Health economics evidence for medical nutrition: are these interventions value for money in integrated care?

Prevalence of malnutrition risk and its association with mortality: nutritionDay Latin America survey results

BACKGROUND & AIMS

Across the globe, the prevalence of hospital malnutrition varies greatly depending on the population served and on local socioeconomic conditions. While malnutrition is widely recognized to worsen patient outcomes and add financial burdens to healthcare systems, recent data on hospital malnutrition in Latin America are limited. Our study objectives were: (1) to quantify the prevalence of malnutrition risk in Latin American hospital wards, and (2) to explore associations between nutritional risk status, in-hospital food intake, and health outcomes.

METHODS

On nutritionDay (nDay), a specific day every year, hospital wards worldwide can participate in a one-day, cross-sectional audit. We analyzed nDay data collected in ten Latin American countries from 2009 to 2015, including demographic and nutrition-related findings for adult patients (≥18 years) from 582 hospital wards/units. Based on patient-reported responses to questions related to the Malnutrition Screening Tool, we determined the prevalence of malnutrition risk (MST score ≥2). We also summarized patient-reported food intake on nDay, and we analyzed staff-collected outcome data at 30 days post-nDay.

RESULTS

The prevalence of malnutrition risk in the Latin American nDay study population (N = 14,515) was 39.6%. More than 50% of studied patients ate one-half or less of their hospital meal, ate less than normal in the week before nDay, or experienced weight loss in the prior three months. The hospital-mortality hazard ratio was 3.63 (95% CI [2.71, 4.88]; P < 0.001) for patients eating one-quarter of their meal (compared with those who ate the full meal), increasing to 6.6 (95% CI [5.02, 8.7]; P < 0.0001) for patients who ate none of the food offered.

CONCLUSIONS

Based on compilation of nDay surveys throughout Latin America, 2 of every 5 hospitalized patients were at risk for malnutrition. The associated risk for hospital mortality was up to 6-fold higher among patients who ate little or none of their meal on nDay. This high prevalence showed scant improvement over rates two decades ago-a compelling rationale for new focus on nutrition education and training of professionals in acute care settings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Nutrition and Human Rights. An International Position Paper

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

Clinical nutrition and human rights. An international position paper

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

How a Malnutrition Quality Improvement Initiative Furthers Malnutrition Measurement and Care: Results From a Hospital Learning Collaborative

BACKGROUND

Malnutrition in hospitalized patients can adversely affect health outcomes and increase the cost of care. Real-world strategies are needed for prompt identification and treatment of patients at risk of malnutrition.

OBJECTIVES

The aim of this quality improvement (QI) study was to measure the impact of a nutrition-focused program on the malnutrition care processes of participating hospitals. Secondary objectives were to determine whether improvements in these nutrition-related processes reduced hospital readmissions and length of stay (LOS) in patients ≥65 years.

METHODS

A group of 27 US hospitals ("The Collaborative") implemented the Malnutrition Quality Improvement Initiative (MQii), as guided by a Malnutrition QI Toolkit and 4 electronic clinical quality measures (eCQMs), including (1) nutrition screening; (2) nutrition assessment following detection of malnutrition risk; (3) nutrition care plan for patients identified as malnourished after completed nutrition assessment; and (4) documentation of malnutrition diagnoses. Multivariate analyses identified the variables best correlated with patient outcomes.

RESULTS

Improvements were observed for all 4 eCQMs. The greatest improvements were achieved as a result of timely nutrition assessment (P = .06) and malnutrition diagnosis (P = .02). Patients ≥65 years with a malnutrition diagnosis and nutrition care plan had a 24% lower likelihood of 30-day readmission but a longer mean LOS than did those without a care plan.

CONCLUSIONS

In this study, the implementation of MQii practices significantly improved the identification of malnutrition. The prompt identification and treatment of patients at malnutrition risk can improve patient care and health, as well as reduce costly readmissions.

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

Background

Method

Results

Conclusion

Budget Impact Analysis of a Home-Based Nutrition Program for Adults at Risk for Malnutrition

BACKGROUND

Hospital-based, nutrition-focused interventions have significantly lowered the cost-associated burden of poor nutrition through a reduction in healthcare resource utilization (HCRU). However, for patients at risk for poor nutrition who receive nutritional care at home, limited evidence exists on the economic impact of nutrition-focused interventions.

OBJECTIVE

To estimate the 30-day cost-savings associated with an at-home nutrition-focused quality improvement program in the postacute care setting for patients at risk for poor nutrition from the perspective of a hospital system.

METHODS

We compared the HCRU of 1546 patients enrolled in a quality improvement program during 1 year versus 7413 patients in a pre-program historical cohort who received care during the 1 year before the quality improvement program implementation. The analysis included the number of 30-day hospitalizations, emergency department and outpatient visits for both cohorts, and the associated costs. The main analysis included the fixed and variable costs for the program, and the costs of oral nutritional supplement and delivery. The costs for hospitalization, emergency department, and outpatient visit costs were based on the 2013 Healthcare Cost and Utilization Project and Medical Expenditure Panel Survey.

RESULTS

Based on the 2013 survey, the baseline costs for hospitalization, emergency department, and outpatient visit costs were $18,296, $1312, and $535, respectively. Our health economic analysis about the 30-day overall HCRU has shown that the quality improvement program group resulted in a total cost-savings of $2,408,668 for the 1546 patients in the program and a net savings of $1558 per patient compared with the costs for the pre-quality improvement program historical cohort.

CONCLUSION

The use of a nutrition-focused quality improvement program led to significant 30-day cost-savings, by reducing HCRU for adults who received nutritional-based care at home. The improvements in HCRU highlight the importance of implementing nutrition-focused quality improvement programs for hospital systems that provide care for patients who are at risk for poor nutrition across a variety of care settings.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated—a true “silent epidemic” in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian–driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.

Nutrition Support Teams: A Systematic Review

BACKGROUND

The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

METHODS

Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

RESULTS

The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

CONCLUSION

Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.

Nutritional Status of Lebanese Hospitalized Patients With Chronic Disease: A Cross-Sectional Study

Background: In a hospitalized setting, malnutrition is known to increase patient's mortality and lower the quality of life; therefore, it is essential to detect such cases and intervene at the earliest possible. The goal of this study is to estimate the rate of malnutrition in hospitalized Lebanese patients, explore its association with different factors, and create a simple tool to detect patients at high risk of malnutrition. Methods: One hundred and fifty Lebanese hospitalized patients, suffering at least from one chronic disease, were randomly chosen from Centre Hospitalier Universitaire Notre Dame de Secours (CHU-NDS) hospital. The Mini Nutritional Assessment (MNA) score was used to assess nutritional status. Results: A total of 34.7% of patients in our sample were at risk of malnutrition and 9.3% were malnourished. A higher risk of malnutrition was found in patients with a low body mass index, who were physically inactive or admitted to the hospital more than once in the past 6 months. The nutritional status was not associated with certain chronic diseases more than others. We designed a simple decision tree model based only on 3 questions to detect patients at high risk of malnutrition/malnourished. This tool has a sensitivity of 62% and a specificity of 77%. Conclusion: The prevalence found in our study was comparable with previous data. However, factors associated with poor nutritional status were somewhat different. Further studies are needed to validate our screening tool and to examine the effect of specific diseases on malnutrition on a larger scale.

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.

Economic analysis of costs with enteral and parenteral nutritional therapy according to disease and outcome

Objective

To conduct an economic analysis of enteral and parenteral diet costs according to the type of disease and outcome (survivors versus deaths).

Methods

It is a cross-sectional, observational, retrospective study with a qualitative and quantitative design, based on analysis of hospital accounts from a healthcare insurance provider in the Southern region of Brazil.

Results

We analyzed 301 hospital accounts of individuals who used enteral and parenteral diets. The total cost of the diet was 35.4% of hospital account total costs. The enteral modality accounted for 59.8% of total dietary costs. The major costs with diets were observed in hospitalizations related to infections, cancers and cerebro-cardiovascular diseases. The major costs with parenteral diet were with admissions related by cancers (64.52%) and dementia syndromes (46.17%). The highest ratio between total diet costs with the total of hospital account costs was in dementia syndromes (46.32%) and in cancers (41.2%). The individuals who died spent 51.26% of total of hospital account costs, being 32.81% in diet (47.45% of total diet value and 58.81% in parenteral modality).

Conclusion

Enteral and parenteral nutritional therapies account for a significant part of the costs with hospitalized individuals, especially in cases of cancers and dementia syndromes. The costs of parenteral diets were higher in the group of patients who died.

Budget Impact of a Comprehensive Nutrition-Focused Quality Improvement Program for Malnourished Hospitalized Patients

BACKGROUND

Nutrition interventions can alleviate the burden of malnutrition by improving patient outcomes; however, evidence on the economic impact of medical nutrition intervention remains limited. A previously published nutrition-focused quality improvement program targeting malnourished hospitalized patients showed that screening patients with a validated screening tool at admission, rapidly administering oral nutritional supplements, and educating patients on supplement adherence result in significant reductions in 30-day unplanned readmissions and hospital length of stay.

OBJECTIVES

To assess the potential cost-savings associated with decreased 30-day readmissions and hospital length of stay in malnourished inpatients through a nutrition-focused quality improvement program using a web-based budget impact model, and to demonstrate the clinical and fiscal value of the intervention.

METHODS

The reduction in readmission rate and length of stay for 1269 patients enrolled in the quality improvement program (between October 13, 2014, and April 2, 2015) were compared with the pre-quality improvement program baseline and validation cohorts (4611 patients vs 1319 patients, respectively) to calculate potential cost-savings as well as to inform the design of the budget impact model. Readmission rate and length-of-stay reductions were calculated by determining the change from baseline to post-quality improvement program as well as the difference between the validation cohort and the post-quality improvement program, respectively.

RESULTS

As a result of improved health outcomes for the treated patients, the nutrition-focused quality improvement program led to a reduction in 30-day hospital readmissions and length of stay. The avoided hospital readmissions and reduced number of days in the hospital for the patients in the quality improvement program resulted in cost-savings of $1,902,933 versus the pre-quality improvement program baseline cohort, and $4,896,758 versus the pre-quality improvement program in the validation cohort. When these costs were assessed across the entire patient population enrolled in the quality improvement program, per-patient net savings of $1499 when using the baseline cohort as the comparator and savings per patient treated of $3858 when using the validated cohort as the comparator were achieved.

CONCLUSION

The nutrition-focused quality improvement program reduced the per-patient healthcare costs by avoiding 30-day readmissions and through reduced length of hospital stay. These clinical and economic outcomes provide a rationale for merging patient care and financial modeling to advance the delivery of value-based medicine in a malnourished hospitalized population. The use of a novel web-based budget impact model supports the integration of comparative effectiveness analytics and healthcare resource management in the hospital setting to provide optimal quality of care at a reduced overall cost.

Economic Burden of Disease-Associated Malnutrition at the State Level

Background

Disease-associated malnutrition has been identified as a prevalent condition, particularly for the elderly, which has often been overlooked in the U.S. healthcare system. The state-level burden of community-based disease-associated malnutrition is unknown and there have been limited efforts by state policy makers to identify, quantify, and address malnutrition. The objective of this study was to examine and quantify the state-level economic burden of disease-associated malnutrition.

Methods

Direct medical costs of disease-associated malnutrition were calculated for 8 diseases: Stroke, Chronic Obstructive Pulmonary Disease, Coronary Heart Failure, Breast Cancer, Dementia, Musculoskeletal Disorders, Depression, and Colorectal Cancer. National disease and malnutrition prevalence rates were estimated for subgroups defined by age, race, and sex using the National Health and Nutrition Examination Survey and the National Health Interview Survey. State prevalence of disease-associated malnutrition was estimated by combining national prevalence estimates with states’ demographic data from the U.S. Census. Direct medical cost for each state was estimated as the increased expenditures incurred as a result of malnutrition.

Principal Findings

Direct medical costs attributable to disease-associated malnutrition vary among states from an annual cost of $36 per capita in Utah to $65 per capita in Washington, D.C. Nationally the annual cost of disease-associated malnutrition is over $15.5 billion. The elderly bear a disproportionate share of this cost on both the state and national level.

Conclusions

Additional action is needed to reduce the economic impact of disease-associated malnutrition, particularly at the state level. Nutrition may be a cost-effective way to help address high health care costs.

Enablers and Barriers in Implementing Integrated Care

Abstract-The integration of medical and social care aims to address the fragmentation in patient services observed in many health care systems. Increasing rates of chronic disease and multimorbidity have drawn attention to the often significant reforms necessary to address these problems. In this article we discuss how integration may be achieved. To date there is no single best practice model or well-defined guidelines for integration. We suggest that three groups of patients with complex health needs would experience the greatest benefit: multimorbid patients with two or more chronic diseases, patients with moderate or severe mental health conditions, and the elderly. Integration has been demonstrated to achieve improvements in the coordination, quality, efficiency, and cost control of health care. Considering these benefits, a broad effort should be made to implement integrated care.

A call-to-action from the feedM.E. Middle East study group. Use of a screen-intervene-supervene strategy to address malnutrition in healthcare

Up to 50% of hospitalized patients worldwide are malnourished or at risk of malnutrition. Guidelines recommend nutritional screening of all patients on hospital admission. Results from studies of hospitalized patients show that screening, with follow-up nutritional assessment and care when indicated, can improve patients' clinical outcomes and reduce healthcare costs. Despite compelling evidence, attention to nutritional care remains suboptimal in clinical settings worldwide. The feedM.E. Global Study Group developed a simple, stepwise Nutrition Care Pathway to facilitate best-practice nutrition care. This pathway guides clinicians to screen patients' nutritional status on hospital admission or at initiation of care; intervene promptly with nutrition care when needed; and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. The feedM.E. Middle East Study Group seeks to extend this program to our region. We advise clinicians to adopt and adapt the Nutrition Care Pathway, bringing quality nutrition care to everyday practice.