Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition indicators to diagnose malnutrition tool in hospitalized adults: a cohort study

BACKGROUND

The lack of a widely accepted, broadly validated tool for diagnosing malnutrition in hospitalized patients limits the ability to assess the integral role of nutrition as an input and outcome of health, disease, and treatment.

OBJECTIVES

This study aimed to evaluate the predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (ASPEN) indicators to diagnose malnutrition (AAIM) tool and determine if it can be simplified.

METHODS

A prospective cohort study was conducted from August 2019 to September 2022 with 32 hospitals in United States. At baseline, 290 adult patients were evaluated for a diagnosis of malnutrition using the AAIM tool, which assesses weight loss, inadequate energy intake, subcutaneous fat and muscle loss, edema, and hand grip strength. Healthcare outcomes were extracted from the medical record: composite incidence of emergency department (ED) visits and hospital readmissions within 90 d postdischarge; length of hospital stay (LOS); and Medicare Severity Disease Related Group (MS-DRG) relative weight (i.e., healthcare resource utilization). We used multilevel, multivariable negative binomial or generalized linear regression models to evaluate relationships between malnutrition diagnosis and healthcare outcomes.

RESULTS

After adjusting for disease severity and acuity and sociodemographic characteristics, individuals diagnosed with severe malnutrition had a higher incidence rate of ED visits and hospital readmissions (incidence rate ratio: 1.89; 95% CI: 1.14, 3.13; P = 0.01), and individuals diagnosed with moderate malnutrition had a 25.2% longer LOS (95% CI: 2.0%, 53.7%; P = 0.03) and 15.1% greater healthcare resource utilization (95% CI: 1.6%, 31.9%; P = 0.03) compared with individuals with no malnutrition diagnosis. Observed relationships remained consistent when only considering malnutrition diagnoses supported by at least 2 of these indicators: weight loss, subcutaneous fat loss, muscle wasting, and inadequate energy intake.

CONCLUSIONS

Findings from this multihospital study confirm the predictive validity of the original or simplified AAIM tool and support its routine use for hospitalized adult patients. This trial was registered at clinicaltrials.gov as NCT03928548 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03928548).

Completion of a Nutrition-Focused Physical Exam with hospitalized adults and pediatric patients: Secondary analysis of a prospective cohort study

BACKGROUND

Nutrition-Focused Physical Exam (NFPE) feasibility is not well-studied. We describe registered dietitian nutritionist (RDN)-reported NFPE completion for hospitalized adult and pediatric patients overall and by assessment parameters.

METHODS

Trained RDNs systematically conducted NFPEs for hospitalized adult and pediatric patients during the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Indicators to diagnose Malnutrition multisite cohort study (ClinicalTrials.gov: NCT03928548). RDNs reported their ability to evaluate assessment sites for subcutaneous fat and muscle loss, fluid accumulation, and micronutrient status and to complete handgrip strength (adults and children ≥6 years) and mid-upper arm circumference measurements (children). RDNs noted if they could complete the full NFPE; if not, they noted challenges. We descriptively summarized results and used multilevel logistic regression models to examine relationships between patient characteristics and NFPE completion.

RESULTS

RDNs from 39 adult and 29 pediatric US hospitals conducted NFPEs for 327 adults and 214 children aged 1 month to 17.9 years. RDNs reported completing the examination for 44% (n = 145) of adults and 15% (n = 33) of children. They successfully evaluated 25 of 27 and 19 of 26 unique NFPE components in >80% of adults and children, respectively. Common reasons the full NFPE was not completed were limited mobility in adults and patient refusal in children. RDNs had lower odds of completing NFPEs in adults with lower vs higher education levels or higher vs lower nutrition complexity and in younger vs older children.

CONCLUSION

RDNs evaluated NFPE components for a high proportion (>80%) of hospitalized patients.

Factors Associated with IRB Review Time in a Non-Federally Funded Study Using an sIRB of Record

From 2018 to 2020, U.S. federal mandates began requiring the use of a single institutional review board (sIRB) of record for federally funded, multisite studies. With an interest in the efficiency of site activation, we compared the frequency with which local review and approval and three different reliance options (ways to establish a reliance agreement between the sIRB and the relying institution) were used during this period in a multisite, non-federally funded study (ClinicalTrials.gov identifier: NCT03928548). Using general linear models, we analyzed the relationships between local reliance or approval and sIRB of record approval times and (a) the regulatory option selected and (b) relying-site and process characteristics. Eighty-five sites received sIRB approval through 72 submissions (40% using local review, 46% using the SMART IRB agreement, 10% using an IRB authorization agreement, and 4% using a letter of support). Median time to establish a local reliance or study approval and sIRB approval were longest for sites using a SMART IRB agreement. Study-site region and the time of submission were significantly associated with local reliance or approval time, which averaged 129 and 107 days faster for Midwestern (p = 0.03) or Western (p = 0.02) sites, respectively, and 70 days slower for Northeastern sites (p = 0.42) compared with sites in the South, and 91 days slower when regulatory communication was initiated during or after February 2019 compared with before (p = 0.02). Similar relationships between sIRB approval time and region and time frame were observed; in addition, approval time was 103 days slower for sites affiliated with a research 1 (R1) university versus not (p = 0.02). Region of the country, time frame, and R1 university affiliation were associated with variations in study-site activation in a non-federally funded, multisite study.

Documentation of the evidence-diagnosis link predicts nutrition diagnosis resolution in the Academy of Nutrition and Dietetics' diabetes mellitus registry study: A secondary analysis of Nutrition Care Process outcomes

Objectives

To describe nutrition care documentation patterns and investigate predictors of nutrition diagnosis resolution.

Methods

This is a secondary data analysis of a 2-year pragmatic, quasi-experimental study conducted in outpatient clinics where nutrition care was provided to adults with diabetes Type 1 or 2 from May 2017 to June 2019 (n = 564 patients). The main outcome measures were frequency of standardized Nutrition Care Process (NCP) terms, NCP links, nutrition diagnosis resolution and predictors of nutrition diagnosis resolution. Predictors of diagnosis resolution were identified using a multivariable logistic regression model.

Results

The most prevalent resolved diagnoses were excessive carbohydrate intake (32%), undesirable food choices (21%) and excessive energy intake (13%). The top etiology was food and nutrition related knowledge deficit (57%) and interventions were drawn mainly from the Nutrition Education domain (64%). One hundred forty-six patient cases (26%) had at least one follow-up visit and 26% of those with a follow-up (n = 38) had a resolved diagnosis. The presence of the evidence-diagnosis NCP link in documentation predicted diagnosis resolution (OR = 2.80, 95% CI 1.30–6.02; p = 0.008).

Conclusion

Most diagnoses were caused by patients' lack of knowledge and respective interventions focused on nutrition education. Odds of diagnosis resolution improved when the signs and symptoms of the diagnosis were documented during assessment (evidence-diagnosis NCP link). Training dietitians on NCP links may be important to resolve nutrition diagnoses. Presented findings are hypothesis generating.

A quasi-experimental study provides evidence that registered dietitian nutritionist care is aligned with the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and 2 diabetes

Background

One previous study examined implementation of evidence-based nutrition practice guidelines (EBNPG).

Objectives

To describe alignment of registered dietitian nutritionists' (RDNs) documented nutrition care with the Academy of Nutrition and Dietetics' EBNPG for Type 1 and Type 2 diabetes and examine impact of a midpoint training on care alignment with the guideline.

Methods

In this 2-year, quasi-experimental study, 19 RDNs providing outpatient medical nutrition therapy to adults with diabetes (n = 562) documented 787 initial and follow-up encounters. At study midpoint, RDNs received a guideline content training. A validated, automated tool was used to match standardized nutrition care process terminology (NCPT) in the documentation to NCPT expected to represent guideline implementation. A congruence score ranging from 0 (recommendation not identified) to 4 (recommendation fully implemented) was generated based on matching. Multilevel linear regression was used to examine pre-to-post training changes in congruence scores.

Results

Most patients (~75%) had only one documented RDN encounter. At least one guideline recommendation was fully implemented in 67% of encounters. The recommendations “individualize macronutrient composition” and “education on glucose monitoring” (partially or fully implemented in 85 and 79% of encounters, respectively) were most frequently implemented. The mean encounter congruence scores were not different from pre-to-post guideline training (n = 19 RDNs, 519 encounters pre-training; n = 14 RDNs, 204 encounters post-training; β = −0.06, SE = 0.04; 95% CI: −0.14, 0.03).

Conclusions

Most RDN encounters had documented evidence that at least one recommendation from the EBNPG was implemented. The most frequently implemented recommendations were related to improving glycemic control. A midpoint guideline training had no impact on alignment of care with the guideline.

Evaluating the Implementation of Evidence-based Kidney Nutrition Practice Guidelines: The AUGmeNt Study Protocol

Evidence-based nutrition practice guidelines (EBNPGs) inform registered dietitian nutritionist (RDN) care for patients with chronic kidney disease grade 5 treated by dialysis; however, there has been little evaluation of best practices for implementing EBNPGs. In this effectiveness-implementation hybrid study with a quasi-experimental design, United States RDNs in hemodialysis clinics will document initial and follow-up nutrition care for patients with chronic kidney disease grade 5 treated by dialysis using the Academy of Nutrition and Dietetics Health Informatics Infrastructure before and after being randomly assigned to a training model: (1) EBNPG knowledge training or (2) EBNPG knowledge training plus an implementation toolkit. The aims of the study include examining congruence of RDN documentation of nutrition care with the EBNPG; describing common RDN-reported EBNPG acceptability, adoption, and adaptation issues; and determining the feasibility of estimating the impact of RDN care on nutrition-related patient outcomes. The AUGmeNt study can inform effective development and implementation of future EBNPGs. Keywords: Chronic kidney diseases; medical nutrition therapy; implementation science; clinical practice guideline; nutrition care process terminology; dietitian.

Use of SmartIRB Does Not Reduce IRB Review Time in a Non-federally Funded, Multi-Site Malnutrition Study

Objectives

We evaluated the efficiency of using the SmartIRB platform compared to other site IRB approval mechanisms in the multi-site Academy and ASPEN Indicators to Diagnose Malnutrition (AAIM) Validation and Staffing Optimization Study.

Methods

Process data on the time to execute reliance agreements were collected when on-boarding sites for the AAIM Study (ClinicalTrials.gov: NCT03928548). Acute care hospital site recruitment occurred from September 2018 to December 2021. Research sites joined the study by either executing a reliance agreement with the single IRB of Record (sIRB) or by obtaining full local IRB approval from their institution. Reliance agreements were established through the SmartIRB model, an IRB authorization agreement (IAA), or a Letter of Support. Data are presented descriptively as number of observations and respective percentages or means ± standard deviations (SD).

Results

As of September 2021, 82 sites received IRB approval for the AAIM Study through the submission of 69 individual IRB applications. Sixty sites were affiliated with SmartIRB. Forty-one applications established a reliance agreement with the sIRB: 31 of 69 used the SmartIRB model (44.9%), 7 used an IAA (10.1%), and 3 used a Letter of Support (4.3%). Twenty-eight applications were submitted for full local review (40.6%). For all 69 submissions, the average time from the initial contact to site activation by the sIRB was 496.9 ± 213.6 (SD) days. SmartIRB had the longest review period of 546.1 ± 220 days; followed by full local review (492.6 ± 213.9 days), then IAA (377.4 ± 143.7 days), and Letter of Support (306.3 ± 58.2 days).

Conclusions

The use of an sIRB and the SmartIRB platform did not to reduce the time required for IRB review of this non-federally funded study. These findings should be interpreted acknowledging several disruptions to IRB activity during the study recruitment timeframe (e.g., accelerated implementation of single IRB review starting in 2018, Common Rule changes in 2019, and the COVID-19 pandemic starting in 2020).

Funding Sources

The AAIM Study was funded by the Academy of Nutrition and Dietetics Foundation, the Commission on Dietetic Registration, the Pediatric Nutrition Practice Group, the Clinical Nutrition Management Dietetic Practice Group, and the Renal Dietitians Practice Group.

Study Protocol To Establish Validity and Reliability of Consensus-Derived Diagnostic Indicators for Malnutrition in Hospitalized Adult and Pediatric Patients

Objectives

The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition have developed a set of consensus-derived indicators (the AACI) for the diagnosis of malnutrition in hospitalized adult and pediatric patients. This study aims to establish the predictive criterion and construct validity and reliability of the adult and pediatric AACI.

Methods

Within the context of a larger cohort study, 600 adult and 600 pediatric patients will be enrolled at ∼120 acute care hospital sites. Patients will be randomly selected and stratified approximately 1:1 as high- and low-risk for malnutrition based on the Malnutrition Screening Tool (adults) and STRONGkids screening tool (children). Registered dietitian nutritionists (RDNs) will collect AACI indicators and complete a Nutrition Focused Physical Exam for these patients. At a subset of 10–20 sites, bioelectrical impedance analysis (BIA) data will be collected to serve as an objective measure of body composition. After 90 days, follow-up data on nutrition care and medical outcomes (e.g., mortality, morbidity, hospital readmissions, length of stay, and healthcare costs) will be extracted from the medical record. Multilevel linear, logistic, multinomial, Poisson, or Cox regression models will be used to assess AACI validity as appropriate for each medical and BIA outcome, controlling for measures of disease severity, RDN-delivered medical nutrition therapy and other important patient-, RDN-, and site-level covariates as appropriate. The interrater reliability of the AACI will be evaluated by having multiple RDNs independently complete the AACI on the same patient to assess the agreement, using Cohen's kappa, on specific indicators and overall malnutrition diagnosis. This study design follows recently published recommendations for assessing the validity and reliability of criteria for diagnosing malnutrition in hospitalized patients.

Results

N/A.

Conclusions

Validation and reliability results will allow clinicians to standardize the way they diagnose malnutrition in hospitalized patients.

Funding Sources

This study is funded by the Academy of Nutrition and Dietetics Foundation, the Commission on Dietetic Registration, and the Pediatric Nutrition, Clinical Nutrition Management, and Renal Dietitians Dietetic Practice Groups.

Academy of Nutrition and Dietetics Nutrition Research Network: Validation of a Novel Nutrition Informatics Tool to Assess Agreement Between Documented Nutrition Care and Evidence-Based Recommendations

More evidence regarding registered dietitian nutritionist implementation of evidence-based nutrition practice guidelines (EBNPGs) is needed. We assessed the utility of an automated informatics tool to evaluate congruence of documented nutrition care with 13 individual recommendations in the diabetes mellitus (DM) EBNPG and with the guideline overall. A concurrent validation study was conducted using Nutrition Care Process Terminology documentation entered in the Academy of Nutrition and Dietetics Health Informatics Infrastructure by registered dietitian nutritionists caring for patients with DM. A 15% subset (n = 115) of the 790 patient encounters recorded were selected randomly, and the documented care was evaluated using the automated DM Expected Care Plan (ECP) Analyzer and expert audit. Recommendation-level congruence, as determined by each method, was compared using Cohen's κ analysis, and the accuracy, sensitivity, and specificity of the DM ECP Analyzer for assessing overall guideline-level congruence was calculated with expert audits as the "gold standard." For recommendation-level congruence, the DM ECP Analyzer identified more instances of recommendation implementation in the patient encounters, and classified more encounters as including partial or full recommendation implementation for 10 of the 13 recommendations, compared with the expert audit. There was slight to fair agreement between the DM ECP and the expert audit for most individual recommendations, with a mean ± standard deviation level of agreement of κ = .17 ± .19 across all eligible recommendations. At the guideline level, the DM Analyzer had high accuracy (98.3%) and sensitivity (99.1%) and low specificity (0%; no true negatives detected). The DM ECP Analyzer is acceptable for conducting automated audits of nutrition documentation to assess congruence of documented care with recommendations for evidence-based care. Future changes to the EBNPG, Nutrition Care Process Terminology, Academy of Nutrition and Dietetics Health Informatics Infrastructure, and the DM ECP Analyzer could potentially improve recommendation-level performance. The DM ECP Analyzer can be modified for other EBNPGs to facilitate automated assessment of guideline implementation.