Community-Based Health Financing and Child Stunting in Rural Rwanda.

OBJECTIVES: We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. METHODS: We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. RESULTS: Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). CONCLUSIONS: This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.

Practice paper of the academy of nutrition and dietetics: principles of productivity in food and nutrition services: applications in the 21st century health care reform era.

Food and nutrition services, along with the health care organizations they serve, are becoming increasingly complex. These complexities are driven by sometimes conflicting (if not polarizing) human, department, organization, and environment factors and will require that managers shift how they think about and approach productivity in the context of the greater good of the organization and, perhaps, even society. Traditional, single-factor approaches to productivity measurements, while still valuable in the context of departmental trend analysis, are of limited value when assessing departmental performance in the context of an organization's goals and values. As health care continues to change and new models of care are introduced, food and nutrition services managers will need to consider innovative approaches to improve productivity that are consistent with their individual health care organization's vision and mission. Use of process improvement tools such as Lean and Six Sigma as strategies for evaluating and improving food and nutrition services efficiency should be considered.

A state-level examination of the association between home and community-based services and rates of nursing home residency with special attention to nutrition programs.

Federal food and nutrition programs implemented by the Administration on Aging and funded by the Older Americans Act (OAA) seek to enable older adults to remain in their homes and communities through a comprehensive, coordinated, and cost-effective array of services. We hypothesized that expenditures devoted to nutrition programs for home and community-based nutrition services were inversely related to changes in state-level rates of institutionalization for older adults from one year to the next, such that states that spend more money per capita on community-based nutrition programs would have smaller increases or greater decreases in rates of institutionalization, controlling for expenditures on other home and community-based services. We found, however, that there was not an effect of OAA Nutrition Services on the change in rates of nursing home residency. We noted, though, that states that direct a greater proportion of their long-term care expenditures to home and community-based services appear to have more reduction in their rates of nursing home residency. Further longitudinal work at the state and individual levels is warranted.

Developing dietetic positions in rural areas: what are the key lessons?

INTRODUCTION: Rural and remote communities in Australia are typically underserviced by dietitians. The recruitment of dietitians to rural areas has improved in recent years; however, retention remains an issue. Key factors that lead to an increase in funding and the development of more dietetic positions in rural areas are unknown. The purpose of this study was to describe dietetic services in rural areas and to determine the drivers for and barriers to the development of dietetic positions in rural areas. METHODS: A sequential explanatory mixed methods approach was used to examine six case study sites of dietetic service delivery in rural northern New South Wales (NSW) Australia between 1991 and 2006. The six sites represented different models of dietetic service delivery from the study area. Data sources included workforce documents and in-depth individual interviews on position development with 40 key informants, including past and present dietitians, dietetic managers and health service managers. Interview data were thematically analysed with the aid of NVivo7 (www.qsrinternational.com). Themes were coded into common categories, using a constant comparison inductive approach. RESULTS: Forty key informants agreed to participate in the in-depth, semi-structured interview. Participants included 28 dietitians (past and present), three dietetics managers and nine managers. The majority of participants were female (87.5%). Document analysis showed that the dietetic workforce had a 5.6-fold increase across the six sites over the 15 years. Themes that emerged from the interviews indicated that new positions were established through ad hoc and opportunistic funding, a gradual increase in funding or due to concerted efforts by champions advocating for increased funding. CONCLUSION: The findings from this study have important implications for the development of dietetic staffing in rural areas. There is an inconsistent approach to the development of dietetic positions in rural areas of Australia. Factors that inhibited the development of positions included a general lack of funds and competing priorities. A systematic, planned approach to the development of dietetic positions is needed in rural Australia. Champions for the development of positions were effective in increasing positions, particularly when they have management support.

Increasing supplemental nutrition assistance program/electronic benefits transfer sales at farmers' markets with vendor-operated wireless point-of-sale terminals.

BACKGROUND: Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamp Program) participants can use their benefits at many farmers' markets. However, most markets have only one market-operated wireless point-of-sale (POS) card swipe terminal for electronic benefits transfer (EBT) transactions. It is not known whether providing each farmer/vendor with individual wireless POS terminals and subsidizing EBT fees will increase SNAP/EBT purchases at farmers' markets. OBJECTIVE: To evaluate the effects of multiple vendor-operated wireless POS terminals (vs a single market-operated terminal) on use of SNAP benefits at an urban farmers' market. DESIGN: Time-series analyses of SNAP/EBT sales. SETTING: The Clark Park farmers' market in West Philadelphia, PA, which accounts for one quarter of all SNAP/EBT sales at farmers' markets in Pennsylvania. INTERVENTION: Vendors were provided with individual wireless POS terminals for 9 months (June 2008-February 2009.) The pilot program covered all equipment and wireless service costs and transaction fees associated with SNAP/EBT, credit, and debit sales. MAIN OUTCOME MEASURE: Monthly SNAP/EBT sales at the Clark Park farmers' market. STATISTICAL ANALYSES: SNAP/EBT sales data were collected for 48 months (January 2007-December 2010). Time-series regression analysis was used to estimate the effect of the intervention period (June 2008-February 2009) on SNAP/EBT sales, controlling for seasonal effects and total SNAP benefits issued in Philadelphia. RESULTS: The intervention was associated with a 38% increase in monthly SNAP/EBT sales. Effects were greatest during the busy fall market seasons. SNAP/EBT sales did not remain significantly higher after the intervention period. CONCLUSIONS: Providing individual wireless POS terminals to farmers' market vendors leads to increased sales. However, market vendors indicated that subsidies for equipment costs and fees would be needed to break even. Currently, SNAP provides some support for these services for supermarket and other SNAP retailers with landline access, but not for farmers' markets.

Cost-effectiveness of medical nutrition therapy and therapeutically designed meals for older adults with cardiovascular disease.

BACKGROUND: Many older adults experience hyperlipidemia and hypertension, but there is little information about whether medical nutrition therapy (MNT) or therapeutic meals have independent or joint beneficial effects on older adults with these diagnoses. OBJECTIVE: To assess the cost-effectiveness of MNT and therapeutic meals for older adults with hyperlipidemia and/or hypertension. DESIGN: A 1-year prospective four-arm controlled randomized community-based clinical trial. SUBJECTS/SETTING: Participants were people ages 60 years or older residing in community settings who were medically diagnosed with either hypertension or hyperlipidemia. They were recruited through a number of venues beginning in May 2003. INTERVENTION: The 321 eligible individuals were assigned to one of four arms: (a) a literature control group, (b) a therapeutic meal group that received seven diagnosis-appropriate therapeutic meals a week, (c) an MNT group, and (d) an MNT-plus-therapeutic meal group. MAIN OUTCOME MEASURE: The outcome measure was quality-adjusted life-years (QALYs). Costs included both intervention and medical costs. STATISTICAL ANALYSES: Estimations of separate models of costs and QALYs facilitated the construction of incremental cost-effectiveness ratios. Net benefit analysis produced the probability that each intervention was cost-effective given different values for society's willingness to pay for a QALY. RESULTS: Therapeutic meals are cost-effective. Using the net benefit approach and a willingness to pay of $109,000 per QALY, the probability that the therapeutic meal delivery program is cost-effective is 95% and for MNT the probability is 90%. However, the combination of MNT and therapeutic meals did not have an independent significant effect on QALYs. CONCLUSIONS: Results inform the debate about extending Medicare funding for MNT to individuals with hypertension and hyperlipidemia. Future research should include more individuals who are not currently receiving medications for these diseases.

The effects of the National School Lunch Program on education and health.

This paper estimates the effects of participating in the National School Lunch Program in the middle of the 20th century on adult health outcomes and educational attainment. I utilize an instrumental variables strategy that exploits a change in the formula used by the federal government to allocate funding to the states. Identification is achieved by the fact that different birth cohorts were exposed to different degrees to the original formula and the new formula, along with the fact that the change of the formula affected states differentially by per capita income. Participation in the program as a child appears to have few long-run effects on health, but the effects on educational attainment are sizable. These results may suggest that subsidized lunches induced children to attend school but displaced food consumption from other sources. Alternatively, the program may have had short-run health effects that dissipated over time but that facilitated higher educational attainment.

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost.

BACKGROUND: The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs. METHODS: A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available. RESULTS: Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs. CONCLUSIONS: This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Nutritional care of medical inpatients: a health technology assessment.

BACKGROUND: The inspiration for the present assessment of the nutritional care of medical patients is puzzlement about the divide that exists between the theoretical knowledge about the importance of the diet for ill persons, and the common failure to incorporate nutritional aspects in the treatment and care of the patients. The purpose is to clarify existing problems in the nutritional care of Danish medical inpatients, to elucidate how the nutritional care for these inpatients can be improved, and to analyse the costs of this improvement. METHODS: Qualitative and quantitative methods are deployed to outline how nutritional care of medical inpatients is performed at three Danish hospitals. The practices observed are compared with official recommendations for nutritional care of inpatients. Factors extraneous and counterproductive to optimal nutritional care are identified from the perspectives of patients and professional staff. A review of the literature illustrates the potential for optimal nutritional care. A health economic analysis is performed to elucidate the savings potential of improved nutritional care. RESULTS: The prospects for improvements in nutritional care are ameliorated if hospital management clearly identifies nutritional care as a priority area, and enjoys access to management tools for quality assurance. The prospects are also improved if a committed professional at the ward has the necessary time resources to perform nutritional care in practice, and if the care staff can requisition patient meals rich in nutrients 24 hours a day. At the kitchen production level prospects benefit from a facilitator contact between care and kitchen staff, and if the kitchen staff controls the whole food path from the kitchen to the patient. At the patient level, prospects are improved if patients receive information about the choice of food and drink, and have a better nutrition dialogue with the care staff. Better nutritional care of medical patients in Denmark is estimated to hold a cost savings potential reaching approximately USD 22 million. CONCLUSION: Every hospital and every bed ward has its strengths and weaknesses, but none of the participating bed wards fully satisfy nutritional care success criteria. All organisational levels have a significant potential for improvements of nutritional care of medical inpatients.

Health system frailties in tuberculosis service provision in Russia: an analysis through the lens of formal nutritional support.

OBJECTIVE: The aim of this study was to describe health system challenges faced by tuberculosis (TB) treatment facilities in Russia through an analysis of formal institutional dietary provisions to patients in an inpatient facility that provides care for poor patients. METHODS: Analysis of formal dietary provisions by institutions and financing data from TB hospitals in Samara Oblast, Russia. RESULTS: Formal dietary provision for inpatients with TB has fallen substantially in recent years. In a hospital providing inpatient care for the poorest patients with fewest social support networks, this has been very pronounced. The likely reason for this is that financial support for other budget lines, principally salaries, has required protection. CONCLUSION: Formal institutional nutritional support in institutions providing care for the poorest patients with TB is unlikely to be enhancing the speed of recovery, or reducing the duration of infectiousness. Furthermore, the role that hospital may have played in the past in enabling patients to regain weight lost before admission may have been limited by reductions in formal financing. Reductions in state provision of food for patients may serve as an important illustration of wider TB control system frailties in the Russian Federation.

Systematic review of literature on the cost-effectiveness of nutrition services.

Employers and health plan directors would like to know whether it is cost-effective to include outpatient nutrition services as a covered benefit. The purpose of this systematic review was to examine the strength of evidence on the cost-effectiveness of outpatient nutrition services from an economic perspective. All randomized controlled trials published between January 1966 and September 2001 that reported on costs and effectiveness of outpatient nutrition services for any indicated condition were identified and reviewed. Paired reviewers abstracted data from and assessed the quality of each eligible randomized controlled trial; 13 studies met the eligibility criteria. Relatively consistent evidence exists to support the cost-effectiveness of nutrition services in the reduction of serum cholesterol levels (eg, 20 dollars to 1,268 dollars per mmol/L decrease in serum low-density lipoprotein level), weight loss (2.40 dollars to 10 dollars per pound lost), and blood glucose (5 dollars per mmol/L decrease), and for target populations with diabetes mellitus and hypercholesterolemia. However, the randomized controlled trials had important limitations and used different cost perspectives. Limited evidence of economic benefit exists to support coverage of outpatient nutrition services for selected indications. More randomized controlled trials of nutrition services should be conducted, taking into consideration all potential candidates for nutrition therapy and all potential costs to patients, providers, and payers.