Importance of Integrating Malnutrition Care Into U.S. Healthcare

Given that up to 50 percent of hospitalized patients are malnourished or at risk of malnutrition, the importance of identifying and addressing nutritional status is clear. The authors highlight two innovative strategies.

Compromised nutritional status in hospitalized patients (especially those who are chronically ill) is substantially overlooked in the treatment process. While up to 50 percent of hospitalized patients are malnourished or at risk of malnutrition,1 only 8 percent receive a medical diagnosis of malnutrition during their hospital stays.2

This lack of adequate identification is often due to insufficient awareness of and screening for malnutrition by clinicians (including screening of overweight and obese patients), breakdowns in communication and care coordination, and lack of appropriate documentation of malnutrition diagnoses. Importantly, physicians typically are the only clinicians who can provide a medical diagnosis of malnutrition, making them critical to ensure documentation of malnutrition and facilitate continued care with next-in-line providers. Malnourished adults have been found to use more healthcare resources with more visits to physicians, hospitals, and emergency rooms compared to their well-nourished counterparts, contributing to $49 billion —or 12.6 percent—of hospital costs annually.2 Hospitalized malnourished patients have up to a five-fold increase in mortality and up to a 50 percent increase in readmissions when compared to well-nourished patients.2

Malnutrition —particularly for older adults —can increase risk of functional disability, falling, and early mortality.3,4 Fortunately, interdisciplinary collaboration to support effective, diagnosis, and treatment can help prevent many of these adverse outcomes. The need to better identify and address the nutritional status of hospitalized patients is clear. With few requirements at the state or national levels, hospitals, health systems, and other care providers must establish their own programs to address malnutrition. We highlight here two innovative approaches to caring for individuals experiencing or at risk for malnutrition in the Veterans Health Administration (VHA) hospitals and in a collaborative of public and private acute care hospitals in the Malnutrition Quality Improvement Initiative (MQii). The distinct but related efforts of the VHA and the MQii highlight models for physicians and their interdisciplinary colleagues to lead malnutrition-focused quality improvement (QI) to improve health outcomes for patients.

VHA: MALNUTRITION IDENTIFICATION

The Veterans Health Administration, with 170 medical centers, is the largest integrated health system in the United States. It has focused on improving clinical nutrition management for patients by adopting screening, diagnosis, and treatment care programs throughout the VHA system. These programs are implemented through a set of national policies, strategic goals, and strong field-based leadership in the VHA Nutrition and Food Services (NFS) department.

In 2014, NFS set a strategic goal to train dietitians on the new criteria for documentation of adult malnutrition, as recommended in the 2012 consensus statement on malnutrition documentation.5 At the end of the year, 78 percent of dietitians had completed the training and a new internal Registered Dietitian Nutritionist (RDN) workload-capture code was developed to identify veterans meeting the criteria for malnutrition.

As the first step to treatment, NFS aimed to establish a baseline of veterans identified over the next year. In the first nine months of this program, adoption spread as 14,419 veterans were identified with this new code as malnourished.

In 2016, the NFS strategic goal was to establish a training baseline and increase trainings by 30 percent for malnutrition identification and treatment. To reach the new goal, dietitians conducted 463 interdisciplinary trainings for physicians and other team members and shared best practices across all VHA hospitals. To measure the impact of these trainings, ICD-10 codes for malnutrition were tracked over the course of the year and documented that more than 77,000 inpatient and outpatient veterans had been identified with a malnutrition code.

This strategic effort has enabled the VHA to significantly increase the identification of malnutrition by its interdisciplinary teams. In the future, VHA will track the provision of nutrition interventions to these patients and associated patient outcomes to understand which are most effective in both improving health outcomes and reducing costs of care.

MQII: MALNUTRITION DIAGNOSIS

The Malnutrition Quality Improvement Initiative aims to advance evidence-based care for hospitalized older adults (aged 65+) who are malnourished or at risk for malnutrition. The MQii offers hospitals a unique “dual-pronged” approach to malnutrition QI by providing a toolkit for interdisciplinary teams (including physicians, dietitians, nurses, and pharmacists) to diagnose and treat malnutrition, coupled with four electronic clinical quality measures (eCQMs) to assess the impact of their QI programs.

Since 2016, more than 260 hospitals across the United States have joined the MQii Learning Collaborative. These facilities use interdisciplinary teams to implement malnutrition QI projects focused on screening, assessment, care plan development, diagnosis, monitoring and evaluation, and discharge planning. Their projects aim to improve nutrition care and subsequent patient outcomes.

While each facility addresses unique nutrition care gaps, many have demonstrated notable improvements. For example, from baseline to post-implementation, 2017 Learning Collaborative sites (N = 27 hospitals, 39,788 encounters) increased malnutrition diagnosis rates among patients aged 65+ by 19 percent (p < 0.01).

In 2018, Learning Collaborative sites collecting malnutrition data (N = 41 hospitals, 35,366 encounters) identified and diagnosed malnutrition in 11.09 percent of patients aged 65+, reflecting an increase of 24 percent (p < 0.01) from 2017.

LEVERAGING LEADERSHIP

Interdisciplinary malnutrition care initiatives also have been shown to improve patient outcomes. For example, Health and Human Services Secretary Alex Azar pointed to the experience of Illinois-based Advocate Health Care’s malnutrition quality improvement program as a successful effort to address social determinants of health and reduce readmissions.

Advocate’s program to screen high-risk patients for malnutrition and provide nutritional support during and after discharge led to savings of more than $3,800 per patient in the acute care setting,6 with additional savings due to avoided hospitalizations when continued in the ambulatory care setting.7

Additionally, the American Society for Parenteral and Enteral Nutrition (ASPEN) recently estimated potential annual cost savings of $580 million when Medicare claims modeling was applied to five therapeutic areas.8

Models established by the VHA and MQii provide a leadership pathway for physicians to actively engage their interdisciplinary teams to identify and effectively address care gaps for patients who are malnourished or at risk for malnutrition.

Physicians are optimally positioned to improve malnutrition care by leveraging their leadership role to advance screening and diagnosis, improve staff communication and training, and connect patients to nutrition resources in the hospital, at discharge, and in the community.

In addition, physicians have a unique opportunity to increase awareness among hospital executives on how optimal malnutrition care can improve patient outcomes, reduce readmissions, and improve quality ratings. As demonstrated recently in the Nutrition in Clinical Practice journal, the potential benefits for both physicians and patients are substantial.9

Albert Barrocas, MD, FACS, is adjunct professor of surgery at Tulane School of Medicine in New Orleans, Louisiana, and the retired chief medical officer for Atlanta Medical Center. He currently serves on the American Society for Parenteral and Enteral Nutrition’s board of advisors.

Anne Utech, PhD, RDN, is the national director for Nutrition and Food Services in the Veterans Affairs central office in Washington, D.C., and an assistant professor at Baylor College of Medicine in Houston, Texas.

Kristi Mitchell, MPH, is practice director at the Center for Healthcare Transformation at Avalere Health, Washington, D.C.

REFERENCES

1. Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence,Identification, and Impact on Patients and the Healthcare System. Int JEnviron Res Public Health. 2011;8:514-527.

2. Barrett ML, Bailey MK, Owens PL. Non-maternaland Non-neonatal Inpatient Stays in the United States Involving Malnutrition, 2016. U.S. Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/reports/HCUPMalnutritionHospReport 083018.pdf. Published August 30, 2018. Accessed October 18, 2019.

3. Agarwal E, Ferguson M, Banks M, et al. Malnutrition and Poor Food IntakeAre Associated with Prolonged Hospital Stay, Frequent Readmissions, and Greater In-hospital Mortality: Results from the Nutrition Care Day Survey2010. Clin Nutr. 2013;32(5):737-745.

4. Walston JD. Sarcopenia in Older Adults. Curr Opin Rheumatol.2012;24(6):623-627.

5. White JV, Guenter P, Jensen G, et al. Consensus Statement: AcademyOf Nutrition and Dietetics and American Society for Parenteral and EnteralNutrition. J Parenter Enteral Nutr. 2012;36(3):275-283.

6. Azar AM. The Root of the Problem: America’s Social Determinants of Health. U.S Department of Health and Human Services. https://www.hhs .gov/about/leadership/secretary/speeches/2018-speeches/the-root-of-the-problem-americas-social-determinants-of-health.html. Published November 14, 2018.Accessed October 18, 2019.

7. Riley K, Sulo S, Dabbous F, et al. Reducing Hospitalizations and Costs: AHome Health Nutrition-Focused Quality Improvement Program. J Parenter Enteral Nutr. 2020;44(1):58-68.

8. Tyler R, Barrocas A, Guenter P, et al. Value of Nutrition Support Therapy Impact on Clinical and Economic Outcomes in the United States. [Published online ahead of print January 29, 2020]. J Parenter Enteral Nutr. 2020.

9. Barrocas A. Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams? Nutr Clin Pract. 2019;34(6):806-821.

This article appears in the Nov/Dec 2020 issue of the Physician Leadership Journal.