, as well as accompanying resources to successfully implement malnutrition screening programmes for community-dwelling older adults.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of ‘Moderate’ (<75th centile), ‘High’ (75th–89th centile) and ‘Very High’ ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann–Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). ‘Moderate’ ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), ‘High’ users were dispensed 420 units (EUR 806) and ‘Very High’ users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Association between protein intake and mortality in older patients receiving parenteral nutrition: a retrospective observational study

BACKGROUND

Malnutrition of inpatients is often overlooked and remains a serious concern. However, there are few studies on the relations between infused energy and amino acid intakes and clinical outcomes in older patients on parenteral nutrition.

OBJECTIVES

We aimed to determine the short-term outcomes of infused energy and amino acid intakes in older patients receiving parenteral nutrition.

METHODS

We conducted a retrospective observational study using a national inpatient database covering >1000 hospitals in Japan. Participants were those who underwent central venous (CV) port insertion between 2011 and 2016, were aged ≥65 y, and did not have cancer. Based on the types and amounts of products used for enteral feeding and intravenous feeding on postoperative day (POD) 7 after CV port insertion, the infused energy and amino acid intakes were estimated. The primary end point was mortality on POD 90. Multivariable logistic regression was performed to investigate the relations of infused energy and amino acid intakes with mortality on POD 90.

RESULTS

A total of 10,153 patients aged ≥65 y who underwent CV port insertion were included. The mortality rates at 90 d after central venous port insertion were 14.9% and 14.0% (risk difference, 0.9%; 95% CI: -0.5%, 2.3%; P = 0.216) with infused energy intakes <20 and ≥20 kcal/kg, respectively, and 15.4% and 13.2% (risk difference, 2.2%; 95% CI: 0.9%, 3.6%; P = 0.001) with infused amino acid intakes <0.8 and ≥0.8 g/kg, respectively. The differences were retained after adjustment for multiple variables including hospital, age, sex, BMI, emergency admission, and 27 major underlying diseases. The OR for the ≥0.8-g/kg group compared with the <0.8-g/kg group was 0.87 (95% CI: 0.77, 0.99; P = 0.028).

CONCLUSIONS

A positive relation between infused amino acid intake and mortality was found in older patients receiving parenteral nutrition.

The economic cost of not coding disease-related malnutrition: A study in cancer inpatients

BACKGROUND & AIMS

Disease-related malnutrition (DRM) coding rate is usually low in hospitalised patients. The objective of our study was to estimate the percentage of correct DRM coding in cancer inpatients and to calculate the economic losses caused by such lack of coding.

METHODS

This was an observational, prospective study that was conducted in patients hospitalised in the Medical Oncology Unit of our hospital. A nutritional assessment was performed through subjective global assessment (SGA). The all patient refined-diagnosis related group (APR-DRG) weights were obtained at the moment of discharge; moreover, recalculation was done after including the diagnosis of malnutrition in the medical record of those patients in whom it had not been initially coded. The associated cost reimbursement were calculated based on the weight before and after revising the diagnosis of DRM.

RESULTS

A total of 266 patients were evaluated. From them, 220 (82.7%) suffered from DRM according to the SGA. In 137 (51.5%) of these patients, diagnosis was coded, as opposed to 83 (31.2%) cases (33 subjects with moderate and 50 with severe DRM) in whom it was not coded. The sum of the APR-DRG weights before revising the diagnosis of malnutrition was 343.4 points (mean: 1.29 ± 0.89). Whereas, after revising the diagnosis, it increased up to 384.3 (1.44 ± 0.96). The total cost reimbursement for the hospital before revising the diagnosis of malnutrition was 1,607,861.21€ and after revision it increased up to 1,799,199.69€, which means that 191,338.48€ were not reimbursed to the hospital due to the lack of coding of malnutrition. The cost reimbursement for each admission increased an average of 719.32€.

CONCLUSION

The prevalence of DRM in cancer inpatients is high. Nevertheless, the diagnosis is not coded in one third of patients, which results in important economic losses for the hospitals.

Diagnostic accuracy of the Mini Nutritional Assessment – Short Form to identify malnutrition among older adults: protocol for a systematic review and meta-analysis

Malnutrition has many associated physiological and psychological consequences for older adults that can result in reduced quality of life, poor disease outcomes and more frequent and longer hospital stays. Early recognition of malnutrition allows for timely intervention and treatment. There are several screening tools for nutrition risk. The most common one for malnutrition developed and validated for older adults is the short-form of the Mini Nutritional Assessment (MNA-SF). It can be completed in just a few minutes and applied in all health care settings. This systematic review and meta-analysis serves to synthesise the totality of evidence regarding the diagnostic accuracy of the MNA-SF tool compared with the full-form of the Mini Nutritional Assessment (MNA-FF) in older adults for the diagnosis of malnutrition in healthcare settings. Systematic searches of five bibliographical databases will be performed and will include the Pubmed, EMBASE, Cochrane Library, CINAHL and Web of Science to identify all studies that validate the MNA-SF for malnutrition among older adults in healthcare settings. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pre-specified MNA-SF scores will be used to identify patients’ risk of malnutrition. Using data from 2x2 tables, studies will be pooled to generate summary estimates of sensitivity and specificity using a bivariate random effects model. The findings of this systematic review of diagnostic accuracy will provide evidence for healthcare professionals to make informed decisions regarding the optimum use of the MNA-SF as a nutrition risk screening tool to identify malnutrition among older people. Registration details: Prospero registration number CRD42019131847

Healthcare professionals' perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study

BACKGROUND & AIM

Protein-energy malnutrition is under-recognised in the community despite being common in older adults due to physiological and social changes which are often compounded by chronic disease. This qualitative study aimed to explore the opinions of healthcare professionals (HCPs) working in the primary care and community settings about the management of malnutrition and the prescription of oral nutritional supplements (ONS), often included in the treatment of malnutrition.

METHODS

Twelve healthcare professional (HCP) focus groups with 75 participants were conducted: community dietitians (n = 17), registered dietitians working in industry (n = 5), community and residential care nurses (n = 22), physiotherapists (n = 12), pharmacists (n = 9), occupational therapists (n = 6) and speech and language therapists (n = 4). Focus group discussions were audio-recorded and transcribed verbatim. The data were coded and analysed using thematic analysis and key themes with illustrative quotes extracted are presented.

RESULTS

Similar views on malnutrition management existed across professions. 'Gaps in Primary Care Management' was the first key theme wherein HCPs identified limitations in malnutrition management in the community. Barriers included limited or no dietetic services available in primary care and poor communication between general practitioners and wider primary care team members which resulted in inappropriate or delayed treatment. The second key theme, 'Challenges with ONS use in the Community', encapsulated several issues HCPs experienced with ONS usage including inappropriate prescribing and lack of monitoring of treatment goals. Conflicts of interest regarding dietitians working in industry assessing and treating older adults in residential care settings was highlighted by participants.

CONCLUSIONS

This study highlights that more emphasis is needed to identify patients when they are at risk of malnutrition to avoid advanced or severe malnutrition presentations currently seen. Community dietitians for older people are required to address many of the issues raised including the need for awareness, education and training, resources, and malnutrition care pathway structures.

The nutritional status and dietary intake of free-living seniors: A cross-sectional study

BACKGROUND AND AIMS

Older adults are a population group at risk of inadequate nutrition due to reduced appetite, malabsorption, taste alterations and social factors. Yet, dietary investigations in Irish older adults are scarce. The aim of this study was to analyse the nutritional status and dietary intake of a sample of community-dwelling Irish elderly, in addition to the effect of age and gender on dietary intake in this age group.

METHODS

A cross-sectional study was performed in 162 (n = 91 female, n = 71 male, age 73.8 ± 6.8 years) adults aged 65 years and over in a region of Southern Ireland. Nutritional status was measured using the Mini Nutritional Assessment - Short Form (MNA-SF). Dietary intake was assessed using a semi-quantitative food frequency questionnaire (FFQ).

RESULTS

21.0% and 1.2% of the study population were at risk of malnutrition and malnourished, respectively. A high prevalence of dietary insufficiencies was observed. The most common insufficiencies reported were energy (54.9%), fibre (82.7%), calcium (58.6%), magnesium (62.3%), iron (54.9%), folate (66.0%), vitamin D (93.2%) and vitamin E (61.1%). Increasing age did not significantly influence nutrient intakes in males, while vitamin C and vitamin D intakes decreased with age in females, and the incidence of dietary folate insufficiency was higher in the oldest females. Gender differences in dietary intake were evident, with a higher prevalence of dietary inadequacy in male subjects. Excessive intake of sugars, snacks and fats was observed, particularly in males, while dairy recommendations were not being met. Dietary supplement use was rare (27.2%).

CONCLUSIONS

The poor dietary quality of this cohort may have significant health implications. Public health strategies to improve the diets of older adults are warranted, with a particular focus on increasing micronutrient intakes.

The prevalence of malnutrition and impact on patient outcomes among older adults presenting at an Irish emergency department: a secondary analysis of the OPTI-MEND trial

Background

Malnutrition is common among older adults and is associated with adverse outcomes but remains undiagnosed on healthcare admissions. Older adults use emergency departments (EDs) more than any other age group. This study aimed to determine the prevalence and factors associated with malnutrition on admission and with adverse outcomes post-admission among older adults attending an Irish ED.

Methods

Secondary analysis of data collected from a randomised controlled trial exploring the impact of a dedicated team of health and social care professionals on the care of older adults in the ED. Nutritional status was determined using the Mini Nutritional Assessment- short form. Patient parameters and outcomes included health related quality of life, functional ability, risk of adverse health outcomes, frailty, hospital admissions, falls history and clinical outcomes at index visit, 30-day and 6-month follow up. Aggregate anonymised participant data linked from index visit to 30-days and 6-month follow-up were used for statistical analysis.

Results

Among 353 older adults (mean age 79.6 years (SD = 7.0); 59.2% (n = 209) female) the prevalence of malnutrition was 7.6% (n = 27) and ‘risk of malnutrition’ was 28% (n = 99). At baseline, those who were malnourished had poorer quality of life scores, functional ability, were more frail, more likely to have been hospitalised or had a fall recently, had longer waiting times and were more likely to be discharged home from the ED than those who had normal nutrition status. At 30-days, those who were malnourished were more likely to have reported another hospital admission, a nursing home admission, reduced quality of life and functional decline than older adults who had normal nutrition status at the baseline ED visit. Differences between the MNA SF and 6-month outcomes were similar but not statistically significant.

Conclusion

Over one-third of older adults admitted to an Irish ED are either malnourished or at risk of malnourishment. Malnutrition was associated with a longer stay in the ED, functional decline, poorer quality of life, increased risk of hospital admissions and a greater likelihood of admission to a nursing home at 30 days.

Trial registration

Protocol registered in ClinicalTrials.gov, ID: NCT03739515, first posted November 13, 2018.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

General practitioners' views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study

BACKGROUND & AIMS

Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners' (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland.

METHODS

Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management.

RESULTS

Three main themes were identified. Theme 1: 'Malnutrition is a secondary concern', encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: 'Responsibility for malnutrition and ONS management in the community', highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: 'Reluctance to prescribe ONS', emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient's meals and the costs associated with the prescription of ONS.

CONCLUSIONS

GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.

Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review

Medical nutrition therapy in critically ill patients remains challenging, not only because of the pronounced stress response with a higher risk for complications, but also due to their heterogeneity evolving from different phases of illness. The present review aims to address current knowledge and guidelines in order to summarize how they can be best implemented into daily clinical practice. Further studies are urgently needed to answer such important questions as best timing, route, dose, and composition of medical nutrition therapy for critically ill patients and to determine how to assess and to adapt to patients’ individual needs.

Economic burden of hospital malnutrition and the cost-benefit of supplemental parenteral nutrition in critically ill patients in Latin America

AIM

Disease-related malnutrition (DRM) is a prevalent condition that significantly increases the risk of adverse outcomes in hospitalized patients, particularly those with critical illness. Limited data is available on the economic burden of DRM and the cost-benefit of nutrition therapy in high-risk populations in Latin America. The aims of the present study were to estimate the economic burden of DRM and evaluate the cost-benefit of supplemental parenteral nutrition (SPN) in critically ill patients who fail to receive adequate nutrient intake from enteral nutrition (EN) in Latin America.

METHODS

Country-specific cost and prevalence data from eight Latin American countries and clinical data from studies evaluating outcomes in patients with DRM were used to estimate the costs associated with DRM in public hospitals. A deterministic decision model based on clinical outcomes from a randomized controlled study and country-specific cost data were developed to examine the cost-benefit of administering SPN to critically ill adults who fail to reach ≥60% of the calculated energy target with EN.

RESULTS

The estimated annual economic burden of DRM in public hospitals in Latin America is $10.19 billion (range, $8.44 billion-$11.72 billion). Critically ill patients account for a disproportionate share of the costs, with a 6.5-fold higher average cost per patient compared with those in the ward ($5488.35 vs. $839.76). Model-derived estimates for clinical outcomes and resource utilization showed that administration of SPN to critically ill patients who fail to receive the targeted energy delivery with EN would result in an annual cost reduction of $10.2 million compared with continued administration of EN alone.

LIMITATIONS

The cost calculation was limited to the average daily cost of stay and antibiotic use. The costs associated with other common complications of DRM, such as prolonged duration of mechanical ventilation or more frequent readmission, are unknown.

CONCLUSIONS

DRM imposes a substantial economic burden on Latin American countries, with critically ill patients accounting for a disproportionate share of costs. Cost-benefit analysis suggests that both improved clinical outcomes and significant cost savings can be achieved through the adoption of SPN as a therapeutic strategy in critically ill patients who fail to receive adequate nutrient intake from EN.

Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review

Background

observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care.

Setting

residential aged care homes.

Methods

systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies.

Results

eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low.

Conclusion

this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

Frequency of and Reasons for False-Positive Consults Generated by the Malnutrition Screening Tool

BACKGROUND

Nutrition screening on admission is one way to identify patients with malnutrition. The Malnutrition Screening Tool (MST) is a commonly used screening tool but has been found to generate false-positive consults.

PURPOSE

The purpose of this research was two-fold: (1) to determine the percentage of nursing screens, using the MST, that generated a false-positive consult for a registered dietitian, and (2) to identify the reasons for these false-positive consults.

METHODS

During a 3-month period, registered dietitians documented the number of false-positive consults received from the MST and reasons they were received.

RESULTS

Of the registered dietitian consults generated, 5.5% were deemed false-positive. The most common reason for a false-positive consult was patient-reported weight loss that had resolved.

CONCLUSIONS

As nurses are integral to completion of the MST, data generated can be used in ongoing education of nursing staff.

Finding the time: an audit of the acute ward mealtime processes

It has been found that many organisations still fail to meet the basic rights of those in their care, in terms of access to food, drink and support when they need it. In acknowledgment that food service in hospitals must be given a higher priority, and be recognised as an integral part of the patient's treatment and care, Irish hospitals must now have a system to evaluate the nutritional and hydrational care for patients admitted to hospital. The purpose of this audit was to examine the level of mealtime support available to patients during the main mealtime service in our hospital. As the audit highlighted the need to alter ward processes around the mealtime service, quality improvement initiatives were introduced. These initiatives had a positive impact, enabling ward staff to improve adequacy of mealtime support to patients, leading to better patient quality care at this time.

Malnutrition in Hospitalised Older Adults: A Multicentre Observational Study of Prevalence, Associations and Outcomes

BACKGROUND

Malnutrition is common in older adults and is associated with high costs and adverse outcomes. The prevalence, predictors and outcomes of malnutrition on admission to hospital are not clear for this population.

DESIGN

Prospective Cohort Study.

SETTING

Six hospital sites (five public, one private).

PARTICIPANTS

In total, 606 older adults aged 70+ were included. All elective and acute admissions to any speciality were eligible. Day-case admissions and those moribund on admission were excluded.

MEASUREMENTS

Socio-demographic and clinical data, including nutritional status (Mini-Nutritional Assessment - short form), was collected within 36 hours of admission. Outcome data was collected prospectively on length of stay, in-hospital mortality and new institutionalisation.

RESULTS

The mean age was 79.7; 51% were female; 29% were elective admissions; 67% were admitted to a medical specialty. Nutrition scores were available for 602/606; 37% had a 'normal' status, 45% were 'at-risk', and 18% were 'malnourished'. Malnutrition was more common in females, acute admissions, older patients and those who were widowed/ separated. Dementia, functional dependency, comorbidity and frailty independently predicted a) malnutrition and b) being at-risk of malnutrition, compared to normal status (p < .001). Malnutrition was associated with outcomes including an increased length of stay (p < .001), new institutionalisation (p =<0.001) and in-hospital mortality (p < .001).

CONCLUSIONS

These findings support the prioritisation of nutritional screening in clinical practice and public health policy, for all patients ≥70 on admission to hospital, and in particular for people with dementia, increased functional dependency and/or multi-morbidity, and those who are frail.

Hospital malnutrition in Latin America: A systematic review

BACKGROUND

Disease-related malnutrition is a major public health issue in both industrialised and emerging countries. The reported prevalence in hospitalised adults ranges from 20% to 50%. Initial reports from emerging countries suggested a higher prevalence compared with other regions, with limited data on outcomes and costs.

METHODS

We performed a systematic literature search for articles on disease-related malnutrition in Latin American countries published between January 1995 and September 2014. Studies reporting data on the prevalence, clinical outcomes, or economic costs of malnutrition in an adult (≥18 years) inpatient population with a sample size of ≥30 subjects were eligible for inclusion. Methodological quality of the studies was assessed by two independent reviewers using published criteria.

RESULTS

We identified 1467 citations; of these, 66 studies including 29 ,474 patients in 12 Latin American countries met the criteria for inclusion. There was considerable variability in methodology and in the reported prevalence of disease-related malnutrition; however, prevalence was consistently in the range of 40%-60% at the time of admission, with several studies reporting an increase in prevalence with increasing duration of hospitalisation. Disease-related malnutrition was associated with an increase in infectious and non-infectious clinical complications, length of hospital stay, and costs.

CONCLUSION

Disease-related malnutrition is a highly prevalent condition that imposes a substantial health and economic burden on the countries of Latin America. Further research is necessary to characterise screening/assessment practices and identify evidence-based solutions to this persistent and costly public health issue.

Analysis of resources assisting in coping with swallowing difficulties for patients with Parkinson's disease: a cross-sectional study

BACKGROUND

Malnutrition induced by swallowing difficulties (SD) impairs the quality of life and gives rise to SD-related costs in Parkinson's disease (PD) patients. With results of a swallowing difficulty questionnaire and data of resources specifically obtained such as SD-related costs, caregivers, and dietary therapies, this study is to suggest statistically supported ideas for improvements in arrangements for how participants cope with SD and maintain general well-being.

METHODS

We interviewed 237 PD patients. The SD-related costs involved those incurred by the provision of dietary modifications, care oriented foods, alternatives, and supplements. Dietary therapies included rice porridge and commercially available care foods. The relationships between BMI (body mass index) and the severity of SD assumed in this paper as indicators for general well-being and as resources for coping with SD for PD patients were statistically analyzed.

RESULTS

A lower BMI was found in participants eating porridge consistency rice (p = 0.003) and eating porridge rice is significantly related to the severity of SD (p < 0.0001) and PD (p = 0.002). The severity of SD increased with age and PD duration (p = 0.035, p = 0.0005). Outlays for dietary modifications are the lowest reported here (p < 0.004) but the number of participants using dietary modifications is the largest among the SD-related items (n = 58). Eating care foods were reported for 11 older participants (p < 0.0001), most female (10/11). No lower BMI was found in participants eating care foods when compared with participants eating ordinary foods. Dietary modifications were performed by caregivers (OR: 6.8, CI: 3.1-15.2, p < 0.0001) and were related to the presence of children (OR: 3.4, CI: 1.2-11.4. p = 0.024). Older participants commonly live with spouses and children.

CONCLUSIONS

Severe SD is associated with higher costs of coping with SD. A lower BMI is associated with modified foods, mostly eaten to cope with SD. Presence of caregivers and other persons residing with the participants here are related to dietary modifications but not to care food-related costs. Care foods may be effective in preventing malnutrition although the number who are able to cover the added expenses is limited because of the higher prices and shortage of information on the usefulness of care foods.

Risk Assessment of Fluoride Intake from Tea in the Republic of Ireland and its Implications for Public Health and Water Fluoridation

The Republic of Ireland (RoI) is the only European Country with a mandatory national legislation requiring artificial fluoridation of drinking water and has the highest per capita consumption of black tea in the world. Tea is a hyperaccumulator of fluoride and chronic fluoride intake is associated with multiple negative health outcomes. In this study, fifty four brands of the commercially available black tea bag products were purchased and the fluoride level in tea infusions tested by an ion-selective electrode method. The fluoride content in all brands tested ranged from 1.6 to 6.1 mg/L, with a mean value of 3.3 mg/L. According to our risk assessment it is evident that the general population in the RoI is at a high risk of chronic fluoride exposure and associated adverse health effects based on established reference values. We conclude that the culture of habitual tea drinking in the RoI indicates that the total cumulative dietary fluoride intake in the general population could readily exceed the levels known to cause chronic fluoride intoxication. Evidence suggests that excessive fluoride intake may be contributing to a wide range of adverse health effects. Therefore from a public health perspective, it would seem prudent and sensible that risk reduction measures be implemented to reduce the total body burden of fluoride in the population.

Clinical outcome of protein-energy malnourished patients in a Brazilian university hospital

Protein-energy malnutrition (PEM) is a treatable disease with high prevalence among hospitalized patients. It can cause significant increases in the duration of hospitalization and costs. PEM is especially important for health systems since malnourished patients present higher morbidity and mortality. The objective of the present study was to assess the evolution of nutritional status (NS) and the effect of malnutrition on clinical outcome of patients at a public university hospital of high complexity in Brazil. Patients hospitalized in internal medicine (n = 54), oncology (n = 43), and infectious diseases (n = 12) wards were included. NS was evaluated using subjective global assessment up to 48 h after admission, and thereafter at intervals of 4-6 days. On admission, patients (n = 109) were classified as well-nourished (n = 73), moderately malnourished or at risk of malnutrition (n = 28), and severely malnourished (n = 8). During hospitalization, malnutrition developed or worsened in 11 patients. Malnutrition was included in the clinical diagnosis of only 5/36 records (13.9% of the cases, P = 0.000). Nutritional therapy was administered to only 22/36 of the malnourished patients; however, unexpectedly, 6/73 well-nourished patients also received commercial enteral diets. Complications were diagnosed in 28/36 malnourished and 9/73 well-nourished patients (P = 0.000). Death occurred in 12/36 malnourished and 3/73 well-nourished patients (P = 0.001). A total of 24/36 malnourished patients were discharged regardless of NS. In summary, malnutrition remains a real problem, often unrecognized, unappreciated, and only sporadically treated, even though its effects can be detrimental to the clinical course and prognosis of patients. The amount of public and private funds unnecessarily dispersed because of hospital malnutrition is significant.