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Leveraging Inpatient Malnutrition Care to Address Health Disparities

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Malnutrition is a complex and burdensome condition that is often connected to social determinants of health—including food insecurity—that can widen disparities in health outcomes.

Screening for and identifying malnutrition can help flag individuals who may be food insecure. Similarly, identifying food insecurity may suggest the presence or risk of malnutrition. Given that hospitals have the infrastructure, workflow, and trained clinicians to conduct these screenings, they are the optimal setting of care for identification of both malnutrition and food insecurity, particularly given the acute population they serves.

Routine use of a malnutrition care process, as measured by the National Quality Forum (NQF)-endorsed Global Malnutrition Composite Score, allows hospitals to:

  • Identify patients who are malnourished or at risk of malnutrition and who may also require screening for food insecurity
  • Develop a care plan reflecting patients’ nutrition needs, document appropriate diagnoses for next-in-line providers, and initiate treatments
  • Provide support to access community-based resources following their discharge

The Burden of Malnutrition and Food Insecurity

Malnutrition is an increasingly concerning health issue in the US. The Agency for Healthcare Research and Quality estimates that malnutrition affects more than 30% of hospitalized patients, but only 9% of discharged patients had a coded malnutrition diagnosis in 2018. According to a recent study in Nutrition in Clinical Practice, unaddressed malnutrition (whether unidentified or untreated) can worsen health outcomes and increase risk of readmissions and costs of care. Compared to patients without a clinical diagnosis of malnutrition, patients with malnutrition experienced:

  • Longer length of stay: 9.0 vs. 4.7 days
  • Higher hospitalization costs: $23,579 vs. $13,610 per stay; accounting for 13.2% of total aggregate costs but only 8.9% of patients
  • Higher readmission rates: 89.2% vs. 77.2%
  • Higher in-hospital mortality: 3.4 times greater

Food insecurity is connected with malnutrition and has a multi-dimensional effect on health through factors including overconsumption of nutrient-poor foods, underconsumption of nutrient-dense foods, and stress. These factors contribute to diseases such as obesity or diabetes, which also worsen outcomes for comorbid conditions. In 2020, 10.5% of US households were food insecure at some point. Further, prevalence differs significantly by household characteristics; non-Hispanic Black, Hispanic, low-income, and rural households, and households headed by single parents and containing children are more likely to be food insecure. Older adults are at particularly high risk for food insecurity, yet less than 50% of older adults who quality for the federal Supplemental Nutrition Assistance Program are enrolled and participate.

The COVID-19 pandemic has exacerbated malnutrition directly through reduced access to healthcare and indirectly through increased food insecurity and additional social needs driven by isolation, underemployment, rising prices of consumer goods, and other reasons.

Disparities in Malnutrition Identification, Diagnosis, and Outcome

While malnutrition occurs in people of all backgrounds and settings, the burden is not distributed equally. Social risk factors and existing chronic conditions increase malnutrition risk, disproportionately burdening vulnerable populations. In an analysis of 2019 data from the Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative (see Figures 1 and 2), which now reflects more than 1.5 million patient records from hospitals across the US, Avalere found substantial disparities in malnutrition diagnoses and readmissions. For example, non-Hispanic Black individuals with malnutrition experienced a readmission rate of more than 26%, while the rate was less than 19% among non-Hispanic White individuals. Further disparities are also reflected in the rates of malnutrition diagnoses provided by registered dietitian nutritionists (RDNs) as compared to those by medical doctors (MDs; see Figure 2).

Figure 1. Malnutrition Readmissions Stratified by Race/Ethnicity
Figure 1. Malnutrition Readmissions Stratified by Race/Ethnicity

Data sourced from analysis of aggregated data from MQii Learning Collaborative participating facilities.

Figure 2. Malnutrition Diagnosis Rates by RDNs vs. MDs Stratified by Race/Ethnicity
Figure 2. Malnutrition Diagnosis Rates by RDNs vs. MDs Stratified by Race/Ethnicity

Data sourced from analysis of aggregated data from MQii Learning Collaborative participating facilities.

Alleviating Malnutrition and Addressing Health Disparities Through Quality Measurement

Quality measures are an important tool to evaluate provider performance and drive healthcare improvement. The Global Malnutrition Composite Score is an NQF-endorsed electronic composite measure to identify and manage malnutrition in hospitalized adults. Increasing the use of malnutrition-related quality measurement in the inpatient setting can better enable:

  • Identification of patients with nutrition risks who may require additional screening for food insecurity
  • Provision of early and effective interventions for patients with malnutrition and food insecurity
  • Documentation of provider concerns regarding malnutrition and food insecurity for transmission to the next-in-line provider
  • Referral for additional evaluation by a RDN and connection to resources post-discharge, such as prescriptions for food pharmacies, access to meal boxes, home-delivered meals, and connection to community-based organizations addressing nutrition needs

Implementing and tracking nutrition-focused quality measures in the hospital can help reduce disparities in accessing healthy food and healthcare following discharge and begin to address associated worsened patient outcomes. Figure 3 illustrates a recommended workflow to screen for and address food insecurity and malnutrition risk in the clinical setting in which quality measurement can be integrated.

Figure 3. Food Insecurity and Nutrition Risk Screening Workflow
Figure 3. Food Insecurity and Nutrition Risk Screening Workflow

Image sourced from MQii Food Insecurity and Nutrition Risk Screening Resources.

Examples of Success in Improving Malnutrition Care & Addressing Food Insecurity

Committed to improving malnutrition care delivery, MQii Learning Collaborative members are undertaking innovative nutrition initiatives to improve health and advance equity; 2 examples are described in Figure 4.

Figure 4. Example Initiatives Addressing Malnutrition and Food Insecurity
Figure 4. Example Initiatives Addressing Malnutrition and Food Insecurity

New Hanover Regional Medical Center

Uncovered gaps in post-discharge nutrition care for malnourished patients, indicated by high readmissions and food insecurity prevalence, after introducing malnutrition measures to track care delivery.

Implemented Malnutrition Transitions of Care Program, which included:

  • Adding malnutrition and food insecurity screenings in clinical workflow
  • Targeting at-risk adults for intervention

Intervention includes post-discharge food box for food insecure patients and a home visit by an outreach dietitian for malnourished patients.

Promising results for patients who received the intervention included:

  • 24% lower readmission rates after 1 year
  • Significantly lower healthcare utilization and costs

Legacy Health Salmon Creek

Pursuit of more accurate measurement of malnutrition prevalence among hospital patients revealed need for nutrition department to develop post-discharge intervention.

Implemented a pilot month-long meal-delivery program for malnourished patients.

Intervention includes end-of-month in-home checkups alongside the weekly meal-delivery.

Promising results included:

  • Increased strength and improved health among all patients
  • High patient satisfaction with delivered meals

Aims to expand reach by scaling program and implementing it in other Legacy Health facilities.

The success of these hospitals in implementing comprehensive, patient-centered programs demonstrates the value of identifying risk early, providing coordinated care, and addressing upstream social factors to improve health outcomes.

Key Takeaways for Advancing Health Equity Through Malnutrition Care

Lack of recognition of malnutrition and food insecurity by providers is worsening the health needs of various patient populations and exacerbating health inequities. Integrating quality measurement and thoughtful nutrition care in the clinical setting can promote the identification and treatment of malnutrition and food insecurity, and ultimately improve health outcomes.

The Academy of Nutrition and Dietetics has been at the center of developing solutions for malnutrition care for more than a decade, including stewarding the Global Malnutrition Composite Score. In addition, the Academy has focused efforts to advance health equity and mitigate food insecurity through RDNs working in population health settings. As the Centers for Medicare and Medicaid Services, private payers, and other key healthcare stakeholders consider opportunities to address health inequities, tackling nutrition needs through expanded malnutrition measurement may help fill gaps in understanding and providing access to nutrition resources. Examples include:

  • Improving meaningful and effective nutrition data collection and analysis
  • Convening to share experiences and leverage successes in improving quality nutrition care
  • Collaborating with community-based organizations to implement pilot studies to generate evidence about effective nutrition interventions across care transitions

Avalere has robust experience working with a variety of healthcare stakeholders to improve quality of care and advance health equity in the nutrition space and beyond, including as a measure developer. Our team brings extensive expertise in quality and value, data analysis, clinical and public health nutrition, and food and health policy. To receive Avalere updates and learn how we support clients in quality improvement, connect with us.

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