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

Energy and protein intake threshold modelling using nutrition dashboard technology and sensitivity of hospital malnutrition identification

AIMS

Hospital food provision/intake dashboards may improve malnutrition screening. The aim of this study was to use Nutrition Dashboard data to determine the optimal threshold for screening for malnutrition risk, and compare the accuracy of this method with estimated dietary requirements.

METHODS

Observational data were extracted from medical files and food service records of 267 patients for a 4-month period in a 99-bed hospital. Energy (2500-8000 kJ) and protein (30-90 g) thresholds were applied for Nutrition Dashboard categorisation by supply and intake of food. Deficits in estimated requirements (105 kJ/kg/day and 0.75 g/kg/day) were also applied as a comparative method. The association between Nutrition Dashboard categories and the Malnutrition Screening Tool was explored using generalised estimating equations.

RESULTS

A total of 267 patients and 1908 days of data were analysed. The use of estimated requirements for Nutrition Dashboard categorisation was not a statistically significant predictor of malnutrition risk. Application of energy (≤6000 kJ) and protein (≤65 g) thresholds for categorisation was significant (χ2 = 9.50, df = 3, p = 0.023). When 5000 kJ and 55 g of protein were used for categorisation, patients were more likely to be at malnutrition risk when within low supply (odds ratio = 2.11, p = 0.002) and low intake (odds ratio 2.23, p < 0.001) categories.

CONCLUSIONS

Nutrition Dashboard categories are associated with an increased risk of malnutrition when categorised using thresholds of up to 6000 kJ and 65 g protein. Technologies like the Nutrition Dashboard present innovative opportunities for dietitians to utilise nutrition informatics to enhance and optimise nutrition care.

Nutritional screening on hospital admission and one-year clinical outcomes in a prospective cohort of older patients

BACKGROUND & AIMS

Malnutrition negatively affects the prognosis and quality of life of hospitalized patients. However, there are several gaps between evidence-based knowledge and current clinical practice. Our primary aim was to describe the prevalence of malnutrition risk in a cohort of in a cohort of older inpatients; secondly, we explored its predictors and its independent impact on 12-month survival.

METHODS

Prospective study focused on patients aged 65 years and older consecutively admitted for any reason to the acute geriatric and general medical units of an Italian university hospital. Comprehensive geriatric assessment data, including the short form of the Mini Nutritional Assessment (MNA-SF), were collected within 48 hours of admission. The prevalence of malnutrition and risk of malnutrition according to the MNA-SF represented the main outcome. Correlations among clinical variables, nutritional status, and one-year survival were analyzed using multivariable and Cox models.

RESULTS

Among 594 patients (median age: 84 years, 49.5 % female), mostly living at home with moderate functional autonomy, 82.3 % were identified as probably malnourished or at risk of malnutrition according to MNA-SF (39.9 % and 42.4 %, respectively). Malnutrition and the risk of malnutrition were positively associated with living alone at home (OR 2.803, 95%CI 1.567-5.177, p < 0.001), and negatively associated with autonomy in IADL (OR 0.765, 95%CI 0.688-0.846, p < 0.001) and the best performance at HST (OR 0.901, 95%CI 0.865-0.936; p < 0.001). After 12 months, 31.8 % of patients was dead and mortality was positively correlated with malnutrition according to MNA-SF (OR 2.493, 95%CI 1.345-4.751, p = 0.004), institutionalization (OR 2.815, 95%CI 1.423-5.693, p = 0.003) and severe cognitive impairment (OR 1.701, 95%CI 1.031-2.803, p = 0.036).

CONCLUSION

Malnutrition is common among older inpatients upon admission, primarily influenced by their functional and cognitive status, and it is linked to a worse prognosis. Early incorporation of thorough nutritional and functional assessments into clinical practice is crucial to improve prognosis prediction and enable timely, focused interventions targeting modifiable causal factors in a patient-centered approach.

Improving physician documentation for malnutrition: A sustainable quality improvement initiative

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

Malnutrition in older adults

Malnutrition is a highly prevalent condition in older adults, and poses a substantial burden on health, social, and aged-care systems. Older adults are vulnerable to malnutrition due to age-related physiological decline, reduced access to nutritious food, and comorbidity. Clinical guidelines recommend routine screening for malnutrition in all older adults, together with nutritional assessment and individually tailored nutritional support for older adults with a positive screening test. Nutritional support includes offering individualised nutritional advice and counselling; oral nutritional supplements; fortified foods; and enteral or parenteral nutrition as required. However, in clinical practice, the incorporation of nutritional guidelines is inadequate and low-value care is commonplace. This Review discusses the current evidence on identification and treatment of malnutrition in older adults, identifies gaps between evidence and practice in clinical care, and offers practical strategies to translate evidence-based knowledge into improved nutritional care. We also provide an overview of the prevalence, causes, and risk factors of malnutrition in older adults across health-care settings.

Interaction between malnutrition and physical disability in older adults: is there a malnutrition-disability cycle?

Malnutrition and physical disability are urgent issues in super-aging societies and the 2 phenomena are closely linked in older adults. Both conditions have common underlying causes, including physiological changes due to aging and burdens imposed by disease or injury. Accordingly, a concept of the malnutrition-disability cycle was generated and a comprehensive literature search was performed. There was insufficient evidence to prove an interrelationship between malnutrition and physical disabilities, because of the study design and poor quality, among other factors. However, some evidence exists for the interaction between low body mass index and swallowing disorders, and the effects of some malnutrition and disability components. This review provides the rationale for this interaction, the concept of a malnutrition-disability cycle is proposed, and the available evidence is critically appraise.

Implementation of an electronic solution to improve malnutrition identification and support clinical best practice

BACKGROUND

Routine malnutrition risk screening of patients is critical for optimal care and comprises part of the National Australian Hospital Standards. Identification of malnutrition also ensures reimbursement for hospitals to adequately treat these high-risk patients. However, timely, accurate screening, assessment and coding of malnutrition remains suboptimal. The present study aimed to investigate manual and digital interventions to overcome barriers to malnutrition identification for improvements in the hospital setting.

METHODS

Retrospective reporting on malnutrition identification processes was conducted through two stages: (1) manual auditing intervention and (2) development of a digital solution - the electronic malnutrition management solution (eMS). Repeated process audits were completed at approximately 6-monthly intervals through both stages between 2016 and 2019 and the results were analysed. In Stage 2, time investment and staff adoption of the digital solution were measured.

RESULTS

Overall, the combined effect of both regular auditing and use of the eMS resulted in statistically significant improvements across all six key measures: patients identified (97%-100%; p < 0.001), screened (68%-95%; p < 0.001), screened within 24 h (51%-89%; p < 0.001), assessed (72%-95%; p < 0.001), assessed within 24 h (66%-93%; p < 0.001) and coded (81%-100%; p = 0.017). The eMS demonstrated a reduction in screening time by over 60% with user adoption 100%. Data analytics enabled automated, real-time auditing with a 95% reduction in time taken to audit.

CONCLUSIONS

A single digital solution for management of malnutrition and automation of auditing demonstrated significant improvements where manual or combinations of manual and electronic systems continue to fall short.

Medical Nutrition Reimbursement in Singapore: Who Are the Patients Receiving MediFund Assistance? An Audit of Clinical Outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore

BACKGROUND

Financial reimbursement (MediFund) of medical nutrition products (MNPs) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy and the benefits conferred.

METHODS

We performed a 1-year retrospective audit of patients in a tertiary hospital who received MediFund. Demographics, presupport and postsupport clinical outcomes, and cost of support were determined and analyzed.

RESULTS

A total of 129 patients received MediFund for MNPs. The median length of financial support was 115 days (interquartile range, 37-269). Overall, body mass index increased after nutrition support (20.9 ± 5.1 vs 20.4 ± 5.3; P = .012). There was a significant decrease in the number of malnourished patients (final, 55.1% vs initial, 86.8%; P < .001) and a significant increase in 7-point subjective global assessment scores (final, 4.9 ± 1.3 vs initial, 4.1 ± 1.3; P < .001) after MNP support. MNP adherence was high for 88.5% of patients who returned for follow-up appointments. Patients who defaulted follow-up appointments were more likely to have 30-day readmission (50% vs 19.5%; P < .001) and had higher mortality rates (35.7% vs 10.3%; P < .001). Total reimbursement of S $108,960 was provided to subsidize MNPs over 1 year.

CONCLUSION

Supporting patients with financial difficulties led to an improvement in their nutrition status. Regular dietitian reviews of patients and monitoring compliance to consumption of MNPs are essential to ensure patients benefit from the support.