Evaluating the impact of using a wound-specific oral nutritional supplement to support wound healing in a rehabilitation setting.

Chronic wounds adversely affect patient quality of life, increase the risk of mortality, and impose high costs on healthcare systems. Since protein-energy malnutrition or specific nutrient deficiencies can delay wound healing, nutritionally focused care is a key strategy to help prevent or treat the occurrence of non-healing wounds. The objective of our study of inpatients in a rehabilitation hospital was to quantify the effect of daily wound-specific oral nutritional supplementation (WS-ONS) on healing chronic wounds. Using electronic medical records, we conducted a retrospective analysis of patients with chronic wounds. We identified records for (a) a treatment group who received standard wound care + usual hospital diet + daily WS-ONS for ≥14 days, and (b) a control group who received standard wound care + a usual hospital diet. We collected data for demographics, nutritional status, and wound-relevant health characteristics. We examined weekly measurements of wound number and sizes (surface area for superficial wounds or volume for non-superficial wounds). There were 341 patients identified, 114 with 322 wounds in the treatment group and 227 patients with 420 wounds in the control group. We found that rehabilitation inpatients who were given nutritional support had larger wounds and lower functional independence on admission. At discharge, wound area reduction (percent) was nearly two-fold better in patients who were given daily WS-ONS + usual hospital diet compared to those who consumed usual diet only (61.1% vs 34.5%). Overall, weekly wound improvement (lowered wound area or wound volume) was more likely in the WS-ONS group than in the Control group, particularly from the start of care to week 2. Inpatients with largest wounds and lowest functional independence on admission were most likely to be given WS-ONS, an indication that caregivers recognised the need for supplementation. Week-to-week improvement in wound size was more likely in patients who received WS-ONS than in those who did not. Specifically, wound areas and wound volumes were significantly lower at discharge among patients who were given specialised nutritional support. More research in this field is needed to improve care and reduce healthcare costs.

A nutritionally focused program for community-living older adults resulted in improved health and well-being.

OBJECTIVES: Among older adults, malnutrition is common and is associated with increased risk for impaired health and functionality, conditions further associated with poorer quality of life. In this study of community-living older adults, our objective was to quantify outcome changes following identification and treatment of malnutrition or its risk. DESIGN: Our intervention was a nutritional quality improvement program (QIP). The nutritional QIP included: (i) education of participants about the importance of complete and balanced macro- and micronutrient intake plus physical exercise, (ii) nutritional intervention with dietary counseling; and (iii) provision of oral nutritional supplements (ONS) for daily intake over 60 days. Follow-up measurements took place 30 days after ONS treatment ended, i.e., 90 days after start of intervention. SETTING AND PARTICIPANTS: We recruited 618 transitional-care, chronically ill, older adults (>60 years) with malnutrition/risk (per Mini Nutrition Assessment-Short Form, MNA-SF) from the outpatient clinic of Hospital Universitario San Ignacio, in Bogotá, Colombia. METHODS: For pre-post comparisons, we examined cognition (Mini-Mental State Exam, MMSE), physical abilities (Barthel Activities of Daily Living, ADL; Short Physical Performance Battery, SPPB), affective disorder status (Global Depression Scale, GDS), and quality of life (QoL; EuroQoL-5D-3L, EQ-5D-3L; EuroQoL-Visual Analog Scale, EQ-VAS). RESULTS: Participants were mean age 74.1 ± 8.7 y, female majority (69.4%), and had an average of 2.6 comorbidities with cardiovascular and respiratory diseases predominant (28.5%). QIP-based nutritional intervention led to significant improvements in cognitive (MMSE) and physical functions (ADL and SPPB), affective disorder status (GDS), and health-related quality of life (EQ-VAS); all differences (P < 0.001). Self-reported QoL (EQ-5D-3L) also improved. CONCLUSIONS AND IMPLICATIONS: Over 90 days, the nutritional QIP led to improvements in all measured outcomes, thus highlighting the importance of addressing malnutrition or its risk among community-living older adults. From a patient's perspective, maintaining mental and physical function are important and further linked with quality of life. BRIEF SUMMARY: For older, community-living adults, nutrition care can improve health and well-being outcomes. Care includes screening for malnutrition risk, dietary and exercise counseling, and daily nutritional supplements when needed. GOV IDENTIFIER: NCT04042987.

Use of a nutrition-focused quality improvement program for community-living older adults at malnutrition risk is associated with better nutritional outcomes.

BACKGROUND & AIMS: Among older adults, malnutrition or its risk is common and is associated with increased morbidity and mortality plus increased need for healthcare utilization. We aimed to identify and treat malnutrition risk among older adults who received care at an outpatient clinic after a recent hospitalization and/or for management of a chronic disease. METHODS: From the outpatient clinic of Hospital Universitario San Ignacio, Bogotá, Colombia, we recruited older adults (>60 years) with malnutrition or its risk according to the Mini Nutritional Assessment-Short Form (MNA-SF). Patients were excluded if they had dementia or were not expected to live 90 days or more. Intervention was a nutrition-focused quality improvement program (QIP) including: i) education of patients and caregivers about the health importance of complete and balanced macro- and micronutrient intake plus physical exercise; and ii) nutritional intervention with dietary counseling and provision of oral nutritional supplements (ONS) for daily intake. To assess the effect of our intervention, we collected nutritional outcome data pre- and post-participation of patients in the nutrition-focused QIP. For pre-post comparisons, we used MNA-SF scores and calf circumference (a proxy for leg muscle mass) measures along with nutrition-related anthropometric determinations of body weight and body mass index (BMI). The ONS treatment phase was 60 days, with follow-up measurements up to 30 days after ONS treatment ended (90 days after intervention start). RESULTS: Of 677 enrolled patients, 618 completed the QIP, while 565 had complete anthropometric data. Patients had a mean age of 74.1 ± 8.7 years, an average of 2.6 comorbidities, included a high proportion of females (69.4%), with medium socioeconomic status (76%). After QIP intervention, 324 (52.4%) patients had improvement in nutritional outcomes; improvement was significant in all four measures (P-values < 0.001). Higher ONS adherence was associated with the highest improvement in nutritional status. CONCLUSIONS: For community-living older adults receiving outpatient care, comprehensive nutritional care offered via a nutrition-focused QIP was associated with significant improvements in indicators of nutritional status (MNA-SF scores and calf circumference) and maintenance or improvements in nutrition-related anthropometric measures (body weight and BMI). GOV IDENTIFIER: NCT04042987.

Implementation of malnutrition quality improvement reveals opportunities for better nutrition care delivery for hospitalized patients.

BACKGROUND: Gaps in hospital-based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services. METHODS: Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019. RESULTS: Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001). CONCLUSIONS: The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.

Hospital nutrition care informs potential cost-savings for healthcare: A budget impact analysis.

BACKGROUND AND AIM: In Mexico, about half of hospitalized patients are malnourished or at risk of malnutrition upon hospital admission, while many others experience deterioration of their nutritional status while in the hospital. Such patients often experience poor health outcomes and have increased hospital costs. The aim of our budget-impact analysis was to estimate potential savings associated with the implementation of a Mexican hospital-based program of nutrition care for patients at malnutrition risk or malnourished. METHODS: The budget-impact model was based on data published previously. Our model compared patients assigned to receive individualized early nutrition therapy (initiated within 24-48 h of hospital admission) with those who received standard delayed nutrition therapy (not initiated early). Outcomes included length of stay, infectious complications, and 30-day readmissions. We modeled a 30-day time-horizon, estimated event probabilities on the basis of published data, and projected costs in 2020 US dollars. RESULTS: Average total healthcare costs over 30-days were $3527 for patients with early nutrition therapy vs $6032 for patients with standard nutrition therapy-a savings of $2505 per early nutrition-treated patient (41.5% lower). Cost differences between the groups were $2336 vs $3065 for hospital-associated costs (23.8% lower), $262 vs $780 for 30-day readmissions (66.4% lower) and $1348 for malnutrition-associated infections. Applying these potential savings from individualized early nutrition care to a one-year estimate of 3.22 million Mexican hospital patients with malnutrition or its risk, the total overall savings for public health expenditures was equivalent to $8.1 billion per year or 32.1% of total healthcare expenditures. CONCLUSIONS: The results demonstrated the potential for hospital-based nutrition care programs to reduce costs of patient hospitalizations. These notable findings provide a rationale for Mexican healthcare institutions to implement programs of comprehensive nutrition-focused care for inpatients with malnutrition or its risk. To this end, we advise implementation of professional programs for education and training in order to increase awareness of patients' nutritional needs and to better prepare clinical personnel to identify, treat, and monitor patients at-risk/malnourished.

Postoperative Utilization of Oral Nutrition Supplements in Surgical Patients in US Hospitals.

BACKGROUND: Postoperative nutrition delivery is essential to surgical recovery; unfortunately, postoperative dietary intake is often poor. Recent surgical guidelines recommend use of oral nutritional supplements (ONS) to improve nutrition delivery. Our aim was to examine prevalence of coded ONS use over time and coded malnutrition rates in postoperative patients. METHODS: The Premier Healthcare Database (PHD) was queried for postoperative patients found to have charges for ONS between 2008-2014. ONS use identified via charge codes. Descriptive statistics utilized to examine prevalence of malnutrition and ONS utilization. Multilevel, multivariable logistic regression models were fit to examine factors associated with ONS use. RESULTS: A total of 2,823,532 surgical encounters were identified in PHD in 172 hospitals utilizing ONS charge codes. ONS-receiving patients were 72% Caucasian, 65% Medicare patients with mean age of 66 ± 16.5 years. Compared with patients not receiving ONS, ONS patients had higher van Walraven severity scores (7.3 ± 7.8 vs 2.3 ± 5.6, P < .001) with greater comorbidities. Overall coded malnutrition prevalence was 4.3%. Coded malnutrition diagnosis increased from 4.4% to 5.2% during study period. Only 15% of malnourished patients received ONS. Individual hospital practice explained much of variation in early postoperative ONS use. CONCLUSION: In this large surgical population, inpatient ONS use is most common in older, Caucasian, Medicare patients with high comorbidity burden. Despite increased malnutrition during study period, observed ONS prescription rate did not increase. Our data indicate current ONS utilization in surgical patients, even coded with malnutrition, is limited and is a critical perioperative quality improvement opportunity.

Community-Dwelling Adults at Nutrition Risk: Characteristics in Relation to the Consumption of Oral Nutritional Supplements.

Purpose: Nutrition risk and utilization rate of simple but effective interventions such as oral nutritional supplementation (ONS) in community settings in the United States, particularly among older adults, has received little emphasis. We conducted a cross-sectional study of community-dwelling adults ≥55 years of age and living independently to assess their risk of poor nutrition and characteristics in relation to ONS consumption. Methods: Demographic characteristics, activities of daily living (ADL), and health care resource utilization in the past 6 months were also collected via telephone survey. Nutrition risk was assessed with the abridged Patient-Generated Subjective Global Assessment (abPG-SGA) and the DETERMINE Checklist. A logistic regression model tested possible predictors of ONS use. Results: Of 1001 participants surveyed, 996 provided data on ONS use and 11% (n = 114) reported consuming ONS during the past 6 months. ONS users were more likely to be at high nutrition risk than nonusers based on both abPG-SGA (43% vs 24%, P < .001) and DETERMINE Checklist (68% vs 48%, P < .001) scores. ONS users reported less functional independence based on ADL scores (86% vs 92%, P = .03), taking ≥3 medications/day (77% vs 53%, P < .001), and utilizing more health care services. Higher nutrition risk (per abPG-SGA), lower body mass index, hospitalization in the past 6 months, and ≥3 medications/day were each independently associated with ONS use (P < .05). Conclusions: Although one in four, urban community-dwelling adults (≥55 years of age) were classified as at high nutrition risk in our study, only 11% reported consuming ONS-a simple and effective nutrition intervention. Efforts to improve identification of nutrition risk and implement ONS interventions could benefit nutritionally vulnerable, community-dwelling adults.

Targeting malnutrition: Nutrition programs yield cost savings for hospitalized patients.

BACKGROUND & AIMS: Between 30 and 50% of Colombian patients are malnourished or at-risk of malnutrition on hospital admission. Malnutrition is associated with poor outcomes and increased costs. We used cost modeling to estimate savings that could be derived from implementation of a nutrition therapy program for patients at malnutrition risk. METHODS: The budget impact analysis was performed using previously-published outcomes data. Outcomes included length of stay, 30-day readmissions, and infectious/non-infectious complications. We developed a Markov model that compared patients who were assigned to receive early nutrition therapy (started within 24-48 h of hospital admission) with those assigned to receive standard nutrition therapy (not started early). Our model used a 60-day time-horizon and estimated event probabilities based on published data. RESULTS: Average total costs over 60 days were $3770 US dollars for patients with delayed nutrition therapy vs $2419 for patients with early nutrition therapy-a savings of $1351 (35.8% decrease) per nutrition-treated patient. Cost differences between the groups were: $2703 vs $1600 for hospital-associated costs; $883 vs $665 for readmissions; and $176 vs $94 for complications. Taken broadly, the potential costs savings from a nutrition care program for an estimated 638,318 hospitalized Colombian patients at malnutrition risk is $862.6 million per year. CONCLUSIONS: Our budget impact analysis demonstrated the potential for hospital-based nutrition care programs to improve health outcomes and reduce healthcare costs for hospitalized patients in Colombia. These findings provide a rationale for implementing comprehensive nutrition care in Colombian hospitals.

Similar health economic outcomes in low-risk and high-risk malnourished inpatients as screened by the Malnutrition Screening Tool after delivery of oral nutritional supplements.

OBJECTIVE: The aim of this study was to determine whether modified low- and high-risk Malnutrition Screening Tool (MST) scores (2 versus >2, respectively) were independently predictive of health economic outcomes. METHODS: We analyzed data from a recent nutrition-based quality improvement program (QIP) that prescribed daily oral nutritional supplements for all hospitalized adults at risk for malnutrition. In the original study, an electronic medical records-based MST was administered at the time of admission, and patients were classified as "low risk" or "high risk" for malnutrition based on MST scores (2 versus ≥2). We compared health economic outcomes for patients at low or high risk for malnutrition based on a modified score (MST = 2 versus >2, respectively), looking for between-group differences in length of stay (LOS) and unplanned 30-d readmissions. Analyses were additionally stratified by age (<65 versus ≥65 y of age). RESULTS: Of the 1269 patients enrolled in the QIP, 413 (32.5%) had MST of 2 and 856 (67.5%) had MST >2. Mean LOS was 5.19 d (±4.78) for patients with MST 2 and 4.49 d (±4.69) with MST >2 (non-statistically significant between-group difference; P = 0.277). There were no significant differences in unplanned 30-d readmission rates (14% for low-risk and 17.1% for high-risk patients; P = 0.171). These findings remained statistically insignificant when the low- and high-risk MST score groups were further stratified by age. CONCLUSIONS: Outcomes of hospitalized patients with MST 2 were not significantly different from those with an MST >2. This suggests that patients at both lower and higher risk for malnutrition (based on MST scores of 2 versus ≥3) were similar in terms of LOS and 30-d readmission rates. To avoid overlooking cases of malnutrition risk, the validated cutoff scores for the MST should be consistently implemented. Training that is consistent with the validated MST is recommended rather than attempting to reduce the case burden by "raising the bar" and attempting to classify patients with an MST = 2 as "low risk."

The Association between Oral Nutritional Supplements and 30-Day Hospital Readmissions of Malnourished Patients at a US Academic Medical Center.

BACKGROUND: Malnutrition affects up to 50% of hospitalized patients and contributes to adverse health and economic outcomes, but often remains unrecognized or undertreated. OBJECTIVE: This study assessed the utilization of oral nutritional supplements (ONS) and its association with the number of 30-day unplanned hospital readmissions of adult malnourished patients in comparison with the readmissions rates of their malnourished counterparts who did not receive ONS. DESIGN: This was a retrospective cohort study. PARTICIPANTS/SETTING: Of 153,161 inpatient encounters analyzed, a total of 8,713 (5.7%) malnourished adults admitted to an academic medical center hospital in the United States between October 1, 2016, and September 30, 2017 were included in the analyses. The study utilized records of patients at risk of malnutrition on admission and subsequently diagnosed as malnourished by a registered dietitian following established criteria. MAIN OUTCOMES MEASURES: ONS utilization rate, hospital length of stay (LOS), and 30-day unplanned hospital readmissions data were obtained from electronic medical records. STATISTICAL ANALYSES PERFORMED: The associations between the number of 30-day unplanned hospital readmissions and ONS use were analyzed using mixed-effects negative binomial regression models, with coefficients and 95% CIs reported. Important covariates such as age, sex, and the severity of illness index were included in the regression models. RESULTS: Only 3.1% of malnourished patients received ONS. ONS users had 38.8% fewer readmissions compared with non-ONS counterparts (P=0.017). The reduction in hospital readmissions by ONS was even greater for oncology patients (46.1%, P<0.001). A 50% reduction in time from hospital admission to ONS provision was associated with a 10.2% (P<0.01), 10.2% (P=0.014), and 16.6% (P<0.01) decrease in LOS for overall, oncology, and intensive care unit encounters, respectively. CONCLUSIONS: In a large cohort of malnourished adult inpatient encounters, ONS provision rate was low, but when used, ONS intervention was associated with 38.8% fewer 30-day readmissions. This association was more pronounced for oncology encounters. Shorter LOS was observed when the interval between admission and ONS initiation was shorter. Reduced LOS and readmissions rates could result in financial benefits for health care systems prioritizing hospital nutrition care, in addition to informing significant medical benefits for their patients.

Prevalence and characteristics of malnutrition among community-dwelling older adults in Israel.

BACKGROUND & AIMS: Limited data are available on the characteristics of older adults (age ≥ 65) diagnosed with malnutrition in the community in Israel. This retrospective cohort study describes the prevalence and characteristics of malnutrition among a representative cohort of Israeli community-dwelling older adults. To better understand the characteristics of oral nutritional supplement (ONS) users with malnutrition, we also compared this group to non-ONS users with malnutrition. METHODS: Older adults enrolled in a large not-for-profit healthcare organization in Israel were defined as malnourished according to a diagnosis of malnutrition and/or body mass index (BMI) ≤ 20 kg/m2. Index date was defined by the earliest indication of malnutrition. ONS purchases in the year following index date were used to classify patients into ONS and non-ONS users. RESULTS: The malnutrition prevalence rate was 3.4%. ONS users comprised 19.9% (1881/9445) of the malnourished patients. The mean age of ONS users was higher than that of non-ONS users (80.5 vs. 75.4 years, P ≤ 0.001), and women were predominant in both groups (59.2% ONS users vs. 61.8% non-ONS users, P = 0.04). ONS users (vs. non-ONS users) were significantly (P < 0.05) more likely to have co-morbidities such as cardiovascular disease (49.5% vs. 35.1%), diabetes mellitus (26.5% vs. 20.9%), hypertension (72.2% vs. 57.4%), cancer (32.0% vs. 20.7%), and dementia (24.8% vs. 9.8%). Mean baseline BMI (up to a year before index date) was similar in ONS users (20.74 kg/m2) and non-ONS users (20.26 kg/m2). ONS users had higher health services utilization, including visits to primary care physicians and dietitians, and hospitalizations (P-values < 0.05). CONCLUSIONS: Malnutrition is prevalent among 3.4% of community-dwelling older Israeli adults. However, older adults are not screened and treated for malnutrition systematically. Improved guidance from healthcare professionals, including earlier nutrition screening and assessment, may lead to improved health outcomes and reduced healthcare services utilization.

A Comprehensive Nutrition-Focused Quality Improvement Program Reduces 30-Day Readmissions and Length of Stay in Hospitalized Patients.

BACKGROUND: Although screening patients for malnutrition risk on hospital admission is standard of care, nutrition shortfalls are undertreated. Nutrition interventions can improve outcomes. We tested effects of a nutrition-focused quality improvement program (QIP) on hospital readmission and length of stay (LOS). MATERIALS AND METHODS: QIP included malnutrition risk screening at admission, prompt initiation of oral nutrition supplements (ONS) for at-risk patients, and nutrition support. A 2-group, pre-post design of malnourished adults with any diagnosis was conducted at 4 hospitals: QIP-basic (QIPb) and QIP-enhanced (QIPe). Comparator patients had a malnutrition diagnosis and ONS orders. For QIPb, nurses screened all patients on admission using an electronic medical record (EMR)-cued Malnutrition Screening Tool (MST); ONS was provided to patients with MST scores ≥2 within 24-48 hours. QIPe had ONS within 24 hours, postdischarge nutrition instructions, telephone calls, and ONS coupons. Primary outcome was 30-day unplanned readmission. We used baseline (January 1-December 31, 2013) and validation cohorts (October 13, 2013-April 2, 2014) for comparison. RESULTS: Patients (n = 1269) were enrolled in QIPb (n = 769) and QIPe (n = 500). Analysis included baseline (n = 4611) and validation (n = 1319) comparator patients. Compared with a 20% baseline readmission rate, post-QIP relative reductions were 19.5% for all QIP, 18% for QIPb, and 22% for QIPe, respectively. Compared with a 22.1% validation readmission rate, relative reductions were 27.1%, 25.8%, and 29.4%, respectively. Similar reductions were noted for LOS. CONCLUSIONS: Thirty-day readmissions and LOS were significantly lowered for malnourished inpatients by use of an EMR-cued MST, prompt provision of ONS, patient/caregiver education, and sustained nutrition support.

A randomized controlled trial to determine the effects of music and relaxation interventions on perceived anxiety in hospitalized patients receiving orthopaedic or cancer treatment.

BACKGROUND: Nonpharmacological interventions, including combinations of music, education, coping skills, and relaxation techniques, have been found to have a positive effect on patients' perceived anxiety in many settings. However, few research studies have assessed and compared the effectiveness of music and relaxation interventions in reducing the anxiety levels of orthopaedic and oncology patients. PURPOSE: We conducted a prospective, randomized, controlled study to examine the effectiveness of music and relaxation interventions on perceived anxiety during initial hospitalization for patients receiving orthopaedic or cancer care treatment at a Midwestern teaching hospital. METHOD: This was a pre-test/post-test study design utilizing the State-Trait Anxiety Inventory. One hundred twelve patients were randomized into 3 study groups. Thirty-eight subjects (34%) were randomized in the music-focused relaxation group, 35 subjects (31%) in the music and video group, and 39 (35%) subjects in the control group. Fifty-seven (51%) were orthopaedic patients and 55 (49%) were oncology patients. RESULTS: Comparison of the 3 study groups showed no statistically significant differences with regard to patients' demographics. Although reduced anxiety levels were reported for all 3 groups postintervention, the differences were not statistically significant (p > .05). Also, there was no significant difference found between the perceived anxiety levels of patients admitted to the orthopaedic and oncology care units (p > .05). Finally, the results of the intragroup comparisons (regardless of the group assignment) showed a significant decrease in anxiety levels reported by all patients postintervention (p < .001). CONCLUSIONS: Music and relaxation interventions could be an additional tool in assisting patients to become less anxious during their hospital stay. Music focused relaxation and music and video are both valuable and cost-effective strategies that can assist the orthopaedic and oncology patient population. Identifying opportunities to make these interventions easily accessible to healthcare professionals can assist in the management of patient anxiety during hospitalization.