Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

The patient generated subjective global assessment short form is a useful screening tool to detect risk for malnutrition in patients with cirrhosis.

BACKGROUND AND AIMS: Malnutrition is a modifiable risk factor for morbidity and mortality in cirrhosis. Nutrition risk screening is recommended in cirrhosis nutrition guidelines, but is not routinely completed in practice. The patient-generated subjective global assessment short form (PG-SGA SF) is a patient-completed screen that has potential to be a substitute for more time and resource intensive nutrition screens. The aim of this cross-sectional study was to compare the PG-SGA SF and three other patient-completed screens against the nutrition assessment reference method in cirrhosis, the Royal Free Hospital subjective global assessment (RFH-SGA). We also explored whether being classified "at-risk" on a nutritional screening tool was associated with clinical outcomes of unplanned hospitalization or death. METHODS: Patients completed four nutrition screening tools with or without support from a caregiver. The RFH-SGA was carried out by a blinded registered dietitian. The four screening tools were compared against the RFH-SGA to calculate sensitivity, specificity, and positive and negative predictive value. RESULTS: A total of 121 patients were included. The PG-SGA SF screened the highest number of patients positive for malnutrition risk (52%), was the most accurate, and had the highest sensitivity. Being at risk for malnutrition on the PG-SGA SF was associated with a higher risk of unplanned hospitalization (unadjusted sHR 2.78 (95% CI 1.3-5.9), p = 0.009). CONCLUSIONS: The PG-SGA SF identifies malnutrition risk at similar or superior rates to other patient-generated screening tools in patients with cirrhosis. Our findings support its potential as a patient completed solution for identifying malnutrition risk in cirrhosis.

Piloting a training program in computed tomography skeletal muscle assessment for registered dietitians.

BACKGROUND: Consensus definitions for disease-associated malnutrition and sarcopenia include reduced skeletal muscle mass as a diagnostic criterion. There is a need to develop and validate techniques to assess skeletal muscle in clinical practice. Skeletal muscle mass can be precisely quantified from computed tomography (CT) images. This pilot study aimed to train registered dietitians (RDs) to complete precise skeletal muscle measurements using CT. METHODS: Purposive sampling identified RDs employed in clinical areas in which CT scans are routinely performed. CT training included (1) a 3-Day training session focused on manual segmentation of skeletal muscle cross-sectional areas (cm2 , centimeter squared) from abdominal CT images at the third lumbar vertebra (L3), using sliceOmatic® software, and (2) a precision assessment to quantify the intraobserver and interobserver precision error of repeated skeletal muscle measurements (30 images in duplicate). Precision error is reported as the root mean standard deviation (cm2 ) and percent coefficient of variation (%CV), our primary performance indicator, was defined as a precision error of <2%. RESULTS: Five RDs completed CT training. RDs were from three clinical areas: cancer care (N = 1), surgery (N = 2), and critical care (N = 1). RDs' precision error was low and below the minimal acceptable error of <2%; intraobserver error was ≤1.8 cm2 (range, 0.8-1.8 cm2 ) or ≤1.5% (range, 0.8%-1.5%) and interobserver error was 1.2 cm2 or 1.1%. CONCLUSION: RDs can be trained to perform precise CT skeletal muscle measurements. Increasing capacity to assess skeletal muscle is a first step toward developing this technique for use in clinical practice.

Predicted estimates of resting energy expenditure have limited clinical utility in patients with cirrhosis.

BACKGROUND & AIMS: Malnutrition is associated with adverse clinical outcomes in patients with cirrhosis. Accurate assessment of energy requirements is needed to optimize dietary intake. Resting energy expenditure (REE), the major component of total energy expenditure, can be measured using indirect calorimetry (mREE) or estimated using prediction equations (pREE). This study assessed the usefulness of predicted estimates of REE in this patient population. METHODS: Individual mREE data were available for 900 patients with cirrhosis (mean [±1 SD] age 55.7±11.6 years-old; 70% men; 52% south-east Asian) and 282 healthy controls (mean age 36.0±12.8 years-old; 52% men; 18% south-east Asian). Metabolic status was classified using thresholds based on the mean ± 1 SD of the mREE in the healthy controls. Comparisons were made between mREE and pREE estimates obtained using the Harris-Benedict, Mifflin, Schofield and Henry equations. Stepwise regression was used to build 3 new prediction models which included sex, ethnicity, body composition measures, and model for end-stage liver disease scores. RESULTS: The mean mREE was significantly higher in patients than controls when referenced to dry body weight (22.4±3.8 cf. 20.8±2.6 kcal/kg/24 hr; p <0.001); there were no significant sex differences. The mean mREE was significantly higher in Caucasian than Asian patients (23.1±4.4 cf. 21.7±2.9 kcal/kg/24 hr; p <0.001). Overall, 37.1% of Caucasian and 25.3% of Asian patients were classified as hypermetabolic. The differences between mREE and pREE were both statistically and clinically relevant; in the total patient population, pREE estimates ranged from 501 kcal/24 hr less to 548 kcal/24 hr more than the mREE. Newly derived prediction equations provided better estimates of mREE but still had limited clinical utility. CONCLUSIONS: Prediction equations do not provide useful estimates of REE in patients with cirrhosis. REE should be directly measured. LAY SUMMARY: People with cirrhosis are often malnourished and this has a detrimental effect on outcome. Provision of an adequate diet is very important and is best achieved by measuring daily energy requirements and adjusting dietary intake accordingly. Prediction equations, which use information on age, sex, weight, and height can be used to estimate energy requirements; however, the results they provide are not accurate enough for clinical use, particularly as they vary according to sex and ethnicity.

More-2-Eat implementation demonstrates that screening, assessment and treatment of malnourished patients can be spread and sustained in acute care; a multi-site, pretest post-test time series study.

BACKGROUND: Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown. AIMS: To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients. METHODS: Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1. RESULTS: 5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p < 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p < 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance). CONCLUSION: Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

Contexte: L'initiative de récupération améliorée après la chirurgie (RAAC) est un projet international d'amélioration de la qualité en chirurgie. On en sait peu sur les retombées économiques, tant à court qu'à long terme, de la mise en œuvre de multiples lignes directrices de RAAC. Méthodes: Nous avons réalisé une analyse du rendement sur l'investissement (RSI) visant la mise en œuvre de multiples lignes directrices de RAAC (pour les opérations colorectales, pancréatiques, hépatiques ou d'oncologie gynécologique et la cystectomie) dans 9 hôpitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L'incidence de la RAAC sur l'utilisation des services de santé (durée du séjour à l'hospitalisation initiale, nombre de réadmissions, durée du séjour à la réhospitalisation et nombre de visites à l'urgence, en consultation externe, chez un spécialiste et chez un omnipraticien) a été évaluée à l'aide d'un modèle multiniveau de régressions binomiales négatives à effets mixtes multivariés. Les bénéfices nets et le RSI ont été estimés à l'aide d'un processus de modélisation analytique décisionnelle. Tous les coûts ont été rapportés en dollars canadiens de 2019. Résultats: Les économies nettes du système de santé allaient de 26,35 $ à 3606,44 $ par patient, et le RSI variait de 1,05 à 7,31; chaque dollar investi dans l'initiative de RAAC a donc généré un retour sur l'investissement de 1,05 $ à 7,31 $. Les probabilités d'économie grâce au RAAC allaient de 86,5% à 99,9%. Les retombées générées augmentaient avec un horizon temporel à plus long terme, ce qui suggère que l'utilisation unique d'un horizon temporel de 30 jours aurait mené à une sousestimation des bénéfices. Conclusion: Les résultats montrent que la mise en œuvre de multiples lignes directrices de RAAC a permis des économies en Alberta. En vue d'obtenir un RSI optimal, il est important de tenir compte d'une grande variété d'utilisations des services de santé, des retombées à long terme, des économies d'échelle, de l'efficacité productive et de l'efficience des allocations pour la pérennité, la mise à l'échelle et la diffusion des projets de mise en œuvre de RAAC.

The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial.

BACKGROUND: Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta. METHODS: A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework. DISCUSSION: The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04149223, November 4, 2019.

The Role of Preoperative Parenteral Nutrition.

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives.

BACKGROUND: Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system. METHODS: Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple's, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12. RESULTS: Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines. CONCLUSIONS: Health care leaders have unique perspectives and approaches to support spread, scale and sustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.

Systematic review with meta-analysis: Nutritional screening and assessment tools in cirrhosis.

BACKGROUND & AIMS: Disease-related malnutrition is common in cirrhosis. Multiple studies have evaluated nutritional screening tools (NSTs, rapid bedside tests targeting who needs assessment) and nutritional assessment tools (NATs, used in diagnosing malnutrition) as predictors of clinical outcome in this population. We performed a systematic review and meta-analysis of this literature with the aim of summarising the varying definitions of malnutrition across studies, the available evidence for NSTs and the ability of NSTs and NATs to predict clinical outcomes in cirrhosis. METHODS: The primary outcome measures were pre- and post-transplant mortality with a range of secondary outcomes. Inclusion: cirrhosis over age 16. Exclusion: >25% with hepatocellular carcinoma, primarily laboratory test-based NATs or lack of screening, assessment or outcome criteria. RESULTS: Eight thousand eight hundred fifty patients were included across 47 studies. Only 3 studies assessed NSTs. Thirty-two definitions for malnutrition were utilised across studies. NATs predicted pre-transplant mortality in 69% of cases that were assessed with a risk ratio (RR) of 2.38 (95% CI 1.96-2.89). NATs were prognostic for post-transplant mortality only 28% of the times they were assessed, with a RR of 3.04 (95% CI 1.51-6.12). CONCLUSIONS: The cirrhosis literature includes limited data on nutrition screening and multiple definitions for what constitutes malnutrition using NATs. Despite this discordance, it is clear that malnutrition is a valuable predictor of pre-transplant mortality almost regardless of how it is defined. We require clinical and research consensus around the definition of malnutrition and the accepted processes and cut-points for nutrition screening and assessment in cirrhosis.

Are Predictive Energy Expenditure Equations Accurate in Cirrhosis?

Malnutrition is associated with significant morbidity and mortality in cirrhosis. An accurate nutrition prescription is an essential component of care, often estimated using time-efficient predictive equations. Our aim was to compare resting energy expenditure (REE) estimated using predictive equations (predicted REE, pREE) versus REE measured using gold-standard, indirect calorimetry (IC) (measured REE, mREE). We included full-text English language studies in adults with cirrhosis comparing pREE versus mREE. The mean differences across studies were pooled with RevMan 5.3 software. A total of 17 studies (1883 patients) were analyzed. The pooled cohort was comprised of 65% men with a mean age of 53 ± 7 years. Only 45% of predictive equations estimated energy requirements to within 90⁻110% of mREE using IC. Eighty-three percent of predictive equations underestimated and 28% overestimated energy needs by ±10%. When pooled, the mean difference between the mREE and pREE was lowest for the Harris⁻Benedict equation, with an underestimation of 54 (95% CI: 30⁻137) kcal/d. The pooled analysis was associated with significant heterogeneity (I2 = 94%). In conclusion, predictive equations calculating REE have limited accuracy in patients with cirrhosis, most commonly underestimating energy requirements and are associated with wide variations in individual comparative data.

Home Enteral Nutrition: Towards a Standard of Care.

The purpose of this overview is to make the case for the establishment and publication of standards for home enteral nutrition (HEN) therapy in adult patients who require a long-term alternative to oral feeding. Overviews can provide a broad and often comprehensive summation of a topic area and, as such, have value for those coming to a subject for the first time. It will provide a broad summation, background and rationale, review specific considerations unique to HEN (tubes, products and supplies) and we describe a recent audit of seven HEN programs which highlights tube and process related challenges. Based on the overview of the literature and our experience with the audit we propose a way forward for best home enteral nutrition care.

Assessment of Computed Tomography (CT)-Defined Muscle and Adipose Tissue Features in Relation to Short-Term Outcomes After Elective Surgery for Colorectal Cancer: A Multicenter Approach.

BACKGROUND: Sarcopenia, visceral obesity (VO), and reduced muscle radiodensity (myosteatosis) are suggested risk factors for postoperative morbidity in colorectal cancer (CRC), but usually are not concurrently assessed. Published thresholds used to define these features are not CRC-specific and are defined in relation to mortality, not postoperative outcomes. This study aimed to evaluate body composition in relation to length of hospital stay (LOS) and postoperative outcomes. METHODS: Pre-surgical computed tomography (CT) images were assessed for total area and radiodensity of skeletal muscle and visceral adipose tissue in a pooled Canadian and UK cohort (n = 2100). Sex- and age-specific values for these features were calculated. For 1139 of 2100 patients, LOS data were available, and sex- and age-specific thresholds for sarcopenia, myosteatosis, and VO were defined on the basis of LOS. Association of CT-defined features with LOS and readmissions was explored using negative binomial and logistic regression models, respectively. RESULTS: In the multivariable analysis, the predictors of LOS (P < 0.001) were age, surgical approach, major complications (incidence rate ratio [IRR] 2.42; 95% confidence interval [CI] 2.18-2.68), study cohort, and three body composition profiles characterized by myosteatosis combined with either sarcopenia (IRR, 1.27; 95% CI 1.12-1.43) or VO (IRR, 1.25; 95% CI 1.10-1.42), and myosteatosis combined with both sarcopenia and VO (IRR, 1.58; 95% CI 1.29-1.93). In the multivariable analysis, risk of readmission was associated with VO alone (odds ratio [OR] 2.66; 95% CI 1.18-6.00); P = 0.018), VO combined with myosteatosis (OR, 2.72; 95% CI 1.36-5.46; P = 0.005), or VO combined with myosteatosis and sarcopenia (OR, 2.98; 95% CI 1.06-5.46; P = 0.038). Importantly, the effect of body composition profiles on LOS and readmission was independent of major complications. CONCLUSION: The findings showed that CT-defined multidimensional body habitus is independently associated with LOS and hospital readmission.

Nutrition Care in Patients With Head and Neck or Esophageal Cancer: The Patient Perspective.

BACKGROUND: Patients with head/neck or esophageal (HNE) cancer are likely to develop malnutrition throughout the course of their disease and its treatment. Although nutrition care is considered a cornerstone of disease management, clinical practices to treat malnutrition vary. The objective of this qualitative study is to understand the patients' experiences with nutrition care in the context of their treatment and recovery. METHODS: A descriptive qualitative study design was used to explore patients' experiences. Ten patients with head and neck (HN) cancer and 10 patients with esophageal cancer were interviewed near the completion of their cancer treatment using a semistructured interview guide. The data sets were analyzed separately using qualitative content analysis. The preliminary findings from each data set were compared and contrasted; 3 themes that crossed both data sets were identified. RESULTS: Three themes were identified: (1) coping with physical and psychosocial aspects of illness and nutrition; (2) understanding the nature of the illness, treatment, and nutrition pathway; and (3) being supported during the trajectory of care. The major differences between HN and esophageal groups were identified in the context of understanding and being supported: the lack of coordination throughout the trajectory of care and conflicting messages from healthcare providers were a source of uncertainty, confusion, and isolation in the HN group. The need for timely and ongoing patient-focused nutrition care, with formal and informal support, was identified in both groups. CONCLUSION: Models for nutrition care should support provision of consistent information across health professionals and throughout the treatment trajectory.

Costs of hospital malnutrition.

BACKGROUND & AIMS: Hospital malnutrition has been established as a critical, prevalent, and costly problem in many countries. Many cost studies are limited due to study population or cost data used. The aims of this study were to determine: the relationship between malnutrition and hospital costs; the influence of confounders on, and the drivers (medical or surgical patients or degree of malnutrition) of the relationship; and whether hospital reported cost data provide similar information to administrative data. To our knowledge, the last two goals have not been studied elsewhere. METHODS: Univariate and multivariate analyses were performed on data from the Canadian Malnutrition Task Force prospective cohort study combined with administrative data from the Canadian Institute for Health Information. Subjective Global Assessment was used to assess the relationship between nutritional status and length of stay and hospital costs, controlling for health and demographic characteristics, for 956 patients admitted to medical and surgical wards in 18 hospitals across Canada. RESULTS: After controlling for patient and hospital characteristics, moderately malnourished patients' (34% of surveyed patients) hospital stays were 18% (p = 0.014) longer on average than well-nourished patients. Medical stays increased by 23% (p = 0.014), and surgical stays by 32% (p = 0.015). Costs were, on average, between 31% and 34% (p-values < 0.05) higher than for well-nourished patients with similar characteristics. Severely malnourished patients (11% of surveyed patients) stayed 34% (p = 0.000) longer and had 38% (p = 0.003) higher total costs than well-nourished patients. They stayed 53% (p = 0.001) longer in medical beds and had 55% (p = 0.003) higher medical costs, on average. Trends were similar no matter the type of costing data used. CONCLUSIONS: Over 40% of patients were found to be malnourished (1/3 moderately and 1/10 severely). Malnourished patients had longer hospital stays and as a result cost more than well-nourished patients.

Implementation of Enhanced Recovery After Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience.

BACKGROUND: Enhanced recovery after surgery (ERAS) colorectal guideline implementation has occurred primarily in standalone institutions worldwide. We implemented the guideline in a single provincial healthcare system, and our study examined the effect of the guideline on patient outcomes [length of stay (LOS), complications, and 30-day post-discharge readmissions] across a healthcare system. METHODS: We compared pre- and post-guideline implementation in consecutive elective colorectal patients, ≥ 18 years, from six Alberta hospitals between February 2013 and December 2014. Participants were followed up to 30 days post discharge. We used summary statistics, to assess the LOS and complications, and multivariate regression methods to assess readmissions and to estimate cost impacts. RESULTS: A total of 1333 patients (350 pre- and 983 post-ERAS) were analysed. Of this number, 55 % were males. Median overall guideline compliance was 39 % in pre- and 60 % in post-ERAS patients. Median LOS was 6 days for pre-ERAS compared to 4.5 days in post-ERAS patients with the longest implementation (p value <0.0001). Adjusted risk ratio (RR) was 1.71, 95 % CI 1.09-2.68 for 30-day readmission, comparing pre- to post-ERAS patients. The proportion of patients who developed at least one complication was significantly reduced, from pre- to post-ERAS, difference in proportions = 11.7 %, 95 % CI 2.5-21.0, p value: 0.0139. The net cost savings attributable to guideline implementation ranged between $2806 and $5898 USD per patient. CONCLUSION: The findings in our study have shown that ERAS colorectal guideline implementation within a healthcare system resulted in patient outcome improvements, similar to those obtained in smaller standalone implementations. There was a significant beneficial impact of ERAS on scarce health system resources.

An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta

BACKGROUND: In February 2013, Alberta Health Services established an Enhanced Recovery After Surgery (ERAS) implementation program for adopting the ERAS Society colorectal guidelines into 6 sites (initial phase) that perform more than 75% of all colorectal surgeries in the province. We conducted an economic evaluation of this initiative to not only determine its cost-effectiveness, but also to inform strategy for the spread and scale of ERAS to other surgical protocols and sites. METHODS: We assessed the impact of ERAS on patients’ health services utilization (HSU; length of stay [LOS], readmissions, emergency department visits, general practitioner and specialist visits) within 30 days of discharge by comparing pre- and post-ERAS groups using multilevel negative binomial regressions. We estimated the net health care costs/savings and the return on investment (ROI) associated with those impacts for post-ERAS patients using a decision analytic modelling technique. RESULTS: We included 331 pre- and 1295 post-ERAS patients in our analyses. ERAS was associated with a reduction in all HSU outcomes except visits to specialists. However, only the reduction in primary LOS was significant. The net health system savings were estimated at $2 290 000 (range $1 191 000–$3 391 000), or $1768 (range $920–$2619) per patient. The probability for the program to be cost-saving was 73%–83%. In terms of ROI, every $1 invested in ERAS would bring $3.8 (range $2.4–$5.1) in return. CONCLUSION: The initial phase of ERAS implementation for colorectal surgery in Alberta is cost-saving. The total savings has the potential to be more substantial when ERAS is spread for other surgical protocols and across additional sites.

Piloting online WellnessRx learning modules: demonstration of developmental evaluation.

WellnessRx is a health initiative focusing on healthy living through education, knowledge translation, and community engagement. Stakeholders of WellnessRx identified web-based education learning modules on nutrition and physical education as a priority to be integrated into existing health sciences curricula, as well as adapted for use by health professionals. Five learning modules were created with essential knowledge, skills, attitudes and resources or tools for health professional students and practitioners. As part of the 'developmental evaluation framework' for WellnessRx, two of these modules were piloted within two health professional student programs. This paper describes the pilot-evaluation experience involving student surveys, focus groups and interviews, and faculty perspectives. For both modules, student pre-post knowledge assessments indicated some improvements in post-module knowledge. Post module evaluations by students indicated benefits with the online delivery being flexible for access, self-health, case-based assessments and useful nutrition and physical activity guides. Challenges for students included their time to do the modules and the activity expectations. Instructors felt each module could be better targeted to different years within an undergraduate program. Through developmental evaluation, the pilot results along with recommendations and lessons learned provided the direction needed to further develop the WellnessRx logic model and proposed learning modules.

Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission.

BACKGROUND: Nutritional assessment commonly includes multiple nutrition indicators (NIs). To promote efficiency, a minimum set is needed for the diagnosis of malnutrition in the acute care setting. OBJECTIVE: The objective was to compare the ability of different NIs to predict outcomes of length of hospital stay and readmission to refine the detection of malnutrition in acute care. DESIGN: This was a prospective cohort study of 1022 patients recruited from 18 acute care hospitals (academic and community), from 8 provinces across Canada, between 1 July 2010 and 28 February 2013. Participants were patients aged ≥18 y admitted to medical and surgical wards. NIs measured at admission were subjective global assessment (SGA; SGA A = well nourished, SGA B = mild or moderate malnutrition, and SGA C = severe malnutrition), Nutrition Risk Screening (2002), body weight, midarm and calf circumference, serum albumin, handgrip strength (HGS), and patient-self assessment of food intake. Logistic regression determined the independent effect of NIs on the outcomes of length of hospital stay (<7 d and ≥7 d) and readmission within 30 d after discharge. RESULTS: In total, 733 patients had complete NI data and were available for analysis. After we controlled for age, sex, and diagnosis, only SGA C (OR: 2.19; 95% CI: 1.28, 3.75), HGS (OR: 0.98; 95% CI: 0.96, 0.99 per kg of increase), and reduced food intake during the first week of hospitalization (OR: 1.51; 95% CI: 1.08, 2.11) were independent predictors of length of stay. SGA C (OR: 2.12; 95% CI: 1.24, 3.93) and HGS (OR: 0.96; 95% CI: 0.94, 0.98) but not food intake were independent predictors of 30-d readmission. CONCLUSIONS: SGA, HGS, and food intake were independent predictors of outcomes for malnutrition. Because food intake in this study was judged days after admission and HGS has a wide range of normal values, SGA is the single best predictor and should be advocated as the primary measure for diagnosis of malnutrition. This study was registered at clinicaltrials.gov as NCT02351661.