Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission

Validity of nutrition screening tools for risk of malnutrition among hospitalized adult patients: A systematic review and meta-analysis

BACKGROUNDS & AIMS

Malnutrition is prevalent among hospitalized patients in developed countries, contributing to negative health outcomes and increased healthcare costs. Timely identification and management of malnutrition are crucial. The lack of a universally accepted definition and standardized diagnostic criteria for malnutrition has led to the development of various screening tools, each with varying validity. This complicates early identification of malnutrition, hindering effective intervention strategies. This systematic review and meta-analysis aimed to identify the most valid and reliable nutritional screening tool for assessing the risk of malnutrition in hospitalized adults.

METHODS

A systematic literature search was conducted to identify validation studies published from inception to November 2023, in the Pubmed/MEDLINE, Embase, and CINAHL databases. This systematic review was registered in INPLASY (INPLASY202090028). The risk of bias and quality of included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2). Meta-analyses were performed for screening tools accuracy using the symmetric hierarchical summary receiver operative characteristics models.

RESULTS

Of the 1646 articles retrieved, 60 met the inclusion criteria and were included in the systematic review, and 21 were included in the meta-analysis. A total of 51 malnutrition risk screening tools and 9 reference standards were identified. The meta-analyses assessed four common malnutrition risk screening tools against two reference standards (Subjective Global Assessment [SGA] and European Society for Clinical Nutrition and Metabolism [ESPEN] criteria). The Malnutrition Universal Screening Tool (MUST) vs SGA had a sensitivity (95% Confidence Interval) of 0.84 (0.73-0.91), and specificity of 0.85 (0.75-0.91). The MUST vs ESPEN had a sensitivity of 0.97 (0.53-0.99) and specificity of 0.80 (0.50-0.94). The Malnutrition Screening Tool (MST) vs SGA had a sensitivity of 0.81 (0.67-0.90) and specificity of 0.79 (0.72-0.74). The Mini Nutritional Assessment-Short Form (MNA-SF) vs ESPEN had a sensitivity of 0.99 (0.41-0.99) and specificity of 0.60 (0.45-0.73). The Nutrition Universal Screening Tool-2002 (NRS-2002) vs SGA had a sensitivity of 0.76 (0.58-0.87) and specificity of 0.86 (0.76-0.93).

CONCLUSIONS

The MUST demonstrated high accuracy in detecting malnutrition risk in hospitalized adults. However, the quality of the studies included varied greatly, possibly introducing bias in the results. Future research should compare tools within a specific patient population using a valid and universal gold standard to ensure improved patient care and outcomes.

Energy Expenditure in Upper Gastrointestinal Cancers: a Scoping Review

Malnutrition is prevalent in people with upper gastrointestinal (GI) cancers and is associated with shorter survival and poor quality of life. In order to effectively prevent or treat malnutrition, nutrition interventions must ensure appropriate energy provision to meet daily metabolic demands. In practice, the energy needs of people with cancer are frequently estimated from predictive equations which are not cancer-specific and are demonstrated to be inaccurate in this population. The purpose of this scoping review was to synthesize the existing evidence regarding energy expenditure in people with upper GI cancer. Three databases (Ovid MEDLINE, Embase via Ovid, CINAHL plus) were systematically searched to identify studies reporting on resting energy expenditure using indirect calorimetry and total energy expenditure using doubly labeled water (DLW) in adults with any stage of upper GI cancer at any point from diagnosis. A total of 57 original research studies involving 2,125 individuals with cancer of the esophagus, stomach, pancreas, biliary tract, or liver were eligible for inclusion. All studies used indirect calorimetry, and one study used DLW to measure energy expenditure, which was reported unadjusted in 42 studies, adjusted for body weight in 32 studies, and adjusted for fat-free mass in 13 studies. Energy expenditure in upper GI cancer was compared with noncancer controls in 19 studies and measured compared with predicted energy expenditure reported in 31 studies. There was heterogeneity in study design and in reporting of important clinical characteristics between studies. There was also substantial variation in energy expenditure between studies and within and between cancer types. Given this heterogeneity and known inaccuracies of predictive equations in patients with cancer, energy expenditure should be measured in practice wherever feasible. Additional research in cohorts defined by cancer type, stage, and treatment is needed to further characterize energy expenditure in upper GI cancer.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

Reprint of: Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults

It is the position of the Academy of Nutrition and Dietetics that, based upon current evidence, the Malnutrition Screening Tool should be used to screen adults for malnutrition (undernutrition) regardless of their age, medical history, or setting. Malnutrition (undernutrition) screening is a simple process intended to quickly recognize individuals who may have a malnutrition diagnosis. While numerous malnutrition screening tools are in use, their levels of validity, agreement, reliability, and generalizability vary. The Academy of Nutrition and Dietetics reviewed the body of evidence supporting malnutrition screening tools and determined a single tool for identifying adults in all settings who may have malnutrition, regardless of their age or medical history. The Nutrition Screening for Adults Workgroup conducted a systematic review of the most robust evidence to promote using the highest-quality malnutrition screening tool available.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Impact of Malnutrition in Patients With Infective Endocarditis

BACKGROUND

Effects of malnutrition on patients with infective endocarditis (IE) have not been fully studied. Because malnutrition is associated with poor health, we hypothesized that among patients with IE, those with malnutrition would have more negative in-hospital outcomes.

METHODS

The National Inpatient Sample was used to identify adults ≥18 years old with IE. We compared outcomes of in-hospital mortality, morbidity, valvular interventions, and utilization of resources between individuals with and without malnutrition.

RESULTS

11,939 adults ≥18 years were hospitalized with IE, 2035 had a secondary diagnosis for malnutrition. There were no significant differences in age (mean age ± SEM: 55.6 ± 1.0 vs 54.3 ± 0.4 years, P = .21) or sex (female: 36.7%; 743/2,035 vs 37.5%; 3,717/9,904, P = .69) in patients with and without malnutrition. Patients with malnutrition had more comorbidities (Charlson comorbidity score ≥3: 36%; 732/2,035 vs 30.7%; 3,040/9,904, P = .04). Despite similar adjusted in-hospital mortality (adjusted odds ratio [aOR], 1.4; 95% CI, 0.8-1.5; P = .23), malnourished patients were more likely to develop sepsis (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) and had higher odds of mitral-valve (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) repairs/replacements. Patients with malnutrition also had increased lengths of stay (adjusted mean difference [aMD], 4.7 days; 95% CI, 2.9-6.5 days; P < .01) and hospital charges (aMD, $36,052; 95% CI, $14,935-$57,168; P < .01).

CONCLUSIONS

Patients with malnutrition and IE are at risk for high morbidity, valvular repairs/replacements, and use of hospital resources.

Assessment of the Nutrition Care Process in US Hospitals Using a Web-Based Tool Demonstrates the Need for Quality Improvement in Malnutrition Diagnosis and Discharge Care

Background: Malnutrition in hospitalized patients is a pervasive problem in the United States. To our knowledge, although malnutrition has been acknowledged as a concern for >40 y, it has not yet been well addressed with a systematic, process improvement approach. Objectives: We aimed to characterize the current nutrition care process in US hospitals to establish a baseline for improvements. We also aimed to demonstrate the application of a web-based quality improvement tool as a simple approach to address malnutrition in hospitalized patients. Methods: We established a web-based tool to measure and assess nutrition care practices from hospital electronic medical records. Individual institutions self-selected to participate and were assigned a unique identifier to input data. Aggregated patient data from registered institutions were assessed. Data from all institutions were combined and are presented as the totals for each variable. Results: Of 243 registered users, 97 provided data and 150 reports were included in the analysis, resulting in a total of 107,106 patients. Almost all patients (89.98%) were screened for malnutrition risk within 24 h of admission, and ∼30% were at risk for malnutrition. Of those at risk, ∼65% received a registered dietitian nutritionist consultation or an order for an oral nutrition supplement. The rate of malnutrition diagnosis for those at risk was ∼14%, and <10% of patients received a recommendation or prescription for an oral nutrition supplement at discharge. Conclusions: Malnutrition remains an issue for hospitalized patients, particularly the gap between those screened as at risk and those diagnosed with malnutrition. Moreover, discharge recommendations for patients who are screened as at risk for malnutrition are also lacking. These data demonstrate that a web-based quality improvement tool could be used to capture the nutrition care practice at an institution level to provide directed approaches for addressing hospital malnutrition and improving care of patients at risk for malnutrition.

Sarcopenia predicts readmission and mortality in elderly patients in acute care wards: a prospective study

BACKGROUND

The aim of this study is to assess the prevalence of sarcopenia and investigate the associations between sarcopenia and long-term mortality and readmission in a population of elderly inpatients in acute care wards.

METHODS

We conducted a prospective observational study in the acute care wards of a teaching hospital in western China. The muscle mass was estimated according to a previously validated anthropometric equation. Handgrip strength was measured with a handheld dynamometer, and physical performance was measured via a 4 m walking test. Sarcopenia was defined according to the recommended diagnostic algorithm of the Asia Working Group for Sarcopenia. The survival status and readmission information were obtained via telephone interviews at 12, 24, and 36 months during the 3 year follow-up period following the baseline investigation.

RESULTS

Two hundred and eighty-eight participants (mean age: 81.1 ± 6.6 years) were included. Forty-nine participants (17.0%) were identified as having sarcopenia. This condition was similar in men and women (16.9% vs. 17.5%, respectively, P = 0.915). During the 3 year follow-up period, 49 men (22.7%) and 9 women (16.4%) died (P = 0.307). The mortality of sarcopenic participants was significantly increased compared with non-sarcopenic participants (40.8% vs. 17.1%, respectively, P < 0.001). After adjusting for age, sex and other confounders, sarcopenia was an independent predictor of 3 year mortality (adjusted hazard ratio: 2.49; 95% confidential interval: 1.25-4.95) and readmission (adjusted hazard ratio: 1.81; 95% confidential interval: 1.17-2.80).

CONCLUSIONS

Sarcopenia, which is evaluated by a combination of anthropometric measures, gait speed, and handgrip strength, is valuable to predict hospital readmission and long-term mortality in elderly patients in acute care wards.

The Indigenous Australian Malnutrition Project: the burden and impact of malnutrition in Aboriginal Australian and Torres Strait Islander hospital inpatients, and validation of a malnutrition screening tool for use in hospitals-study rationale and protocol

BACKGROUND

Malnutrition is associated with adverse outcomes for hospital inpatients and is a significant economic burden on hospitals. Malnutrition is frequently under-recognised in this setting and valid screening and early diagnosis are important for timely nutritional management. Aboriginal Australian and/or Torres Strait Islander peoples (Indigenous Australians) are likely to be at increased risk of malnutrition due to their disproportionate burden, pattern and age-distribution of chronic diseases. Despite this increased risk, the burden and impact of malnutrition in Indigenous Australians is poorly understood. Furthermore, a suitable screening tool has not been validated for this vulnerable patient group. The aim of this study is to determine the burden of malnutrition, understand its impact, and validate a malnutrition screening tool for Indigenous Australian inpatients.

METHODS

This project involves cross-sectional, prospective cohort and diagnostic validation methodologies to assess the burden and impact of malnutrition and to validate a malnutrition screening tool. A target of 752 adult Indigenous and non-Indigenous Australian inpatients will be recruited across three different public hospitals in the Northern Territory and far north Queensland of Australia. Cross-sectional data collection will be used to determine the prevalence of malnutrition using the Subjective Global Assessment and to stratify participants based on the International Consensus Guideline Committee malnutrition aetiology-diagnostic framework. Subjects will then be followed prospectively to measure short and long-term health outcomes such as length of hospital stay, in-hospital mortality, 30-day and 6-month readmission rates. Finally, the utility of a new screening tool, the Australian Nutrition Tool, will be assessed against an existing screening tool, the malnutrition screening tool, used in these settings and the malnutrition reference standard, the Subjective Global Assessment.

DISCUSSION

Indigenous Australians continue to experience poorer levels of health than non-Indigenous Australians and issues such as food insecurity, poor diet, and a disproportionate burden of chronic disease play a key contributing role for malnutrition in Indigenous Australians. To improve the health and hospital outcomes of Indigenous and non-Indigenous Australians, it is important that patients are routinely screened using a validated screening tool. It is also imperative that the burden and impact of malnutrition is properly understood, and fully appreciated, so that early and appropriate nutritional management can be provided to this group of hospital patients.

Scores of nutritional risk and parameters of nutritional status assessment as predictors of in-hospital mortality and readmissions in the general hospital population

BACKGROUND & AIMS

We have no "gold standard" for the diagnosis of malnutrition. The aim of this study was to determine the importance of many of the parameters used in nutritional status screening and assessment among inpatients for the prediction of in-hospital mortality, readmission and length of hospitalization.

METHODS

On the base of the medical documentation a retrospective analysis was performed of nutritional status screening and assessment parameters for all 20,237 non-selected, consecutive hospitalizations in 15,013 patients over 18 years of age treated in one hospital during the course of one year.

RESULTS

The risk of malnutrition expressed as a Nutritional Risk Screening (NRS)-2002 score ≥ 3 concerned 6.4% hospitalizations. The greater risk of in-hospital death, as well as readmission within 14 days and 30 days, was related to an NRS-2002 score ≥3, age >65 years, male gender, urgent admission, body mass deficit calculated as the difference between actual body mass and ideal weight determined according to the Lorentz formula, higher degree of Instant Nutritional Assessment (INA), greater value of a C-reactive protein (CRP)/albumin ratio, and plasma glucose concentration. Whereas, greater blood concentration of albumin, hemoglobin, cholesterol and triglycerides, as well as a greater blood lymphocyte count, were associated with reduced risk of the measured outcomes.

CONCLUSIONS

NRS-2002 score, blood albumin, CRP/albumin ratio, and INA seem to be good predictors of in-hospital mortality, readmission rate and length of hospital stay.