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

Malnutrition among the older adult: an additional challenge for the rehabilitation team-insights of a small population of Switzerland

Introduction

Nutritional deficiency among the older adult is a widespread concern, significantly affecting their health. The prevalence of malnutrition increases with age, concurrent health conditions, and the level of care provided. Hospital stays can affect as 90% of the older adult. Malnutrition can hinder efforts to improve health and regain function in individuals undergoing rehabilitation. This study aims to assess the frequency of malnutrition among geriatric rehabilitation patients.

Materials and methods

A retrospective quantitative analysis was conducted on 357 patients admitted to the geriatric unit at Lucerne Cantonal Hospital Wolhusen in Switzerland. The patients' nutritional status was evaluated using the standardized Mini Nutritional Assessment Long Form questionnaire.

Results

The initial analysis indicated a considerable prevalence of malnutrition among the geriatric population: 31.1% were identified as malnourished (MNA < 17), while an additional 35.8% were at risk of malnutrition (MNA 17-23.5), totaling 66.9% of patients. The Kruskal-Wallis ANOVA test revealed a statistically significant difference in MNA scores among different age groups (p = 0.035). Statistical analysis also suggested a slightly higher prevalence of malnutrition among female patients. The duration of rehabilitation varied from 20.07 ± 6.93 to 22.20 ± 7.50 days, with longer durations associated with lower MNA scores. A correlation analysis between MNA values and body mass index (BMI) showed a positive correlation coefficient (r = 0.56), indicating that lower MNA scores were associated with lower BMI and vice versa.

Conclusion

Malnutrition is prevalent among individuals over 65 years old, highlighting the importance of regular and timely nutritional assessments for geriatric patients to mitigate the complications and enhance prognoses in both acute care and rehabilitation settings. Such assessments can also improve the efficacy of rehabilitation programs and potentially reduce the duration of rehabilitation, thus carrying significant economic implications.

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.

The Role of Amino Acid Supplementation in Orthopaedic Surgery

The nutritional status of patients undergoing orthopaedic surgery has started to garner increasing attention in published literature. Notable previous evidence has demonstrated the negative effect of malnutrition on outcomes after orthopaedic procedures. Although there has been increased recognition of malnutrition as a risk factor for suboptimal outcomes, the use of nutritional supplementation to mitigate those risks is not well understood. The purpose of this review of most current literature on the topic is to introduce and elucidate the role of amino acid supplementation as a countermeasure to muscle loss and improvement of nutritional status in orthopaedic patients to improve results and outcomes after orthopaedic surgery.

Individualised nutritional treatment increases the positive effects of a novel á la carte hospital food service concept: Results of a quasi-experimental study

BACKGROUND & AIMS

One-third of hospitalised patients are at nutritional risk, and limited choice regarding meals and meal times, and inadequate nutritional support may contribute to inadequate nutritional intake during hospitalisation. The aim was to test the effect of a novel á la carte hospital food service concept as a stand-alone intervention and combined with individualised nutritional treatment.

METHODS

Medical inpatients at nutritional risk were recruited for this three-arm quasi-experimental study. The control group received meals from the traditional bulk trolley food service system. Intervention group 1 (IG1) received meals from a novel á la carte food service concept with an electronic ordering system, whereas intervention group 2 (IG2) in addition to this received individualised nutritional treatment by a clinical dietitian. Nutritional intake and length of stay was measured, and patient satisfaction was assessed with purpose-designed questionnaires.

RESULTS

206 patients were included: 67 in the control group, 68 in IG1, and 71 in IG2. The proportion of participants reaching ≥75 % of both their energy and protein requirement was higher in IG1 compared to the control group (34 % vs. 12 %, p = 0.002) and higher in IG2 compared to IG1 (53 % vs. 34 %, p = 0.035). Length of stay was shorter in IG2 compared to the control group (6.0 vs. 8.7 days, p = 0.005). It was important to participants to be able to choose when and what to eat, and this preference was met to a larger extent in the intervention groups.

CONCLUSION

The novel á la carte concept increases energy and protein intake in hospitalised patients, and the positive effects are increased, when the concept is used in combination with individualised nutritional treatment.

Association of Glutamine and Glutamate Metabolism with Mortality among Patients at Nutritional Risk-A Secondary Analysis of the Randomized Clinical Trial EFFORT

Glutamine and its metabolite glutamate serve as the main energy substrates for immune cells, and their plasma levels drop during severe illness. Therefore, glutamine supplementation in the critical care setting has been advocated. However, little is known about glutamine metabolism in severely but not critically ill medical patients. We investigated the prognostic impact of glutamine metabolism in a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care in patients at nutritional risk. Among 234 patients with available measurements, low plasma levels of glutamate were independently associated with 30-day mortality (adjusted HR 2.35 [95% CI 1.18-4.67, p = 0.015]). The impact on mortality remained consistent long-term for up to 5 years. No significant association was found for circulating glutamine levels and short- or long-term mortality. There was no association of glutamate nor glutamine with malnutrition parameters or with the effectiveness of nutritional support. This secondary analysis found glutamate to be independently prognostic among medical inpatients at nutritional risk but poorly associated with the effectiveness of nutritional support. In contrast to ICU studies, we found no association between glutamine and clinical outcome.

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.

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.

The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes

Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.

[Malnutrition in internal medicine : Screening, assessment and importance]

Disease-related malnutrition has a strong influence on the further course of the disease and mortality, especially in chronically ill patients. In recent years it could be shown in large randomized studies that an individual nutrition therapy could significantly and relevantly improve the clinical outcome of patients in internal medicine with a risk of malnutrition, both in hospital and in aftercare. Therefore, due to the increasing proportion of multimorbid patients the significance of malnutrition and its treatment is becoming increasingly more important in the practice and in research. Nutritional medicine should nowadays be considered as an effective and integral component of a holistic treatment in internal medicine; however, further research is necessary in order to investigate new nutritional biomarkers and for a better integration of an evidence-based personalized nutritional medicine into routine clinical practice.

The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Good nutrition across the lifespan is foundational for healthy aging and sustainable development

Ensuring healthy lives and promoting wellbeing across the age spectrum are essential to sustainable development. Nutrition is at the heart of the World Health Organization (WHO) Sustainable Development Goals, particularly for Sustainable Development Goal 2/Subgoal 2, which is to End all forms of malnutrition by 2030. This subgoal addresses people of all ages, including targeted groups like young children and older adults. In recent decades, there have been marked advances in the tools and methods used to screen for risk of malnutrition and to conduct nutritional assessments. There have also been innovations in nutritional interventions and outcome measures related to malnutrition. What has been less common is research on how nutritional interventions can impact healthy aging. Our Perspective article thus takes a life-course approach to consider what is needed to address risk of malnutrition and why, and to examine how good nutrition across the lifespan can contribute to healthy aging. We discuss broad-ranging yet interdependent ways to improve nutritional status worldwide-development of nutritional programs and policies, incorporation of the best nutrition-care tools and methods into practice, provision of professional training for quality nutritional care, and monitoring health and economic benefits of such changes. Taken together, our Perspective aims to (i) identify current challenges to meeting these ideals of nutritional care, and to (ii) discover enabling strategies for the improvement of nutrition care across the lifespan. In harmony with the WHO goal of sustainable development, we underscore roles of nutrition to foster healthy human development and healthy aging worldwide.

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.

Nutritional support during the hospital stay is cost-effective for preventing adverse outcomes in patients with cancer

Objective

Among patients with cancer, malnutrition remains common and is a key challenge in oncology practice today. A prior study from our group revealed that malnourished cancer inpatients who got nutritional treatment (intervention group) had lower mortality and improved functional and quality of life outcomes compared to inpatients without nutritional support (control group). Our present analysis aimed to determine whether the improved patient recovery by nutritional support was paralleled by cost-effectiveness of this nutritional care.

Methods

We analyzed hospital costs and health outcomes in patients with cancer, using a Markov simulation model with daily cycles to analyze the economic impact of nutritional support in malnourished inpatients with malignancies. We compared results for a nutritional intervention group and a control group across a 30-day timeframe. Five health states were designated (malnourished but stable, complications, intensive care unit (ICU) admission, discharge, death). Costs for the different health states were based on publicly available data for the Swiss medical system. Total patient cost categories included in-hospital nutrition, days spent in the normal ward, days in the ICU, and medical complications.

Results

Total per-patient costs for in-hospital supportive nutrition was Swiss francs (CHF) 129. Across a 30-day post-admission interval, our model determined average overall costs of care of CHF 46,420 per-patient in the intervention group versus CHF 43,711 in the control group—a difference of CHF 2,709 per patient. Modeled results showed a cost of CHF 1,788 to prevent one major complication, CHF 4,464 to prevent one day in the ICU, and CHF 3,345 to prevent one death. Recovery benefits of nutritional care were thus paralleled by cost-effectiveness of this care.

Conclusion

In-hospital nutritional support for oncology patients at nutritional risk is a low-cost intervention that has both clinical and financial benefits.

Cost-Effectiveness Analysis of Standardized Clinical Nutrition Diagnosis and Treatment Pathway in Patients with Pulmonary Infection

Objective

From the perspective of economics, this study discusses the value of establishing a standardized clinical nutrition diagnosis and treatment pathway in the diagnosis and treatment of pulmonary infection and provides a reference for optimizing the diagnosis and treatment pathway of pulmonary infection.

Methods

The patients who received the nutrition diagnosis and treatment pathway intervention in 2017 were counted as the routine group and were subdivided into the conventional intervention group (C1) and conventional control group (C2) according to whether the standardized nutrition therapy was applied or not. The patients who received the nutrition diagnosis and treatment pathway intervention in 2020 were counted as the experimental group and were subdivided into the experimental intervention group (T1) and the experimental control group (T2) according to whether standardized intervention was applied or not. The total hospitalization expenses, average daily hospitalization cost, nutrition support expenses, plasma albumin before and after nutrition support, readmission, and other indicators of all patients were recorded and compared. The cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER), and cost-effectiveness threshold for cost-effectiveness analysis were adopted.

Results

Compared with the C2 group, the C1 group had higher total hospitalization expenses, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Compared with the T2 group, the T1 group had higher total hospitalization cost, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Taking the improvement rate of plasma albumin as the effect index, compared with the C1 group, the T1 group has less investment cost and better effect, and the ICER is negative (below the cost-effect threshold). And taking the readmission rate as the effective index, compared with the C1 group, the T1 group invested less cost and had a better effect, and the ICER was negative (below the cost-effect threshold).

Conclusion

For the patients with pulmonary infection, whether the improvement rate of plasma albumin or the readmission rate is used as the impact index, the standardized nutrition diagnosis and treatment pathway in 2020 is more economical than the nonstandardized nutrition diagnosis and treatment pathway.

Are We Identifying Malnutrition in Hospitalized Patients with Hematologic Malignancies? Results from a Quality Clinical Audit

Disease-related malnutrition (DRM) is highly prevalent among patients with hematologic malignancies. The aim of the present study was to evaluate the prevalence of DRM in hospitalized patients with hematologic malignancies and investigate the level of awareness of DRM among the medical team treating this group of patients. A cross sectional quality clinical audit took place in two hematology units of a tertiary university hospital. Inpatients were screened within 48 h of their admission using the Malnutrition Universal Screening Tool (MUST) to identify their nutritional risk, and they were reassessed to identify the implemented interventions during their hospitalization. One hundred eighty-five patients were included in the audit analysis. On admission, 37.3% of the audited population was identified as being at high risk of malnutrition according to the MUST score. Forty-nine (26.5%) patients reported reduced food intake during the past 5 days, while four (2.2%) reported no food intake. During the hospitalization, only five patients (2.7%) received nutritional support, as indicated. Low levels of awareness of the early detection and treatment of DMS were found. Moreover, the prevalence of DRM and low nutritional intake was reported to be low. Measures to increase awareness of DMR in the medical team and better coordination of the nutrition support teams is vital to ensure better management and early nutrition intervention in hematological patients.

Economic Evaluation of Individualized Nutritional Support for Hospitalized Patients with Chronic Heart Failure

Background Malnutrition is a highly prevalent risk factor in hospitalized patients with chronic heart failure (CHF). A recent randomized trial found lower mortality and improved health outcomes when CHF patients with nutritional risk received individualized nutritional treatment. Objective To estimate the cost-effectiveness of individualized nutritional support in hospitalized patients with CHF. Methods This analysis used data from CHF patients at risk of malnutrition (N = 645) who were part of the Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial (EFFORT). Study patients with CHF were randomized into (i) an intervention group (individualized nutritional support to reach energy, protein, and micronutrient goals) or (ii) a control group (receiving standard hospital food). We used a Markov model with daily cycles (over a 6-month interval) to estimate hospital costs and health outcomes in the comparator groups, thus modeling cost-effectiveness ratios of nutritional interventions. Results With nutritional support, the modeled total additional cost over the 6-month interval was 15,159 Swiss Francs (SF). With an additional 5.77 life days, the overall incremental cost-effectiveness ratio for nutritional support vs. no nutritional support was 2625 SF per life day gained. In terms of complications, patients receiving nutritional support had a cost savings of 6214 SF and an additional 4.11 life days without complications, yielding an incremental cost-effectiveness ratio for avoided complications of 1513 SF per life day gained. Conclusions On the basis of a Markov model, this economic analysis found that in-hospital nutritional support for CHF patients increased life expectancy at an acceptable incremental cost-effectiveness ratio.