Estimating Total Energy Expenditure to Determine Energy Requirements in Free-Living Children With Stage 3 Chronic Kidney Disease: Can a Structured Approach Help Improve Clinical Care?

OBJECTIVE: Malnutrition and obesity are complex burdensome challenges in pediatric chronic kidney disease (CKD) management that can adversely affect growth, disease progression, wellbeing, and response to treatment. Total energy expenditure (TEE) and energy requirements in children are essential for growth outcomes but are poorly defined, leaving clinical practice varied and insecure. The aims of this study were to explore a practical approach to guide prescribed nutritional interventions, using measurements of TEE, physical activity energy expenditure (PAEE), and their relationship to kidney function. DESIGN AND METHODS: In a cross-sectional prospective age-matched and sex-matched controlled study, 18 children with CKD (6-17 years, mean stage 3) and 20 healthy, age-matched, and gender-matched controls were studied. TEE and PAEE were measured using basal metabolic rate (BMR), activity diaries and doubly labeled water (healthy subjects). Results were related to estimated glomerular filtration rate (eGFR). The main outcome measure was TEE measured by different methods (factorial, doubly labeled water, and a novel device). RESULTS: Total energy expenditure and PAEE with or without adjustments for age, gender, weight, and height did not differ between the groups and was not related to eGFR. TEE ranged from 1927 ± 91 to 2330 ± 73 kcal/d; 95 ± 5 to 109 ± 5% estimated average requirement (EAR), physical activity level (PAL) 1.52 ± 0.01 to 1.71 ± 0.17, and PAEE 24 to 34% EAR. Comparisons between DLW and alternative methods in healthy children did not differ significantly, except for 2 (factorial methods and a fixed PAL; and the novel device). CONCLUSION: In clinical practice, structured approaches using supportive evidence (weight, height, BMI sds), predictive BMR or TEE values and simple questions on activity, are sufficient for most children with CKD as a starting energy prescription.

Comparative effect of seven prophylactic locks to prevent biofilm biomass and viability in intravenous catheters.

BACKGROUND: Patients requiring long-term intravenous access are at risk of intraluminal catheter bloodstream infection. 'Prophylactic' locks aim to limit this risk but there is uncertainty regarding the most effective lock. OBJECTIVES: To develop a novel technique intended to replicate clinical procedures to compare the effectiveness of various 'prophylactic' locks against biofilm biomass ('biomass') formation and biofilm viability ('viability') of Escherichia coli and Staphylococcus epidermidis in intravenous catheters. METHODS: For 10 consecutive days 106 cfu/mL E. coli NCTC 10418 and S. epidermidis ATCC 12228 were separately cultured in single lumen 9.6 French silicone tunnelled and cuffed catheters. These were flushed with 0.9% w/v sodium chloride using a push-pause technique before and after instillation of seven 'prophylactic' locks (water, ethanol, sodium chloride, heparinized sodium chloride, citrate, taurolidine plus citrate, and taurolidine; each in triplicate) for 6 h daily. Intraluminal 'biomass' and 'viability' were quantified using crystal violet staining and flush culture, respectively. RESULTS: The reduction of 'biomass' and 'viability' depended on both agent and species. Citrate was least effective against E. coli 'viability' and 'biomass' but most effective against S. epidermidis 'viability', and taurolidine was most effective against E. coli 'biomass' and 'viability' but least effective against S. epidermidis 'viability'. 'Biomass' and 'viability' were significantly correlated in E. coli between (r = 0.997, P < 0.001) and within (r = 0.754, P = 0.001) interventions, but not in S. epidermidis. CONCLUSIONS: A novel technique found the effect of 'prophylactic' agents in reducing 'biomass' and 'viability' varied by species. The choice of agent depends on the most likely infecting organism.

'Self-screening' for malnutrition with an electronic version of the Malnutrition Universal Screening Tool ('MUST') in hospital outpatients: concurrent validity, preference and ease of use.

Self-screening using an electronic version of the Malnutrition Universal Screening Tool ('MUST') has been developed but its implementation requires investigation. A total of 100 outpatients (mean age 50 (sd 16) years; 57 % male) self-screened with an electronic version of 'MUST' and were then screened by a healthcare professional (HCP) to assess concurrent validity. Ease of use, time to self-screen and prevalence of malnutrition were also assessed. A further twenty outpatients (mean age 54 (sd 15) years; 55 % male) examined preference between self- screening with paper and electronic versions of 'MUST'. For the three-category classification of 'MUST' (low, medium and high risk), agreement between electronic self-screening and HCP screening was 94 % (κ=0·74, se 0·092; P<0·001). For the two-category classification (low risk; medium+high risk) agreement was 96 % (κ=0·82, se 0·085; P<0·001), comparable with the previously reported paper-based self-screening. In all, 15 % of patients categorised themselves 'at risk' of malnutrition (5 % medium, 10 % high). Electronic self-screening took 3 min (sd 1·2 min), 40 % faster than previously reported for the paper-based version. Patients found the tool easy or very easy to understand (99 %) and complete (98 %). Patients that assessed both tools found the electronic tool easier to complete (65 %) and preferred it (55 %) to the paper version. Electronic self-screening using 'MUST' in a heterogeneous group of hospital outpatients is acceptable, user-friendly and has 'substantial to almost-perfect' agreement with HCP screening. The electronic format appears to be as agreeable and often the preferred format when compared with the validated paper-based 'MUST' self-screening tool.

Basal metabolic rate in children with chronic kidney disease and healthy control children.

BACKGROUND: Meeting energy requirements of children with chronic kidney disease (CKD) is paramount to optimising growth and clinical outcome, but little information on this subject has been published. In this study, we examined basal metabolic rate (BMR; a component of energy expenditure) with the aim to determine whether it is related to kidney function independently of weight, height and lean body mass (LBM). METHODS: Twenty children with CKD and 20 healthy age- and gender-matched control children were studied on one occasion. BMR was measured by indirect open circuit calorimetry and predicted by the Schofield equation. Estimated glomerular filtration rate (eGFR) was related to BMR and adjusted for weight, height, age and LBM measured by skinfold thickness. RESULTS: The adjusted BMR of children with CKD did not differ significantly from that of healthy subjects (1296 ± 318 vs.1325 ± 178 kcal/day; p = 0.720). Percentage of predicted BMR also did not differ between the two groups (102 ± 12% vs. 99 ± 14%; p = 0.570). Within the CKD group, eGFR (mean 33.7 ± 20.5 mL/min/m(2)) was significantly related to BMR (ß 0.3, r = 0.517, p = 0.019) independently of nutritional status and LBM. CONCLUSIONS: It seems reasonable to use estimated average requirement as the basis of energy prescriptions for children with CKD (mean CKD stage 3 disease). However, those who were sicker had significantly lower metabolic rates.

The feasibility and acceptability of training volunteer mealtime assistants to help older acute hospital inpatients: the Southampton Mealtime Assistance Study.

AIMS AND OBJECTIVES: To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients. BACKGROUND: Poor nutrition among hospitalised older patients is common in many countries and associated with poor outcomes. Competing time pressures on nursing staff may make it difficult to prioritise mealtime assistance especially on wards where many patients need help. DESIGN: Mixed methods evaluation of the introduction of trained volunteer mealtime assistants on an acute female medicine for older people ward in a teaching hospital in England. METHODS: A training programme was developed for volunteers who assisted female inpatients aged 70 years and over on weekday lunchtimes. The feasibility of using volunteers was determined by the proportion recruited, trained, and their activity and retention over one year. The acceptability of the training and of the volunteers' role was obtained through interviews and focus groups with 12 volunteers, nine patients and 17 nursing staff. RESULTS: Fifty-nine potential volunteers were identified: 38 attended a training session, of whom 29 delivered mealtime assistance, including feeding, to 3911 (76%) ward patients during the year (mean duration of assistance 5·5 months). The volunteers were positive about the practical aspects of training and ongoing support provided. They were highly valued by patients and ward staff and have continued to volunteer. CONCLUSIONS: Volunteers can be recruited and trained to help acutely unwell older female inpatients at mealtimes, including feeding. This assistance is sustainable and is valued. RELEVANCE TO CLINICAL PRACTICE: This paper describes a successful method for recruitment, training and retention of volunteer mealtime assistants. It includes a profile of those volunteers who provided the most assistance, details of the training programme and role of the volunteers and could be replicated by nursing staff in other healthcare units.

The potential for isothermal microcalorimetry to detect venous catheter infection isolates and establish antibiograms.

OBJECTIVES: Because bloodstream infection and venous catheter (or cannula) bloodstream infection are associated with high morbidity and cost, early identification and treatment are important. Isothermal microcalorimetry can detect microbial growth using thermal power (heat flow), essentially in real time. The aim of this study was to examine the potential of this technique in clinical practice. METHODS: Thermal power of wild-type bacteria (Escherichia coli, Staphylococcus epidermidis, Klebsiella pneumoniae, and Enterococcus faecium) isolated from blood cultures of adult inpatients receiving parenteral nutrition in routine clinical practice was measured at 37°C every 10s using a Thermometric 2277 instrument. Temporal patterns of heat flow were used to detect the presence of bacteria, differentiate between them, and test their antibiotic sensitivity. Within and between batch reproducibility (% coefficient of variation [%CV]) was also established. RESULTS: Isothermal microcalorimetry always correctly detected the absence or presence of wild-type bacteria. Thermograms differed distinctly between species. Key thermographic features, such as peak heights, timing of peak heights, and interval between peak heights, were highly reproducible within each species (within-batch %CV usually about ≤1%, although between-batch %CV was usually higher). The antibiotic sensitivities (tested only for S. epidermidis and K. pneumoniae) confirmed the results obtained from the hospital laboratory. CONCLUSIONS: Isothermal microcalorimetry is a promising and highly reproducible real-time measurement technique with potential application to the investigation, species identification, and targeted antibiotic treatment of bloodstream infection and venous catheter (or cannula) bloodstream infection.

Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis.

Currently, there is confusion about the value of using nutritional support to treat malnutrition and improve functional outcomes in chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis of randomized, controlled trials (RCT) aimed to clarify the effectiveness of nutritional support in improving functional outcomes in COPD. A systematic review identified 12 RCT (n = 448) in stable COPD patients investigating the effects of nutritional support (dietary advice (1 RCT), oral nutritional supplements (10 RCT), enteral tube feeding (1 RCT)) versus control on functional outcomes. Meta-analysis of the changes induced by intervention found that while respiratory function (forced expiratory volume in 1 s, lung capacity, blood gases) was unresponsive to nutritional support, both inspiratory and expiratory muscle strength (maximal inspiratory mouth pressure +3.86 standard error (SE) 1.89 cm H2 O, P = 0.041; maximal expiratory mouth pressure +11.85 SE 5.54 cm H2 O, P = 0.032) and handgrip strength (+1.35 SE 0.69 kg, P = 0.05) were significantly improved and associated with weight gains of ≥2 kg. Nutritional support produced significant improvements in quality of life in some trials, although meta-analysis was not possible. It also led to improved exercise performance and enhancement of exercise rehabilitation programmes. This systematic review and meta-analysis demonstrates that nutritional support in COPD results in significant improvements in a number of clinically relevant functional outcomes, complementing a previous review showing improvements in nutritional intake and weight.

Southampton Mealtime Assistance Study: design and methods.

BACKGROUND: Malnutrition is common in older people in hospital and is associated with adverse clinical outcomes including increased mortality, morbidity and length of stay. This has raised concerns about the nutrition and diet of hospital in-patients. A number of factors may contribute to low dietary intakes in hospital, including acute illness and cognitive impairment among in-patients. The extent to which other factors influence intake such as a lack of help at mealtimes, for patients who require assistance with eating, is uncertain. This study aims to evaluate the effectiveness of using trained volunteer mealtime assistants to help patients on an acute medical ward for older people at mealtimes. METHODS/DESIGN: The study design is quasi-experimental with a before (year one) and after (year two) comparison of patients on the intervention ward and parallel comparison with patients on a control ward in the same department. The intervention in the second year was the provision of trained volunteer mealtime assistance to patients in the intervention ward. There were three components of data collection that were repeated in both years on both wards. The first (primary) outcome was patients' dietary intake, collected as individual patient records and as ward-level balance data over 24 hour periods. The second was clinical outcome data assessed on admission and discharge from both wards, and 6 and 12 months after discharge. Finally qualitative data on the views and experience of patients, carers, staff and volunteers was collected through interviews and focus groups in both years to allow a mixed-method evaluation of the intervention. DISCUSSION: The study will describe the effect of provision of trained volunteer mealtime assistants on the dietary intake of older medical in-patients. The association between dietary intake and clinical outcomes including malnutrition risk, body composition, grip strength, length of hospital stay and mortality will also be determined. An important component of the study is the use of qualitative approaches to determine the views of patients, relatives, staff and volunteers on nutrition in hospital and the impact of mealtime assistance. TRIAL REGISTRATION: Trial registered with ClinicalTrials.gov NCTO1647204.

Obesity: a window of opportunity to intervene? Characteristics and management of morbidly obese adult inpatients in three trusts in Southern England.

Obesity affects 22% of men and 24% of women over the age of 16 years in the general population of the UK and is associated with multiple comorbidities. Little is known about the magnitude of the obesity problem among hospitalised adults and, although significant focus has been given to the identification and treatment of the malnourished inpatient, it is not known to what extent obese inpatients are equally -targeted. National guidelines for consideration of bariatric surgery exist, but it is not known to what extent potentially eligible individuals are referred. This multi-centre study -demonstrates a significant burden of obesity (defined as body mass index [BMI] ≥30 kg/m(2)) among those in hospital, affecting 22% of patients. This was more marked among orthopaedic patients and all-comers to intensive care units than on medical or surgical wards. Of those with BMI ≥35 kg/m(2), only 21% had been reviewed by dietetics and only 10% of patients who were potentially eligible for bariatric surgery had been referred to bariatric services. This study shows that there is an opportunity to recognise obesity and intervene in its management during hospital admission.

No relation between disease activity measured by multiple methods and REE in childhood Crohn disease.

BACKGROUND AND AIMS: Increased resting energy expenditure (REE) unmatched by dietary intake is implicated as a cause of poor nutrition in childhood inflammatory conditions. Adequate description of disease activity and correction of REE data for body composition are important to reach reliable conclusions about changes in REE associated with disease. The present study aimed to determine the effect of disease activity measured by clinical status, systemic and stool inflammatory markers on REE in children with Crohn disease using appropriate correction for confounding factors. METHODS: Sixty children with Crohn disease were recruited from the regional paediatric gastroenterology unit and studied on 1 occasion. REE was measured by indirect calorimetry. Fat-free mass (FFM) was estimated by skinfold thickness. Disease activity was measured using systemic (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and faecal markers of inflammation (lactoferrin, calprotectin) and clinical scores (Paediatric Crohn Disease Activity Index). RESULTS: Using a multiple regression model, there was no significant change in REE from active or inactive disease (ß = 0.03, P = 0.7) nor from CRP (ß = -0.05, P = 0.52), ESR (ß = -0.07, P = 0.43), faecal calprotectin (ß = -0.07, P = 0.38), and faecal lactoferrin (ß = 0.01, P = 0.88). REE/kg FFM was not associated with the Paediatric Crohn Disease Activity Index (r = 0.1, P = 0.44), CRP (r = -0.3, P = 0.84) or ESR (r = 0.12, P = 0.4), faecal calprotectin (r = 0.04, P = 0.97), or faecal lactoferrin (r = 0.02, P = 0.87). CONCLUSIONS: REE corrected for physiologically relevant confounders is not associated with degree of disease activity using clinical tools or systemic and local inflammatory markers, and therefore is an unlikely mechanism for poor nutritional state.

An evidence-based surveillance tool to identify and report catheter/cannula bloodstream infection in patients receiving parenteral nutrition.

OBJECTIVE: Catheter/cannula-bloodstream infection (CBI) has been proposed as a marker of the quality of care provided to patients receiving parenteral nutrition (PN). However, surveillance criteria for CBI are variable, inconsistent, and sometimes confusing and impractical. Surveillance criteria were developed to simply and accurately demonstrate the presence or absence of CBI. The aim of this study was to establish a simple and valid surveillance tool, with consideration of changes in vital signs, to identify CBI in patients receiving PN. METHODS: Adult (≥18 y) inpatients prescribed PN at a single large teaching hospital were recruited between October 11, 2017 and November 16, 2018. Common clinical and laboratory criteria, including blood culture, associated with 100 consecutive PN episodes associated with suspected CBI were examined for potential predictive markers of CBI. Using binary logistic regression, criteria were incorporated into an instrument that was validated against a reference classification of CBI established by an expert multidisciplinary group. RESULTS: The reference classification comprised 12 PN episodes with CBI and 88 without. Abnormal vital signs did not significantly predict CBI, but resolution of fever (≥38°C) and low systolic blood pressure (<100 mm Hg) in response to a specific treatment for CBI (line removal/antibiotics) did. Two other criteria were also significant predictors: positive blood culture; and absence of an alternative source that could explain the septic episode other than the catheter/cannula supplying PN. These two criteria together with a positive response to treatment (temperature and/or blood pressure, incorporated into a single binary variable), resulted in 100% correct CBI classification (100% sensitivity, 100% specificity, and 1.000 area under the curve in receiver operating characteristic analysis). All criteria could be retrospectively extracted from the medical records of all PN episodes. CONCLUSION: A CBI tool shows promise as a surveillance instrument for benchmarking and interinstitutional comparisons of the care received by hospitalized patients given PN.

Considerations for screening tool selection and role of predictive and concurrent validity.

PURPOSE OF REVIEW: Nutrition screening tool selection can be difficult. This review critically examines the relevance of validity, specifically concurrent (agreement between tools) and predictive validity (prediction of outcomes), which have been the focus of several recent studies. An operational framework for screening tool selection is provided to contextualise the findings. RECENT FINDINGS: Studies of predictive and concurrent validity involving screening tools comprising a variable number of nutritional and non-nutritional items (some nonmodifiable) have yielded inconsistent results. The use of one tool as a gold standard to judge the relative merits of other tools can be misleading because there is no agreed gold standard and different tools were designed for diagnostic, prognostic or other purposes. The use of observed outcomes (without nutritional intervention) as the gold standard may not adequately reflect the value of tools designed to assess nutritional status and need for nutritional intervention. SUMMARY: Over-reliance on concurrent and predictive validity can be confusing and even counter-productive if used inappropriately. A proposed framework for screening tool selection indicates many factors should be considered so that there is purpose and harmony between the screening tool and the screening programme.

Contribution of intravenous medication to water and sodium intake in upper and lower gastrointestinal surgical patients.

OBJECTIVES: The quantitative importance of prescribed intravenous (IV) medication to water and sodium intake in routine clinical practice is undocumented, with uncertain influence on clinical outcomes. The present study aimed to redress this issue in surgical patients with gastrointestinal problems. METHODS: The prescription and administration of IV medication and fluids were retrospectively reviewed for water and sodium over 24-h periods in 86 patients in upper and lower gastrointestinal surgical wards in two teaching hospitals. Changes over 5 y were assessed in the same two wards using the same methodology. RESULTS: Among 90.7% of patients prescribed IV medication, the median intake was 272 mL water/d (range, 40-2687 mL water/d) and 27 mmol sodium/d (range, 2-420 mmol sodium/d), with no significant difference between hospitals or ward type. In 28.2% of patients receiving any infusates, the only source of water and sodium was IV medication, and in 14.3% of patients, the medication provided more sodium than other infusates. Antibiotic agents and paracetamol accounted for 58.3% of water and 52.3% of sodium in IV medication. Historic data of IV medicine-related water and sodium intake did not differ significantly from current data. The literature suggests that clinical outcomes can be modulated by variations in water and sodium intake well within the range provided by IV medication. CONCLUSION: IV medicine prescriptions, particularly antibiotic agents and paracetamol, can make substantial and clinically relevant contributions to daily water and sodium intake. These contributions have persisted over time and should be considered during routine assessments of fluid balance and interventions aiming to improve clinical outcomes.

Smaller organ mass with greater age, except for heart.

Autopsy/cadaver data indicate that many organs and tissues are smaller in the elderly compared with young adults; however, in vivo data are lacking. The aim of this study was to determine whether the mass of specific high-metabolic-rate organs is different with increasing age, using MRI. Seventy-five healthy women (41 African-Americans and 34 Caucasians, age range 19-88 yr) and 36 men (8 African-Americans and 28 Caucasians, age range 19-84 yr) were studied. MRI-derived in vivo measures of brain, heart, kidneys, liver, and spleen were acquired. Left ventricular mass (LVM) was measured by either echocardiography or cardiac gated MRI. Total body fat mass and fat-free mass (FFM) were measured with a whole body dual-energy X-ray absorptiometry (DXA) scanner. Multiple regression analysis was used to investigate the association between the organ mass and age after adjustment for weight and height (or DXA measures of FFM), race, sex, and interactions among these variable. No statistically significant interaction was found among age, sex, and race in any regression model. Significant negative relationships between organ mass and age were found for brain (P < 0.0001), kidneys (P = 0.01), liver (P = 0.001), and spleen (P < 0.0001). A positive relationship between LVM and age was found after adjustment for FFM (P = 0.037). These findings demonstrate that age has a significant effect on brain, kidneys, liver, spleen, and heart mass. The age effect was independent of race and sex.

A systematic review and meta-analysis of the risk of microbial contamination of aseptically prepared doses in different environments.

PURPOSE: To review microbial contamination rates about preparation of individual and batch doses using aseptic techniques within pharmaceutical (controlled) and clinical (ward and theatre) environments. METHODS: Systematic review, involving amalgamation of data using a random effect model and metaanalysis. RESULTS: A total of 19 studies from 17 reports (7277 doses), mostly single arm studies, were identified for analysis. The overall contamination rates for doses prepared in clinical environments were found to be 5.0% (95% CI; 1.8%, 13.1%, n = 8 studies) for individual doses and 2.0% (95% CI; 0.3%, 13.1%; n = 5) for doses prepared as part of a batch. Rates for doses prepared in pharmaceutical environments were found to be 1.9% (95% CI; 0.8%, 4.2%; n = 5) for individual doses and 0.0% (95% CI; 0.0%, 0.8%; n= 1) for doses prepared as part of a batch. The results indicate greater overall contamination rates of doses prepared in clinical than pharmaceutical environments, in those prepared individually than in batch preparation, and in those in which additions rather than no additions were made. Significant differences were only found between pharmaceutical and clinical environments for batch doses, and between batch and individual doses prepared in a pharmaceutical environment. The studies differed substantially in sample size, interventions and comparison conditions, especially in the clinical setting. The quality of the data was judged to be low. CONCLUSION: Contamination rates in clinical and pharmaceutical environments were commonly found to be unacceptably high. Intuitive recommendations for reducing contamination rates by carrying out the procedures in a pharmaceutical environment using batch doses are supported by an evidence base that needs to be strengthened further.

Nutritional self-screening in <1 min: Evaluation of a measuring station using sonic measurement of height.

OBJECTIVE: Since nutritional screening is not routinely and accurately performed by busy care workers, the aim of this study was to evaluate a self-screening electronic measuring station that includes sonic height measurements. METHODS: In all, 114 patients, 18 to 85 y of age and attending gastrointestinal outpatient clinics, followed automatically triggered audio-recorded instructions for weight and height measurements. The patients also provided information about unintentional weight loss to establish malnutrition risk using the Malnutrition Universal Screening Tool (MUST). In 56 healthy individuals, the effect of head/foot positions on height was examined using video-recordings. Laboratory studies examined the effects of hair/wigs, the position of a skull and horizontal plates and ambient conditions. Measurements were also made on a mechanical machine for comparison. RESULTS: Of the patients, 21.9% were malnourished, with 99% agreement between sonic and mechanical machine categorization. Patients self-screened in only 35.6 ± 14.8 s (median 32 s) and 77% rated the screening as very easy (22%, easy), despite encountering some remediable snags. Within-subject precision for height was 0.186 cm in healthy individuals and 0.368 cm in patients. Humidity and barometric pressure had negligible/undetectable effects on height measurements, but temperature corrections were confounded by calibration errors. In the most lateral standing positions, height was underestimated curvilinearly. In healthy individuals, height measurements were 0.353 ± 0.542 cm lower on the sonic than mechanical device, which was inadequately explained by standing position or body tilt, although hair was found to be "invisible" only to the sonic machine. CONCLUSION: A method has been developed to rapidly and reliably self-screen for malnutrition using MUST, avoiding calculation and categorization errors, while providing results that can be immediately printed or transmitted electronically into patient notes.

Influence of deprivation on health care use, health care costs, and mortality in COPD.

BACKGROUND AND AIM: Deprivation is associated with the incidence of COPD, but its independent impact on clinical outcomes is still relatively unknown. This study aimed to explore the influence of deprivation on health care use, costs, and survival. METHODS: A total of 424 outpatients with COPD were assessed for deprivation across two hospitals. The English Index of Multiple Deprivation (IMD) was used to establish a deprivation score for each patient. The relationship between deprivation and 1-year health care use, costs, and mortality was examined, controlling for potential confounding variables (age, malnutrition risk, COPD severity, and smoking status). RESULTS: IMD was significantly and independently associated with emergency hospitalization (ß-coefficient 0.022, SE 0.007; p=0.001), length of hospital stay, secondary health care costs (ß-coefficient £101, SE £30; p=0.001), and mortality (HR 1.042, 95% CI 1.015-1.070; p=0.002). IMD was inversely related to participation in exercise rehabilitation (OR 0.961, 95% CI 0.930-0.994; p=0.002) and secondary care appointments. Deprivation was also significantly related to modifiable risk factors (smoking status and malnutrition risk). CONCLUSION: Deprivation in patients with COPD is associated with increased emergency health care use, health care costs, and mortality. Tackling deprivation is complex; however, strategies targeting high-risk groups and modifiable risk factors, such as malnutrition and smoking, could reduce the clinical and economic burden.

Cost-effectiveness of oral nutritional supplements in older malnourished care home residents.

BACKGROUND & AIMS: Malnutrition is common in care home residents, but information on the cost-effectiveness of nutritional interventions is lacking. This study, involving a randomised trial in care home residents, aimed to examine whether oral nutritional supplements (ONS) are cost-effective relative to dietary advice. METHODS: An incremental cost-effectiveness analysis was undertaken prospectively in 104 older care home residents (88 ± 8 years) without overt dementia, who were randomised to receive either ONS or dietary advice for 12 weeks. Costs were estimated from resource use and quality adjusted life years (QALYs) from health-related quality of life, assessed using EuroQoL (EQ-5D-3L, time-trade-off) and mortality. The incremental cost-effectiveness ratio (ICER) was calculated using 'intention to treat' and 'complete case' analyses. RESULTS: The ONS group gained significantly more QALYs than the dietary advice group at significantly greater costs. The ICER (extra cost per QALY gained), adjusted for nutritional status, type of care, baseline costs and quality of life, was found to be £10,961 using the 'intention to treat' analysis (£190.60 (cost)/0.0174 (QALYs); n = 104) and £11,875 using 'complete case' analysis (£217.30/0.0183; n = 76) (2016 prices). Sensitivity analysis based on 'intention to treat' data indicated an 83% probability that the ICER was ≤£20,000 and 92% that it was ≤£30,000. With the 'complete case data' the probabilities were 80% and 90% respectively. CONCLUSION: This pragmatic randomised trial involving one of the oldest populations subjected to a cost-utility analysis, suggests that use of oral nutritional supplements in care homes are cost-effective relative to dietary advice.