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Identifying and Treating Malnutrition Associated with Lower Readmission Rates

Summary

Avalere Health partnered with the Academy of Nutrition and Dietetics and other stakeholders for the Malnutrition Quality Improvement Initiative (MQii) designed to advance evidence-based, high-quality, and patient-driven care for hospitalized older adults who are malnourished or at risk for malnutrition.

As part of the MQii, the partnership launched a hospital learning collaborative–and developed a novel, interdisciplinary toolkit and set of electronic clinical quality measures–that is helping a growing number of hospitals nationwide implement quality improvements projects, track and monitor their progress, and ultimately improve clinical outcomes.

Disease-related malnutrition can too easily be overlooked as an underlying cause of adverse health outcomes and excess financial costs among hospitalized patients. Often upon admission, patients don’t present as obviously malnourished, especially if they are within a normal weight range or overweight. Consequently, while studies show up to 50% of admitted adults are at risk for or are malnourished, only 8% are diagnosed as such during their hospital stay. Yet malnourished adult inpatients have a 54% higher likelihood of hospital 30-day readmissions than those who are well nourished.

The primary objective of the Academy of Nutrition and Dietetics/Avalere malnutrition quality improvement study was to determine whether hospitals in a nutrition-focused learning collaborative could use real-world strategies to measurably improve malnutrition care processes. The secondary objective was to determine whether specific improvements in nutrition-related processes would affect patient outcomes, including 30-day hospital readmissions and length of stay (LOS).

Over the 7-year course of the MQii–from concept through piloting and expansion–both objectives were met. Due to its success, the initiative continues. Involved organizations hope to create the momentum necessary for providers and policymakers to incorporate malnutrition screening, diagnosis, and treatment as standard best practice.

At the time of reporting, the learning collaborative comprised 27 geographically diverse hospitals participating in the MQii, which incorporated a malnutrition quality improvement toolkit and the following 4 electronic clinical quality measures (eCQMs):

  • Screening for malnutrition risk at admission
  • Nutrition assessment when malnutrition risk was found
  • Documentation of malnutrition diagnoses if identified by assessment
  • Development of a nutrition care plan for malnourished patients

Also crucial to the MQii was patient monitoring and evaluation, as well as discharge planning to support ongoing care of patients leaving the hospital with nutrition plans. Data were collected on a total of 43,074 patients in 2017. Patients who were at least 65 years of age, with a LOS of at least 24 hours, and who received a nutrition screening proximal to their admission, were included in the study.

Improvements across all 4 eCQMs were observed. The greatest improvements resulted from timely nutrition assessment and malnutrition diagnosis. MQii findings also showed that patients over 65 with a malnutrition diagnosis and nutrition care plan had a longer mean LOS than those without a nutrition care plan (9.46 vs. 6.46 days), but they had a statistically significant 24% lower likelihood of 30-day hospital readmissions than those without a care plan.

In conclusion, this multi-hospital study involving more than 43,000 patients found that implementing MQii-supported processes significantly improved identification of malnutrition within a population of hospitalized elderly patients. Overall, this finding supports the position that aligning clinical best practices with the adoption of MQii -supported processes is effective at improving hospital nutrition care. Since there is a strong correlation between malnutrition and higher 30-day readmission rates and LOS, findings from this study further indicates that promptly identifying and effectively treating patients with nutritional risk may help improve patient outcomes, including reduced likelihood of hospital readmissions and, eventually, lower hospitalization costs.

Healthcare providers and systems across the nation agree that patient malnutrition is a serious underlying health issue that can compromise optimal outcomes. The MQii demonstrates the utility of instituting screening, diagnosis, and treatment best-practices for inpatients at risk for or currently malnourished to address 30-day readmissions, and potentially reduce hospitalization costs in the process by referring more of those identified patients for nutrition intervention. As hospitals apply the lessons learned from their quality improvement efforts, they have begun to pivot their focus to identifying the most effective interventions for patient subpopulations and providing post-discharge nutrition care for those discharged with malnutrition.

To improve patient health and outcomes and reduce the cost of care, providers, systems, and policymakers must pay close attention to malnutrition and consider incorporating malnutrition improvement best practices across the board.

For more information on the Academy of Nutrition and Dietetics/Avalere MQii and to join the initiative, please visit malnutritionquality.org.

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