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Malnutrition Among Hospitalized Adults: An Opportunity to Improve Care and Reduce Readmissions

Kristi Mitchell | Sep 26, 2016

For Malnutrition Awareness WeekTM, Avalere will be releasing a series of podcasts focused on new tools developed by the Malnutrition Quality Improvement Initiative (MQii) – a collaboration of the Academy of Nutrition and Dietetics, Avalere Health, and other organizations dedicated to improving nutrition care.


Kristi (Moderator):  

Welcome to today’s discussion.  I am Kristi Mitchell, a Senior Vice President at Avalere Health and a contributor to the Malnutrition Quality Improvement Initiative (MQii) - a collaboration of the Academy of Nutrition and Dietetics, Avalere Health, and other organizations dedicated to improving nutrition care. Joining me today to talk about malnutrition care and its impact on patients are Alison Steiber, Chief Science Officer at the Academy of Nutrition and Dietetics, and Beverly Hernandez, the Director of Clinical Nutrition at Tampa General Hospital. Alison served as an advisor to the development of the MQii and Beverly participated as a Learning Collaborative site that implemented and tested the MQii Toolkit.  

Thank you, Alison and Beverly for joining Avalere for the podcast today. We are excited to address this critically important topic, so let’s get started. 

Moderator - Kristi:

Alison, given your role as the Chief Science Officer for the Academy of Nutrition and Dietetics, can you paint us a picture of why addressing malnutrition in the U.S. is so important, and why our health industry should make it a national priority in improving care and outcomes?

Guest speaker - Alison: 

From studies on malnutrition and screening, an estimated 30-50% of hospitalized adult patients are malnourished in the U.S and internationally. However, only 3.2% of adult patients are discharged with an ICD-9 malnutrition diagnostic code, this gap between research estimates and actual medical diagnosis of malnutrition indicates a large gap and a major concern in the quality care of hospitalized patients.  

Studies by Agarwal and Lim, published in Clinical Nutrition, show us that malnourished patients cost more than patients with similar diseases who are well-nourished, demonstrating an independent and additive effect of malnutrition on negative outcomes. 

Kristi: Beverly, given the information Alison shared and your hospital’s recent participation in the Malnutrition Quality Improvement Initiative to improve malnutrition care at your hospital, can you offer your thoughts about the importance of addressing malnutrition for patients, clinicians, and for hospitals? 

Beverly: The importance of addressing malnutrition in the hospital setting cannot be overemphasized.  In 1974, Butterworth described malnutrition as "the skeleton in the hospital closet."  More contemporary studies contend that the skeleton is alive and (I like to say) possibly hiding in a unit near you causing negative health outcomes for our patients. Therefore, addressing malnutrition and providing the appropriate intervention should be a hospital goal.  It’s imperative that we do a deeper dive into how malnutrition impacts critical health outcomes and specific at risk populations. At Our hospital, the impact of malnutrition on these initiatives continues to spawn changes in our technologies that further drives practice changes which in turn positively influences patient care within the organization.

Kristi: Beverly, do you have any data or results to share that help depict the impact the MQii project has had at your facility for patients. Has your facility realized any financial impact? 

Beverly: Absolutely! As stated previously, we used the MQII to help us re-think our performance improvement (PI) strategies.  We developed new Epic-based PI reports that linked malnutrition to critical out comes and found the following: 

1) Discovered that 40% of patients over 65 were either documented with malnutrition or at risk for malnutrition. 

2) The ALOS for these patients was 17.8 days

3) The ALOS for Patients with infections was 15.7 days BUT if they were also malnourished it went up to 27 days 

4) The ALOS for patients with HAPU was 17.2 days BUT if they were also malnourished the ALOS increased to 42 days

5) We identified that 27% of malnourished patients were readmitted.  

No direct financial impact has been realized but:

1. Following the John Hopkins report on their team approach to malnutrition resulting in decreased LOS by 3.2 days decreasing our 27% readmissions alone would result in savings of over $489,000.  

Kristi:  Alison, considering the impact of improving malnutrition in our nation, in closing can you discuss the importance of addressing this gap in care at a national level. What is the potential impact? 

What you would like to see as next steps? 

Alison:  Our goal is to improve patient outcomes. To do this we must address the basics of assessment, diagnosis, appropriate and timely interventions and monitoring of outcomes. Unfortunately, in our national healthcare system today we have huge inconsistencies in how we do these four key steps in nutrition care. As stated in a recent NEJM article by Porter et al, "Health care is shifting focus from the volume of services delivered to the value created from patients with value defined as the outcomes achieved relative to the costs."  Currently in health care we have no consistent method all hospitals use to assess and diagnosis the problem of malnutrition. Therefore, we cannot measure improvement in outcomes and thus in value and cost for our patients. Health care must come together and mandate that all patients are screened with a validated malnutrition screening tool upon admission to the hospital, those patients at risk need to be seen by a RDN and have a comprehensive assessment for malnutrition - malnutrition must be diagnosed the same way in all facilities and then we can move to understanding which interventions are most effective in different patient populations and actually begin to improve outcomes. The creation and adoption of eMeasures focused on malnutrition could have a huge impact in health outcomes for hospitalized patients in the United States. This is why the eMeasures and Toolkit that have been released as part of the MQii are so important to be aware of.  They provide great resources for healthcare providers to begin tackling malnutrition in their hospitals.

Kristi: Thank you both, Alison and Beverly, for your insights today.  We appreciate everything you are doing to help give malnutrition care the attention it deserves.  For those that would like to learn more about optimal practices for malnutrition care and what you can do to improve malnutrition care for your patients, please visit the MQii web page at mqii.today.  

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