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Abbott Nutrition Health Institute 5/31/2019

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MALNUTRITION SCREENING IN ADULTS:COMBINING EVIDENCE AND CLINICAL PRACTICE TO IMPROVE PATIENT CARE

AINSLEY MALONE

ANNALYNN SKIPPER

ANNE COLTMAN

AINSLEY MALONE, MS, RDN, LD, CNSC, FAND, FASPEN

DIETITIAN, NUTRITION SUPPORT TEAM

MT. CARMEL WEST HOSPITAL

COLUMBUS, OH, USA


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DISCLOSURES

• The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional.

• This educational event is supported by Abbott Nutrition Health Institute, Abbott Nutrition and Dietitian Connection.

• Ainsley Malone, MS, RDN, CNSC, FAND, FASPEN has no disclosures to declare.

• Annalynn Skipper, PhD, RDN, FADA, CNSC has no disclosures to declare.

• Anne Coltman, MS, RD, LDN, CNSC has no disclosures to declare.

THE ABBOTT NUTRITION HEALTH INSTITUTE

MISSIONConnect and empower people through science‐based nutrition resources to optimize health worldwide.

VISIONImprove lives through the power of nutrition.

ANHI provides nutrition continuing education and resources for you and your patients. Visit anhi.org

DIETITIANCONNECTION.COM


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OBJECTIVES

• Review the background and evolution of validated malnutrition screening tools for adults.

• Summarize new evidence on validated malnutrition screening tools.

• Discuss the use of validated malnutrition screening tools through real-world examples and clinical practice.

MALNUTRITION IS NOT A NEW ISSUE

• Example: 1936 Publication - “Percentage of Weight Loss: Basic Indicator of Surgical Risk in Patients with Chronic Peptic Ulcer”

Studley HO. J Am Med Assoc. 1936;106(6):458-60.

NUTRITION SCREENING AND THE JOINT COMMISSION – THE UNITED STATES 1995

In 1995 a Nutrition Standards Task Force was created

• “A policy must be in pace to ensure nutrition risk screening in all health care facilities”

• “The hospital completes a nutritional screening (when warranted by the patient’s needs or condition) within 24 hours after inpatient admission”

Dougherty D, et al. Nutr Clin Pract.1995;10:26-31.


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ASPEN NUTRITION SCREENING AND ASSESSMENT SURVEY 2012

Patel V, et al. Nutr Clin Pract. 2014;29:483.

ANNALYNN SKIPPER, PHD, RDN, FADA, CNSC

OAK PARK, IL, USA

ADULT NUTRITION SCREENING WORK GROUP

2018 Volunteers:

– Annalynn Skipper, PhD, RD - Chair

– Pamela Charney, PhD, RD

– Anne Coltman, MS, RD

– Judy Porcari, MBA, MS, RD

– Erin Pover, MS, RDN (resigned March, 2018)

– Jennifer Tomesko, DCN, RD

2018 Academy Staff and Consultants:

– Tami Piemonte, MS, RD

– Feon Cheng, PhD, RD


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A BRIEF NUTRITION SCREENING MEMOIR

• 1970s – screening was developed to identify candidates for enteral and parenteral nutrition

• 1970s -1990s – screening expanded to 60 or more data points based on opinion or association rather than research

• 1990s – 2000s – evidence became important – researchers began testing tools for reliability and validity – validated tools began to appear

• 2005 – after an international conference on malnutrition screening, several of us began to think of the “best” tools to use in practice

IN 2011, OUR WORKGROUP DEFINED NUTRITION SCREENING…

The process of identifying patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian

– May be conducted in any practice setting

– Tools should be quick, easy to use, valid, and reliable for the patient population or setting

– Tools and parameters are established by RDs, but screening may be conducted by others

– Nutrition screening and rescreening should occur within an appropriate time frame

Academy of Nutrition and Dietetics. Evidence Analysis Library. https://www.andeal.org ; Skipper A, et al. JPEN. 2012;36(3):292-298.

…ESTABLISHED CRITERIA FOR SCREENING TOOLS

• Quick and easy (< 10 minutes to complete)

• Acceptable reference standard

• Grade I and II evidence

• Valid

• Reliable



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… ESTABLISHED A MALNUTRITION REFERENCE STANDARD

• Agreement

• Negative Predictive Value

• Positive Predictive Value

• Reliability

• Sensitivity

• Specificity

• Construct validity

• Criterion validity

• Concurrent validity

• Predictive validity

Academy of Nutrition and Dietetics. Evidence Analysis Library. https://www.andeal.org

IN 2011, WE RESEARCHED…

What is the relationship of albumin and prealbumin to the presence of malnutrition?

• There was no relationship or insufficient data for analysis of a relationship between either albumin or prealbumin levels and malnutrition

What is the validity and reliability of 11 malnutrition screening tools?

• There was one tool with grade I evidence (NRS-2002)

• There were four tools with grade II evidence (MNA-SF, MST, MUST and Simple Two Part Tool)

NRS-2002 – Nutrition Risk Screening 2002MNA-SF – Mini Nutritional Assessment – Short FormMST – Malnutrition Screening ToolMUST – Malnutrition Universal Screening Tool

Academy of Nutrition and Dietetics. Evidence Analysis Library. https://www.andeal.org

IN 2011, WE CONCLUDED…

• Future nutrition screening research should:

– Validate screening tools against an appropriate reference standard

– Evaluate sensitivity, specificity, PPV, NPV and reliability

– Report findings in a format consistent with international guidelines to facilitate comparison to other studies

• New tools are not needed

PPV – Positive Predictive ValueNPV – Negative Predictive Value



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A LOT HAS HAPPENED SINCE 2011…

In research,

– Almost 20 new malnutrition screening tools and 300 new articles

In practice,

– Experts developed consensus definitions of malnutrition

– Screening tools and automatic referrals to RDs were incorporated into electronic record systems

– Healthcare systems have diversified far beyond the traditional hospital facilities, but the same nutrition staff often provides services in all of them

– We needed a single, valid, reliable tool that everyone could use for all

adults

ANNE COLTMAN, MS, RD, LDN, CNSC

CLINICAL NUTRITION COORDINATOR

LOYOLA UNIVERSITY MEDICAL CENTER

MAYWOOD, IL, USA

STEPS IN EAL SYSTEMATIC REVIEW PROCESS

• Develop questions on nutrition screening in the adult and pediatric populations

Step 1: Formulate the Question

• Search the literature using search terms, apply inclusion and exclusion criteria

Step 2: Gather Research

• Critically examine methodology for each article for strengths, weaknesses, and overall findings

Step 3: Appraise Articles

• Summarize each article and create an evidence summary of the research

Step 4: Summarize

• Develop a conclusion statement and assign a grade based on the strength of supporting evidence

Step 5: Grade

EAL - Evidence Analysis Library AND Evidence Analysis Library. EAL Systematic Review Process. 2018.


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RESEARCH QUESTIONS

Adults: What malnutrition screening tools have been found to be valid and reliable for adults?

Sub Questions:

1. What is the validity and reliability of each of the six nutrition screening tools for identifying malnutrition risk in adults across care settings, acute and chronic medical conditions, and ages?

2. What is the cost of the malnutrition screening procedure?

INCLUSION CRITERIA

• Adults (19 years and older)

• Published 1997- July 2017

• Undernutrition only

• Acceptable reference standard includes both assessment of body composition at a given time AND changes in body composition over time

– Examples:

• Mini Nutrition Assessment (MNA)

• Subjective Global Assessment (SGA)

• Patient Generated Subjective Global Assessment (PG-SGA)

AND Evidence Analysis Library. EAL Systematic Review Process. 2018.

FLOWCHART OF IDENTIFIED STUDIES

Records identified through database

searching (n = 24,553)

Additional records identified through other

sources (n = 7)

Records after duplicates removed

(n =18,671)

Records screened (n = 18,671)

Records excluded (n = 18,206)

Interim Screening Step

(n = 465)

Full‐text articles excluded with

reasons (n = 90)

Studies included in qualitative synthesis (n = 67)

Records excluded (n = 308)

Full‐text articles assessed for eligibility (n = 157)


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SCREENING TOOLS INCLUDED

Screening ToolRecent Weight Loss

Appetite BMIDisease Severity

Scoring

Malnutrition Screening Tool x x0-1 = No risk2-7 = Risk

Malnutrition Universal Screening Tool x x x0 = Low risk1 = Medium risk2 = High risk

Mini-Nutrition Assessment-Short Form x x x12-14 = Normal8-11 = Risk0-7 = Malnutrition

Short Nutrition AssessmentQuestionnaire

x x2 = Moderate3 = Severe

Mini-Nutrition Assessment-SF-BMI x x x x12-14 = Normal8-11 = Risk0-7 = Malnutrition

Nutrition Risk Screening x x x≥3 points = Initiate nutrition care plan

AND Evidence Analysis Library. NSA: Tool Components. 2018. https://www.andeal.org/topic.cfm?menu=5382&cat=5926

RESULTS-RQ1VALIDITY1

RELIABILITY2 AGREEMENT2 GENERALIZABILITY3

OVERALL GRADE,

STRENGTH OF EVIDENCE4

TOOL SE SP PPV NPVOVERALL VALIDITY2

MST Moderate Moderate Moderate Moderate MODERATE MODERATE MODERATE GOOD I, GOOD/STRONG

MUST Moderate Moderate Moderate High HIGH MODERATE MODERATE FAIR II, FAIR

MNA-SF Moderate Moderate Low Moderate MODERATE MODERATE LOW FAIR II, FAIR

SNAQ Moderate High Low High MODERATE MODERATE - FAIR II, FAIR

MNA-SF-BMI

Moderate Moderate Moderate High HIGH - MODERATE LIMITED II, FAIR

NRS-2002 Moderate High Moderate Moderate MODERATE - MODERATE LIMITED II, FAIR

1Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) cut offs: High: 90-100%, moderate: 80-≤89%, low: ≤79%; reliability and agreement Kappa cut-offs:

High: 0.8-1; moderate: 0.6- ≤7.9; low: ≤5.9.2See Figure 1 for the algorithm to determine the overall validity.3Generalizability was based on usefulness of each tool across the broadest array of adult age groups, locations, diseases, and treatments according to evidence.4Elements considered in the overall grade include: quality of the evidence, consistency of results across studies, quantity of studies and number of subjects, clinical impact of outcomes, and

generalizability to population of interest.

SE – Sensitivity; SP – Specificity PPV – Positive Predictive Value NPV – Negative Predictive Value


RESULTS-RQ2

• The cost ranged from €2 (~$2.27 US) for the SNAQ (2003) to €3.27 (~$2.93 US) for the MNA-SF (2001) per hospital patient

• Grade: III, Limited/weak

• Summary: Two positive quality non-RCTs conducted in the hospital setting examined cost

– No evidence was found using more recent or US data



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TAKE AWAY POINTS

• Single tool with Grade I evidence – MST (moderate validity, reliability and agreement)

• 5 tools with Grade II evidence

– MUST, MNA-SF and SNAQ have moderate or high validity and reliability.

– No reliability evidence for MNA-SF-BMI and NRS-2002 (but moderate or high validity)

– No agreement evidence for SNAQ

• Very limited data related to cost

RESEARCH GAPS/OPPORTUNITIES

• Wide range of validity, reliability and agreement results; fewer studies reported reliability and agreement (kappa)

• Several studies excluded because reference standard was unacceptable (correlation between tools; BMI only, etc.)

• No reliability evidence of MNA-SF-BMI or NRS-2002

• No agreement evidence for SNAQ

• Consider moratorium on new tools until adequate evidence for existing

EXPERT ROUNDTABLE DISCUSSION


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How does using a validated malnutrition screening tool help

Patients?Outcomes?

Overall nutrition care?

Based on the EAL evidence, what tools should we use going forward

in the hospital setting?

My facility uses a facility-specific tool currently (that is not one of the

validated tools) –Should we or should we not

continue using this?


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What 1 thing should I STOP doing in terms of malnutrition screening?

What 1 thing should I START doing?

How does the new GLIM (Global Leadership Initiative on

Malnutrition) consensus impact malnutrition screening and these

recommendations?

Questions from the audience


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Can you recall paper(s) that found prealbumin and albumin were not

related to nutrition status?

The results of research question #1 shows overall GRADE strength

evidence as 1 for MST; however, Dr. Skipper included a slide stating that NRS-2002 was the only tool with GRADE 1 evidence and lists

MST with GRADE 2 evidence. Please clarify.

Why was the SGA not considered as a malnutrition screening tool?


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What are your thoughts on the practice of having dietitians

rescreen all patients after 7 days in the hospital?

Can these tools be used for patients that are obese?

Are you familiar with the Canadian nutrition screening tool and was that included in the systematic

review?


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Are there tools specific for populations?

SUMMARY

• Malnutrition continues to be a global concern across health care settings.

• Malnutrition screening is imperative to identify patients at risk for malnutrition to ensure optimal nutrition care.

• Recent EAL highlights the evidence supporting various validated malnutrition screening tools.

• Existing validated malnutrition screening tools should be used in clinical practice.

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