Outcomes of malnutrition

The No Nonsense Teds Fat Melting

Eat More Diet Less

Get Instant Access

Many retrospective and prospective studies provide evidence that malnourished patients have longer hospital stays [23-31] and significantly increased health care costs [10, 23, 32-33]. Studies comparing specific outcomes with malnutrition are summarized in Table 2.4. In a prospective analysis, Robinson and coworkers found that hospital charges were doubled in malnourished patients when compared with

Table 2.3

Malnutrition Prevalence in Populations

Author n Prevalence Age (%) (mean)

Patient group Assessment tool

Comment

Chailleux 4,088 (2003) [97]

Edington 441

Kagansky (2005) [27]

McWhirter & Pennington (1994) [6]

500 40

58' Medical, hospitalized

69 COPD on long-term oxygen therapy

68 Non-hospitalized cancer and chronic disease

85 Geriatric, hospitalized

16-64 Surgery and medicine, hospitalized

Height, weight, IBW, serum albumin

BMI, TST, MAMC

MNA* and MNA subscore

BMI, TSF, MAMC

• At risk > 1: height for weight <75% IBW, albumin <30g/l, > 10% weight loss 1 month prior to admission

• BMI independent effect on all cause and respiratory mortality in patients with FEVj <55%

• Serum albumin is independent risk factor for death

• Greatest weight loss in patients who were already depleted on admission

• Subgroup prevalence (%): 27 (surgery), 46 (medicine), 43 (geriatrics)

Weinsier (1979) [23]

111 55

837 29

134 48

Medical and surgical, hospitalized

Medical and gastrointestinal, hospitalized Geriatric, nursing home Subacute care

General med, hospitalized

Serum albumin, height and weight, total lymphocyte count

Anthropometrics, MNA, biochemical markers LOM

• "Likelihood of malnutrition" (LOM) based on laboratory data and subjective information of weight loss and physical appearance

• Malnourished on admission = more complications

• 53% hypoalbuminemia

• 63% at risk of malnutrition

• LOM uses anthropometrics, serum albumin, lymphocyte count, hematocrit, folate, and vitamin C

• 33% remained hospitalized > 2 weeks

BMI (body mass index); MAMC (midarm muscle circumference); TSF (triceps skinfold), TST (triceps skinfold thickness); SGA (subjective global assessment)

MNA (Mini Nutritional Assessment)-questionnaire, incorporates four subscores: MNA-1 (anthropometrics), MNA-2 (global evaluation), MNA-3 (assessment of dietary habits), MNA-4(subject assessment of nutrition status) NRI (Nutritional Risk Index) = [(1.5*albumin) + (41.7*present/usual weight)]

MI (Maastricht Index) = [20.68 - (0.24*albumin) - (19.21'transthyretin) - (1.86*lymphocytes) - (0.04*ideal weight)]

Table 2.4

Malnutrition and Outcome in Chronic Disease Populations

Table 2.4

Malnutrition and Outcome in Chronic Disease Populations

Author

N

Patient t LOS t Mortality

Outcomes

Nutrition index

Comment

Chima

173

General +

I Discharge

Height-weight

• 56% at risk, had higher

(1997) [24]

medicine

home

ratio, serum

prevalence of liver disease

t Medical

albumin

(?)confounder

costs

• 1-month follow-up

Edington

10,128

Cancer and +

t Consultation

BMI

• In < 65-year-old group

(1999) [36]

CVD patients

t Prescriptions

BMI is "U" shaped in its

(UK database)

association with mortality

Kagansky

414

Geriatric,

t Infection

MNA and

• Significant I survival in low

(2005) [27]

hospitalized

MNA-3

MNA over 2.7 years

subscores

• MNA-3 strong predictor of

mortality

Martyn

11,357

Chronic +

t Consultation

BMI

• Community-based patients

(1998) [14]

diseases

t Prescriptions

• Mortality 2x greater in

(neuro, Gl,

patients with BMI < 20

pulm)

Mühlethaler

219

Geriatric + +

i Length of

Anthropometrics,

• Prealbumin with hazard ratio

(1995) [26]

overall and at

serum

= 1.9

home survival

biochemical

• 4.5-year follow-up

markers

Pirlich

502

General +

SGA, NRI,

• Malnourished patients were

(2003) [12]

medicine

BMI, body

older

composition

• LOS independent of medical

disease

69 Geriatric

111 Medical and surgical

Robinson (1987) [31]

100 General medicine

Sullivan (1999) [43]

497 Geriatric, medical and surgical 837 Geriatric, subacute care

2,485 Medical and surgical t Infection t Medical costs t

Complications t Medical costs t Weight loss

Î Admissions t Depression t Medical costs

BMI LOM

Visceral proteins, nutrition assessment Nutrient intake

MNA, biomarkers anthropometrics

Weight, height, <75% IBW, serum alb, weight loss > 10% last month before admission

• Episodes of sepsis in 73% malnourished

• Likelihood of malnutrition uses albumin, total lymphocyte, height/weight < 80% and clinical assessment

• Hospital charges and LOS 2x in malnourished patients

• Low nutrient group higher in-hospital and 90-day mortality

• >91% malnourished or at risk on admission

• 25% readmission after 14-month follow-up

• Early nutritional intervention = 1 LOS, 75% variance of LOS account for by Dx, days of intervention and expected LOS

(Continued)

Table 2.4 (Continued)

Author

N

Patient

t LOS t Mortality Outcomes

Nutrition index

Comment

Veterans

2,448

Perioperative

Equal

SGA, NRI

• Effect of TPN on operative

Affairs TPN

surgical

complication

outcome depended on

Cooperative

rates in TPN

baseline nutrition status

Study Group

vs. no TPN

• No significant reduction in

(1991) [114]

t mortality in TPN

morbidity in heterogeneous group of surgical patients

Weinsier

134

General

+ +

LOM

• Nutrition status (LOM)

(1979) [23]

medicine

worsened with hospitalization in 69% patients.

• LOM uses anthropometrics, vitamin C, folate and lymphocytes, albumin, and hematocrit

BMI (body mass index); MAMC (midarm muscle circumference); TSF (triceps skinfold), TST (triceps skinfold thickness); SGA (subjective global assessment); LOM (likeliness of malnutrition)

MNA (Mini Nutritional Assessment)-questionnaire, incorporates four subscores: MNA-1 (anthropometrics), MNA-2 (global evaluation), MNA-3 (assessment of dietary habits), MNA-4 (subject assessment of nutrition status) NRI (Nutritional Risk Index) = [(1.5*albumin) + (41.7*present/usual weight)]

BMI (body mass index); MAMC (midarm muscle circumference); TSF (triceps skinfold), TST (triceps skinfold thickness); SGA (subjective global assessment); LOM (likeliness of malnutrition)

MNA (Mini Nutritional Assessment)-questionnaire, incorporates four subscores: MNA-1 (anthropometrics), MNA-2 (global evaluation), MNA-3 (assessment of dietary habits), MNA-4 (subject assessment of nutrition status) NRI (Nutritional Risk Index) = [(1.5*albumin) + (41.7*present/usual weight)]

well-nourished patients [31]. In a retrospective cohort in Brazil, Correia et al. reported the mean daily hospital costs of malnourished patients were 60% to 300% higher than in well-nourished patients [34]. And although hospital charges are not accurate measures of each specific group's perspective, they illustrate the magnitude of the problem. Higher costs are directly attributable to increased length of stay and increased use of resources for further treatment of complications. Furthermore, the fact that hospital length of stay (LOS) has declined over the last decade secondary to pressures of third party payers compounds the problem.

The failure of accurate identification of malnutrition on hospital admission can lead to further nutritional deterioration, lengthened hospitalizations, and an overall increase in costs. Despite JCAHO's mandate to screen patients for malnutrition, many hospital systems have not implemented efficient ways to collect and study the data. This can partly be explained by both past and present literature that fails to define and properly measure malnutrition. This same trend is consistent outside the United States [35]. A separate Polish study demonstrated a strong correlation between BMI and hospital LOS; only 10% of admissions had a measured BMI.

Although the relationship between malnutrition and length of stay and health care costs remains strong, the causality of these connections is not clear. Appropriate medical nutrition therapy leads to decreased LOS, reductions in hospital costs, and overall improvement in clinical outcomes. Yet, nutritional support is often not provided. The fact that 45% of the malnourished patients exceeded their estimated DRG length of stay suggests that early recognition and treatment of malnourished patients may decrease the length of stay and hospital costs [5, 31].

While specific malnourished patient subpopulations have documented benefits from nutritional support, e.g., perioperative, gastrointestinal, cancer, COPD, chronic dialysis, critical care and elderly, the benefits remain largely debatable. Hospital malnutrition rates are not homogenously distributed among specialty services [36]. This chapter will discuss five patient subgroups not covered elsewhere in this volume, in which malnutrition has affected clinical outcomes.

Was this article helpful?

0 0
Lose 10 Pounds Naturally

Lose 10 Pounds Naturally

Studies show obesity may soon overtake tobacco as the leading cause of death in America. Are you ready to drop those extra pounds you've been carrying around? Awesome. Let's start off with a couple positive don't. You don't need to jump on a diet craze and you don't need to start exercising for hours each day.

Get My Free Ebook


Post a comment