Malnutrition and Quality Improvement

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Tune into another episode of Avalere Health Essential Voice. In this segment of our Disease Education series, experts from our Center for Healthcare Transformation discuss the burden of malnutrition on our healthcare system and how an Avalere-led quality improvement initiative has helped systems across the country improve malnutrition identification and treatment.
“Malnutrition cuts across disease areas, ages, and settings of care. It could be experienced by patients with liver disease, kidney disease, or stroke, for example, and it's experienced by patients ranging from those in the ICU to those dwelling at home.” Christina Badaracco


Angel Valladares , Consultant II

Angel Valladares provides strategic guidance and implementation support for various healthcare stakeholders, specifically on digital health, real-world evidence generation, quality measure development and adoption, and patient and provider engagement.

Christina Badaracco , Research Scientist II, Evidence & Strategy

Christina Badaracco advises clients on quality landscape developments, healthcare quality improvement, performance measurement, and supplemental benefits.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.

If you would like to watch the video version, please visit our video page.


Angel: Hello and welcome to another episode of the Avalere Health Essential Voice Disease Education Series. In this series we’ll be covering topics on a wide range of therapeutic focus areas. My name is Angel Valladares, and I am a Consultant in the Center for Healthcare Transformation at Avalere Health. I am joined today by Christina Badaracco, who is a Research Scientist I and registered dietitian, also in the Center.

In today’s episode, we will discuss the burden of malnutrition on our healthcare system and how our Avalere-led initiative, the Malnutrition Quality Improvement Initiative, or MQii, has helped systems across the country improve malnutrition identification and treatment.

Thanks for joining me today, Christina. Can you paint a picture of what clinical malnutrition looks like and its impact on hospitalized patients?

Christina: Sure, Angel. Malnutrition is a condition in which the diet doesn’t provide enough nutrients or the right balance of nutrients for optimal health. So, it can be manifested as undernutrition, often associated with wasting or diseases caused by nutrition deficiencies, and overnutrition, often associated with obesity and different metabolic diseases, or even a combination of the two. It can affect people of all ages, but it’s especially concerning and prevalent among older adults.

So, malnutrition is caused by many different factors. It could be due to progression of catabolic diseases such as cancer, a nutrient-poor diet, insufficient screening by clinicians, lack of awareness and knowledge among physicians about the importance of nutrition for health and how to improve diets, and many other reasons. Between about 20% and up to 50% of hospitalized patients are thought to be malnourished or at risk, but only about 8% receive a medical diagnosis of malnutrition. That gap indicates that there are many, many undiagnosed and untreated patients.

We also know that about a third of patients experienced nutritional decline during their hospital stays, which could be due to too much time without consuming any source of nutrition or perhaps a worsening disease state. These patients are at further risk of poor outcomes for their disease. So, registered dietitians play a really important role in assessing and diagnosing these patients with malnutrition to ensure they get the care that they need.

Angel: Those are some significant figures in terms of prevalence. What do the outcomes of malnourished patients versus those without malnutrition look like?

Christina: Malnourished patients experienced up to 5 times the likelihood of mortality in the hospital and have been estimated to be 54% more likely to be readmitted. They typically experienced greater risk of complications such as hospital-acquired infections, falls, and pressure ulcers, all of which are preventable injuries, as well as slower wound healing. All of these factors can increase length of stay in the hospital, increase the cost of care, perhaps even doubling it, as one recent study suggests, and reduce the chances of successful recovery and overall quality of life.

Malnutrition cuts across disease areas, ages, and settings of care. It could be experienced by patients with liver disease, kidney disease, or stroke, for example, and it’s experienced by patients ranging from those in the ICU to those dwelling at home.

Angel: It’s pretty clear that there is a significant need for a national focus on this issue, given the impact on patient outcomes and those stark contrasts, which create a major cost burden to the system.

When we were approached by nutrition stakeholders in 2013 to generate a strategy to make this a national priority, we wanted to develop a consensus approach that brought all the important stakeholders to the table to discuss the magnitude of the problem and better understand why the issue was so prevalent, yet there were still many gaps. We convened several critical stakeholders which eventually led to the development of the Malnutrition Quality Improvement Initiative (MQii). The goal of the initiative, as you know, is advancing evidence-based, high-quality, and patient-driven care for hospitalized older adults who are malnourished or at risk of malnutrition.

Christina: I have been working on the MQii project for the last 2 years and I know you’ve been working on it much longer. Can you talk a little bit more about the inspiration for creating this initiative and how it came to be?

Angel: Definitely. This is a collaboration between Avalere and the Academy of Nutrition and Dietetics. We collaborated to launch the MQii to generate evidence, foster policy change, bring awareness to the issue of malnutrition, and shape the dialogue around quality of care. The initiative has spanned 8 years, and we’ve really embarked on a 4-phase initiative.

The first piece included the convening of stakeholders where we worked to understand the key gaps in care that may lead to patients being discharged with untreated malnutrition.

Once we understood those gaps, we were able to design MQii to make sure that it provided the resources that providers need to address malnutrition appropriately and implement evidence-based care that matches what is recommended in the guidelines.

In the next phase, we worked with several pilot demonstration sites to test a set of resources to help providers implement quality care as well as quality measures to allow providers to measure and track how well they were progressing toward best practices. Once we were able to show that the measures were validated and that the resources were usable, feasible, and acceptable to providers and their care teams, we embarked on phase 4, which expanded and spread the use of these tools and measures across providers throughout the country, and we’ve been able to do that successfully over the last few years.

Is there anything you would add?

Christina: Yeah, so to facilitate that expansion you were talking about, it’s been really important to work with the Learning Collaborative of hospitals and systems that we developed several years ago and has been growing each year. We engage primarily with clinical nutrition managers at these hospitals and systems, as well as other providers and their IT colleagues to support data collection. We also provide support for their quality improvement and research efforts, and we hope to connect individuals across these different institutions who are pursuing similar projects.

There are so many important outcomes that can be realized from participating in our initiative. The dietitians and their colleagues experience improved workflows and better collaboration with other clinicians in their institutions. Their patients experience improved outcomes and, of course, that’s been beneficial for the hospital and their insurers. Dietitians themselves and their clinician colleagues can gather more patient data, and then highlight that data to their leadership, which can lead to more support for their department and for our profession. The dietitians can also share best practices with one another and publish papers based on their findings, which contributes to the growing body of literature in this field. They can then reach new audiences throughout the healthcare system.

I’ll also mention that this collective evidence can be used on a broader scale to influence government policies and programs, such as the Medicare Quality Payment programs, access to nutrition care, and more.

Angel: Right. The evidence we have published already has been rather comprehensive and I think an indication of the success of this effort to push the needle for quality care in the malnourished population.

Reflecting on that evidence and the efforts that we’ve taken with our provider partners, we’ve co-authored several articles in peer-reviewed journals, including studies related to the usability and the testing of the tools, called the MQii Toolkit, the package of resources that has been provided to clinicians to implement high-quality care based on these best practices and support their malnutrition-focused quality improvement efforts.

We also did an aggregate impact study to understand what measure implementation looks like, and how it can impact clinical care and outcomes. We developed a composite measure, which reflects the measures that hospitals are implementing. We published the development methodology for that measure, and the results from testing that measure for reliability and validity.

The other paper to mention here is the use of the measure components in hospital subpopulations to assess their malnutrition burden. It gave us a clearer picture as to which departments and service lines in the hospital are more impacted by malnutrition than perhaps the rest of the of the institution.

Christina: As we’ve been working with our Learning Collaborative, and throughout all these different initiatives you’re talking about, we’ve been able to advance opportunities to improve care quality across transitions of care, as well. Many of our Learning Collaborative members are aware of gaps as patients transition out of acute care settings, and they want to be able to better address those patient needs with our support.

These nutrition professionals are seeking to improve strategies to meet patients’ nutritional needs following discharge, whether that’s at home or other institutions. Some examples include sending out dietitians to check on patients at home, connecting patients with healthy food prescriptions after leaving, or perhaps sending them home with shelf-stable food.

A lot of the successes that they’re realizing lead to more recognition among administration and physicians and their hospitals and systems about the need to support your malnutrition programs and to work to address the root causes of malnutrition, often related to food insecurity and other barriers to consuming healthy food outside of the hospital.

Angel: That’s right. As hospitals and health systems have improved their malnutrition care coordination, they’re looking toward other areas of their health system to continue these improvements, specifically post discharge. We’ve overseen a few pilots to continue supporting malnourished patients post discharge, demonstrating some preliminary success. For instance, we have been engaging with some of our longest-participating health systems who are expanding their efforts into outpatient clinics and other settings like surgical and oncology practices. As you indicated, malnutrition can arise in any setting of care and requires comprehensive identification and coordination between clinicians regardless of setting. It’s a natural next step for many of our health systems that have optimized care for malnourished patients to then move on to that next step post discharge.

So, Christina, any other resources or plugs for our listeners who want to learn more about our work in the malnutrition space to keep in mind?

Christina: Sure. First, I would recommend visiting our website, We recently had an opportunity to record a podcast about nutrition and telehealth with 2 of our Learning Collaborative members, and we published an insight about our development of a Malnutrition Composite Measure. All of these are available on the Avalere website.

Finally, I’ll mention that we worked with the Academy of Nutrition and Dietetics to publish a whole supplement to their journal, which includes articles by our leadership, team members, and our Learning Collaborative members.

Angel: Thanks so much for joining me today for this discussion, Christina. I think these insights are invaluable to our listeners. Thank you all for tuning in to Avalere Health Essential Voice. Please stay tuned for more episodes in our Disease Education Series. If you would like to learn more, please visit us at

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