Impact of an interdisciplinary malnutrition quality improvement project at a large metropolitan hospital

Dietitians as innovators: a deductive-inductive qualitative analysis

BACKGROUND

Frontline health professionals are well-placed to develop and implement beneficial innovations. Evidence supports the clinical and financial benefits of Registered Dietitian (RD)-led improvement initiatives, but we know little about how RDs perceive of innovation or of themselves as innovators. The objectives of the study were to gain an understanding of: 1) how RDs define innovation; 2) who RDs perceive as innovative; 3) whether RDs feel prepared to innovate, and; 4) to what extent work context impacts RDs' capacity to innovate at work.

METHODS

All RDs employed in Canada were eligible to participate. Semi-structured interviews were conducted and a deductive-inductive approach was applied to qualitative analysis. Specifically, Scott & Bruce's (1994) Path Model of Individual Innovation in the Workplace was first applied as a coding structure.

RESULTS

Respondents (n = 18) exhibited a pro-innovation disposition and a gendered perception of innovation. Few felt their preparatory education prepared them to be innovators in the workplace. All components of Scott & Bruce's model were supported. Inductive codes were categorized into five themes, including: benefits, dietetics-specific, health care system, technology and individual characteristics.

CONCLUSIONS

Researchers have previously raised concerns about gendered perceptions of innovation; our results support the legitimacy of these concerns. RDs reported entering the workforce unprepared to be innovative. While the applicability of Scott & Bruce's model among RDs was confirmed, deficits in the model were noted beyond what would be expected due to context.

Predictive Feasibility of the Graz Malnutrition Screening, Controlling Nutritional Status Score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index for Postoperative Long-Term Mortality After Surgically Treated Proximal Femur Fracture

BACKGROUND

Hip fractures are a prevalent and serious health issue, particularly among the elderly population aged >65 years. These injuries are associated with elevated rates of postoperative complications and mortality, significantly diminishing patients' quality of life in both the short- and long-term. The prognosis for recovery is further exacerbated in individuals with signs of malnutrition. The primary objective of this study was to evaluate the predictive value of four distinct nutritional assessment scores in relation to postoperative mortality in patients undergoing surgical intervention for hip fractures at 1, 3, 6, 12, and 24 months.

METHODS

This observational study included patients admitted to the Department of Traumatology at the Medical University for the surgical management of hip fractures between January 2019 and November 2021. Nutritional assessment scores were derived from a retrospective analysis of clinical data. The statistical correlation between nutritional scores and postoperative mortality outcomes was rigorously evaluated.

RESULTS

Logistic regression analysis revealed a statistically significant correlation (p < 0.01) between all four nutritional scores and postoperative mortality risk. The malnourished cohorts demonstrated a markedly higher risk of mortality compared to those with adequate nutritional status, as indicated by the following risk ratios: Graz Malnutrition Screening (risk ratio = 2.53-1.68), Prognostic Nutritional Index (risk ratio = 2.44-1.74), Geriatric Nutritional Risk Index (risk ratio = 2.05-1.58), and Controlling Nutritional Status (risk ratio = 2.34-1.46). Despite these findings, the receiver operating characteristic analysis yielded area under the curve (AUC) values ranging from 0.64 to 0.68, indicating limited predictive power.

CONCLUSIONS

Although a significant correlation existed between the evaluated nutritional scores and postoperative mortality, the predictive value of these scores was quantitatively low. No single nutritional assessment tool has emerged as a strong predictor of postoperative outcomes in this patient population. Consequently, implementation of any specific nutritional screening tool for standard assessment in patients with hip fractures is not recommended at this time. Nevertheless, given the established association between malnutrition and postoperative mortality, a comprehensive evaluation of nutritional status is advisable and further research is needed.

Impact of nutrition interventions for malnourished patients: Introduction to health economics and outcomes research with findings from nutrition care studies

Healthcare systems and patients today are challenged by high and ever-escalating costs for care. With increasing costs and declining affordability, public and private healthcare payers are all seeking value in care. As the evidence regarding health benefits of nutrition products and interventional nutrition care is increasing, cost-effectiveness of these interventions needs consideration. Health economics and outcomes research (HEOR) examines the value of healthcare treatments, including nutrition interventions. This review summarizes how HEOR tools are used to measure health impact, that is, the burden of illness, the effect of interventions on the illness, and the value of the nutrition intervention in terms of health and cost outcomes. How studies are designed to compile data for economic analyses is briefly discussed. Then, studies that use HEOR methods to measure efficacy, cost-effectiveness, and cost savings from nutrition care across the healthcare spectrum-from hospitals to nursing homes and rehabilitation centers, to care for community-living individuals, with an emphasis on individuals who are older or experiencing chronic health issues-are reviewed. Overall, findings from HEOR studies over the past decade build considerable evidence to show that nutrition care improves the health of at-risk or malnourished patients effectively and at a reasonable cost. As such, the evidence suggests that nutrition care brings value to healthcare across multiple settings and populations.

2024 Peggi Guenter excellence in clinical practice lectureship: From curiosity and eagerness to passion: Moving the malnutrition needle

Most every new clinician practicing in nutrition support enters their practice environment with wide open eyes and a sense of curiosity as they encounter new patient and clinical experiences. As clinicians expand their expertise, they often identify challenges they are eager to address. Eagerness turns to passion as the desire to affect change grows. Malnutrition has sparked curiosity and interest in many, and, in some, it has become a passion. As a result, many major achievements have occurred both in the United States and globally that have the capability of moving the needle favorably to achieve better outcomes for our patients. This lecture will highlight how curiosity, eagerness, and passion have led to successes in addressing aspects of malnutrition. These successes offer the structure to continue our efforts to move the needle forward. Our patients deserve nothing more.

Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis

BACKGROUND

Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas.

METHODS

Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay.

RESULTS

3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001).

CONCLUSIONS

Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Predicting malnutrition from longitudinal patient trajectories with deep learning

Malnutrition is common, morbid, and often correctable, but subject to missed and delayed diagnosis. Better screening and prediction could improve clinical, functional, and economic outcomes. This study aimed to assess the predictability of malnutrition from longitudinal patient records, and the external generalizability of a predictive model. Predictive models were developed and validated on statewide emergency department (ED) and hospital admission databases for California, Florida and New York, including visits from October 1, 2015 to December 31, 2018. Visit features included patient demographics, diagnosis codes, and procedure categories. Models included long short-term memory (LSTM) recurrent neural networks trained on longitudinal trajectories, and gradient-boosted tree and logistic regression models trained on cross-sectional patient data. The dataset used for model training and internal validation (California and Florida) included 62,811 patient trajectories (266,951 visits). Test sets included 63,997 (California), 63,112 (Florida), and 62,472 (New York) trajectories, such that each cohort’s composition was proportional to the prevalence of malnutrition in that state. Trajectories contained seven patient characteristics and up to 2,008 diagnosis categories. Area under the receiver-operating characteristic (AUROC) and precision-recall curves (AUPRC) were used to characterize prediction of first malnutrition diagnoses in the test sets. Data analysis was performed from September 2020 to May 2021. Between 4.0% (New York) and 6.2% (California) of patients received malnutrition diagnoses. The longitudinal LSTM model produced the most accurate predictions of malnutrition, with comparable predictive performance in California (AUROC 0.854, AUPRC 0.258), Florida (AUROC 0.869, AUPRC 0.234), and New York (AUROC 0.869, AUPRC 0.190). Deep learning models can reliably predict malnutrition from existing longitudinal patient records, with better predictive performance and lower data-collection requirements than existing instruments. This approach may facilitate early nutritional intervention via automated screening at the point of care.

Healthcare Resource Utilization and Cost Comparisons of High-Protein Enteral Nutrition Formulas Used in Critically Ill Patients

Background: High-protein enteral nutrition is advised for patients who are critically ill. Options include immunonutrition formulas of various compositions and standard high-protein formulas (StdHP). Additional research is needed on the health economic value of immunonutrition in a broad cohort of severely ill hospitalized patients. Objective: The study goal was to compare healthcare resource utilization (HCRU) and cost between immunonutrition and StdHP using real-world evidence from a large US administrative database. Methods: A retrospective cohort study was designed using the PINC AI™ Healthcare Database from 2015 to 2019. IMPACT® Peptide 1.5 (IP) was compared with Pivot® 1.5 (PC), and StdHP formulas. Inclusion criteria comprised patients age 18+ with at least 1 day's stay in the intensive care unit (ICU) and at least 3 out of 5 consecutive days of enteral nutrition. Pairwise comparisons of demographics, clinical characteristics, HCRU, and costs were conducted between groups. Multivariable regression was used to assess total hospital cost per day associated with enteral nutrition cohort. Results: A total of 5752 patients were identified across 27 hospitals. Overall, a median 7 days of enteral nutrition was received over a 16-day hospital and 10-day ICU stay. Median total and daily hospital costs were lower for IP vs PC ($71 196 vs $80 696, P<.001) and ($4208 vs $4373, P=.019), with each higher than StdHP. However, after controlling for covariates such as mortality risk, surgery, and discharge disposition, average total hospital cost per day associated with IP use was 24% lower than PC, and 12% lower than StdHP (P<.001). Readmissions within 30 days were less frequent for patients receiving IP compared with PC (P<.02) and StdHP (P<.001). Discussion: Choice of high-protein enteral nutrition for patients in the ICU has implications for HCRU and daily hospital costs. Considering these correlations is important when comparing formula ingredients and per unit costs. Among the enteral nutrition products studied, IP emerged as the most cost-saving option, with lower adjusted hospital cost per day than PC or StdHP. Conclusions: Using a select immunonutrition formula for critically ill patients may provide overall cost savings for the healthcare system.

Individual-Level Factors are Significantly More Predictive of Employee Innovativeness Than Job-Specific or Organization-Level Factors: Results From a Quantitative Study of Health Professionals

Individual innovativeness is particularly indispensable among health professionals. The healthcare environment is complex and its knowledge workers must continually adapt to change and be comfortable with ambiguity. The objective of this study was to determine the relative importance of individual, job-specific, and organizational factors on innovative output of health professionals. Employed Canadian Registered Dietitians (n = 237) completed an online survey incorporating relevant validated tools, including the 10-item Big Five Inventory and the Alberta Context Tool. Factors were classified by level and introduced in blocks to a multivariate linear regression model, with the outcome of self-reported innovative output. Factors included in the model explained 44% of variation in self-reported innovative output. Although all blocks contributed significantly to the model, minimal variation was explained by factors at the job-specific (4%) and organizational levels (4%). Factors at the individual level most predictive of innovative output were role innovation, the personality trait of conscientiousness and voluntary membership in a professional association. To encourage employee innovativeness, health administrators, and managers of health professionals should consider how best to incorporate screens for individual-level indicators of innovative output (eg, personality tests) in their institutional hiring and selection processes.

Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management

Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting.

Serum Leptin Levels, Nutritional Status, and the Risk of Healthcare-Associated Infections in Hospitalized Older Adults

We aimed to determine whether serum leptin levels are predictive of the occurrence of healthcare-associated infections (HAIs) in hospitalized older patients. In a prospective cohort, 232 patients had available data for leptin and were monitored for HAIs for 3 months. Admission data included comorbidities, invasive procedures, the Mini Nutritional Assessment (MNA), BMI, leptin, albumin and C-reactive protein levels, and CD4 and CD8 T-cell counts. Multivariate logistic regression modelling was used to identify predictors of HAIs. Of the 232 patients (median age: 84.8; females: 72.4%), 89 (38.4%) experienced HAIs. The leptin level was associated with the BMI (p < 0.0001) and MNA (p < 0.0001) categories. Women who experienced HAIs had significantly lower leptin levels than those who did not (5.9 μg/L (2.6–17.7) and 11.8 (4.6–26.3), respectively; p = 0.01; odds ratio (OR) (95% confidence interval): 0.67 (0.49–0.90)); no such association was observed for men. In a multivariate analysis of the women, a lower leptin level was significantly associated with HAIs (OR = 0.70 (0.49–0.97)), independently of comorbidities, invasive medical procedures, and immune status. However, leptin was not significantly associated with HAIs after adjustments for malnutrition (p = 0.26) or albuminemia (p = 0.15)—suggesting that in older women, the association between serum leptin levels and subsequent HAIs is mediated by nutritional status.

Opportunities to Improve Quality Outcomes: Integrating Nutrition Care Into Medicare Advantage to Address Malnutrition and Support Social Determinants of Health

Medicare Advantage (MA) is a public-private healthcare program for older adults and individuals with disabilities in the United States (US). MA enrollees receive their benefits from private health plans and the percentage of Medicare beneficiaries in MA plans continues to increase. MA plan enrollees typically have more socioeconomic risk factors compared to traditional Medicare enrollees. The COVID-19 pandemic has highlighted the importance of MA plans' flexibilities to address socioeconomic risk factors, or social determinants of health (SDOH), and to tailor benefits and services to meet individual MA enrollee needs. Poor nutrition-often termed malnutrition or protein calorie malnutrition-is a problem for many Medicare beneficiaries. Malnutrition can prolong recovery and increase medical complications and readmissions. Up to half of older Americans are at risk for malnutrition or are malnourished. Nutrition-related supplemental benefits offered by MA plans can most effectively help address malnutrition and impact SDOH and quality outcomes as part of multi-modal interventions. Multi-modal interventions integrate quality nutrition care throughout the MA care process. This Editorial explores the issue of older adult malnutrition and SDOH and the nutrition-related supplemental benefits currently offered by MA plans. It also identifies opportunities for further nutrition benefit development and impact, including through integration in MA outcome measurements and quality frameworks.

Nutrition Care for Poorly Nourished Outpatients Reduces Resource Use and Lowers Costs

Background and Objectives:

Over 25% of United States (US) community-dwelling, older adults are at nutritional risk. Health and cost burdens of poor nutrition can be lowered by nutrition programs for hospital inpatients, but few studies have looked at the impact on outpatients. The objective of our study was to assess outcomes of a nutrition focused quality improvement program (QIP) on healthcare resource use and costs in poorly nourished outpatients.

Methods:

This pre-post QIP study was implemented at 3 US healthcare system clinics. Included patients (n = 600) were ≥45 years old, had ≥2 chronic conditions, and were enrolled over a 15-month interval. For comparison, historical (n = 600) and concurrent control (n = 600) groups were used. Assessment of poor nutritional status was performed during each patient’s baseline visit. Healthcare resource use (hospitalizations, emergency department visits, and outpatient clinic visits), medication use, and costs were determined for a 90-day interval.

Results:

QIP patients (mean age 61.6 years) were predominantly female (62.5%) and overweight/obese (81.7%). The proportion of QIP outpatients presenting for healthcare services was significantly reduced compared to both historical and concurrent controls—relative risk reduction (RRR) versus historical (11.6%, P < .001) and versus concurrent (8.9%, P = .003). Of those who presented, RRR for healthcare resource use by QIP was significant in comparison with historical (12.9%, P = .022) but not concurrent controls. No significant differences were observed for medication usage. Lower resource use among QIP patients yielded total cost savings of $290 923 or per-patient savings of $485.

Conclusions:

Nutrition QIPs in outpatient clinics are feasible and can reduce healthcare resource use and cut costs. Such findings underscore benefits of nutritional interventions for community-dwelling outpatients with poor nutritional status.

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.

Implementation of malnutrition quality improvement reveals opportunities for better nutrition care delivery for hospitalized patients

BACKGROUND

Gaps in hospital-based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services.

METHODS

Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019.

RESULTS

Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001).

CONCLUSIONS

The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.

Opportunities for Quality Improvement Programs (QIPs) in the Nutrition Support of Patients with Cancer

Malnutrition in patients with cancer is a ubiquitous but neglected problem that can reduce patient survival/quality of life and increase treatment interruptions, readmission rates, and healthcare costs. Malnutrition interventions, including nutrition support through dietary counseling, diet fortification, oral nutrition supplements (ONS), and enteral and parenteral nutrition can help improve health outcomes. However, nutritional care standards and interventions for cancer are ambiguous and inconsistently applied. The lack of systematic malnutrition screening and intervention in ambulatory cancer care has especially significant consequences and thus the nutrition support of patients with cancer represents an area for quality improvement. United States healthcare payment models such as the Oncology Care Model are linked to quality of care and health outcomes. Quality improvement programs (QIPs) can advance patient-centered care, perfect care processes, and help healthcare professionals meet their quality measure performance goals. Malnutrition QIPs like the Malnutrition Quality Improvement Initiative (MQii) have been shown to be effective in identifying and treating malnutrition. However, little is known about or has been reported on nutrition or malnutrition-focused QIPs in cancer care. This paper provides information to support translational research on quality improvement and outlines the gaps and potential opportunities for QIPs in the nutrition support of patients with cancer.