Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.     

Nutritional Assessment in Adult Patients with Dysphagia: A Scoping Review

Malnutrition negatively affects the quality of life of patients with dysphagia. Despite the need for nutritional status assessment in patients with dysphagia, standard, effective nutritional assessments are not yet available, and the identification of optimal nutritional assessment items for patients with dysphagia is inadequate. We conducted a scoping review of the use of nutritional assessment items in adult patients with oropharyngeal and esophageal dysphagia. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched to identify articles published in English within the last 30 years. Twenty-two studies met the inclusion criteria. Seven nutritional assessment categories were identified: body mass index (BMI), nutritional screening tool, anthropometric measurements, body composition, dietary assessment, blood biomarkers, and other. BMI and albumin were more commonly assessed in adults. The Global Leadership Initiative on Malnutrition (GLIM), defining new diagnostic criteria for malnutrition, includes the categories of BMI, nutritional screening tool, anthropometric measurements, body composition, and dietary assessment as its required components, but not the blood biomarkers and the “other” categories. We recommend assessing nutritional status, including GLIM criteria, in adult patients with dysphagia. This would standardize nutritional assessments in patients with dysphagia and allow future global comparisons of the prevalence and outcomes of malnutrition, as well as of appropriate interventions.     

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.     

The Clinical Value of Nutritional Care before and during Active Cancer Treatment

Malnutrition and muscle wasting are frequently reported in cancer patients, either linked to the tumor itself or caused by oncologic therapies. Understanding the value of nutritional care during cancer treatment remains crucial. In fact, cancer-associated sarcopenia plays a key role in determining higher rates of morbidity, mortality, treatment-induced toxicities, prolonged hospitalizations and reduced adherence to anticancer treatment, worsening quality of life and survival. Planning baseline screening to intercept nutritional troubles earlier, organizing timely reassessments, and providing adequate counselling and dietary support, healthcare professional may positively interfere with this process and improve patients’ overall outcomes during the whole disease course. Several screening tools have been proposed for this purpose. Nutritional Risk Screening (NRS), Mini Nutritional Assessment (MNA), Patient Generated Subjective Global Assessment (PG-SGA) are the most common studied. Interestingly, second-level tools including skeletal muscle index (SMI) and bioelectric impedance analysis (BIA) provide a more precise assessment of body composition, even if they are more complex. However, nutritional assessment is not currently used in clinical practice and procedures must be standardized in order to improve the efficacy of standard chemotherapy, targeted agents or even checkpoint inhibitors that is potentially linked with the patients’ nutritional status. In the present review, we will discuss about malnutrition and the importance of an early nutritional assessment during chemotherapy and treatment with novel checkpoint inhibitors, in order to prevent treatment-induced toxicities and to improve survival outcomes.     

The Determination of a Consensus Nutritional Approach for Cancer Patients in Spain Using the Delphi Methodology

Malnutrition has a multifactorial origin and can be caused by cancer. This study determined the consensus of a panel of experts on the nutritional approach for cancer patients in Spain using a multidisciplinary approach. Using the Delphi methodology, a 74-question questionnaire was prepared and sent to 46 experts. The areas of knowledge addressed were the nutritional status of the cancer patient, nutritional screening, nutritional therapy, patient referral, and multidisciplinary care. A total of 91.7% of the experts agreed with the questions posed on nutritional status, 60.0% with those on nutritional screening, 76.7% with those on nutritional therapy, and the entire panel of experts agreed with the questions posed on patient referral and multidisciplinary care. The experts agreed upon a high prevalence of malnutrition among cancer patients in Spain. Unlike medical and radiation oncologists, medical nutrition specialists believe that body composition assessment should not be carried out in all types of cancer patients during nutritional screening and that interventions can be conducted outside the oncology clinic. In general, it is recommended that nursing staff routinely perform nutritional screening before starting cancer treatment. It is necessary to develop a multidisciplinary action protocol that includes nutritional and/or sarcopenia screening.     

Nutritional Risk Assessment Scores Effectively Predict Mortality in Critically Ill Patients with Severe COVID-19

Background: Malnutrition predicts a worse outcome for critically ill patients. However, quick, easy-to-use nutritional risk assessment tools have not been adequately validated. Aims and Methods: The study aimed to evaluate the role of four biological nutritional risk assessment instruments (the Prognostic Nutritional Index—PNI, the Controlling Nutritional Status Score—CONUT, the Nutrition Risk in Critically Ill—NUTRIC, and the modified NUTRIC—mNUTRIC), along with CT-derived fat tissue and muscle mass measurements in predicting in-hospital mortality in a consecutive series of 90 patients hospitalized in the intensive care unit for COVID-19-associated ARDS. Results: In-hospital mortality was 46.7% (n = 42/90). Non-survivors had a significantly higher nutritional risk, as expressed by all four scores. All scores were independent predictors of mortality on the multivariate regression models. PNI had the best discriminative capabilities for mortality, with an area under the curve (AUC) of 0.77 for a cut-off value of 28.05. All scores had an AUC above 0.72. The volume of fat tissue and muscle mass were not associated with increased mortality risk. Conclusions: PNI, CONUT, NUTRIC, and mNUTRIC are valuable nutritional risk assessment tools that can accurately predict mortality in critically ill patients with COVID-19-associated ARDS.     

Malnutrition: Percentage and Association with Prognosis in Patients Hospitalized for Coronavirus Disease 2019

Previous studies have found a correlation between malnutrition and prognosis in respiratory infections. Our objectives were to determine (i) the percentage of malnutrition, and (ii) its prognosis in patients admitted for coronavirus disease 2019 (COVID-19). In this monocentric retrospective study, we consecutively included all adult patients presenting with acute COVID-19 between 9 April and 29 May 2020. Malnutrition was diagnosed on low body mass index (BMI) and weight loss ≥ 5% in the previous month and/or ≥ 10% in the previous six months. The Nutritional Risk Index (NRI) defined nutritional risk. Severe COVID-19 was defined as a need for nasal oxygen ≥ 6 L/min. We enrolled 108 patients (64 men, 62 ± 16 years, BMI 28.8 ± 6.2 kg/m²), including 34 (31.5%) with severe COVID-19. Malnutrition was found in 42 (38.9%) patients, and moderate or severe nutritional risk in 83 (84.7%) patients. Malnutrition was not associated with COVID-19 severity. Nutritional risk was associated with severe COVID-19 (p < 0.01; p < 0.01 after adjustment for C reactive protein), as were lower plasma proteins, albumin, prealbumin, and zinc levels (p < 0.01). The main cause of malnutrition was inflammation. The high percentage of malnutrition and the association between nutritional risk and COVID-19 prognosis supports international guidelines advising regular screening and nutritional support when necessary.     

Optimizing Inpatient Nutrition Care of Adult Patients with Inflammatory Bowel Disease in the 21st Century

Malnutrition is highly prevalent in inflammatory bowel disease (IBD) patients and disproportionately affects those admitted to hospital. Malnutrition is a risk factor for many complications in IBD, including prolonged hospitalization, infection, greater need for surgery, development of venous thromboembolism, post-operative complications, and mortality. Early screening for malnutrition and prompt nutrition intervention if indicated has been shown to prevent or mitigate many of these outlined risk factors. There are many causes of malnutrition in IBD including reduced oral food intake, medications, active inflammation, and prior surgical resections. Hospitalization can further compound pre-existing malnutrition through inappropriate diet restrictions, nil per os (NPO) for endoscopy and imaging, or partial bowel obstruction, resulting in “post-hospital syndrome” after discharge and readmission. The aim of this article is to inform clinicians of the prevalence and consequences of malnutrition in IBD, as well as available screening and assessment tools for diagnosis, and to offer an organized approach to the nutritional care of hospitalized adult IBD patients.     

Evaluation of Nutritional Status and Methods to Identify Nutritional Risk in Rheumatoid Arthritis and Spondyloarthritis

Patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA) experience several nutritional challenges and are prone to develop malnutrition. This observational study aimed to perform a comprehensive nutritional assessment of outpatients diagnosed with RA and SpA, as well as to evaluate methods to identify nutritional risk. Nutritional status was investigated by anthropometric measures, body composition (DXA, dual energy X-ray absorptiometry), and handgrip strength (HGS). Nutritional risk was classified by Nutritional Risk Screening 2002 (NRS2002) and malnutrition was defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria and fat-free mass index (FFMI; kg/m², <16.7 (M), <14.6 (F)). Out of 71 included patients, 46 (66%) were abdominally obese, 28 (39%) were obese in terms of body mass index (BMI), and 33 (52%) were obese in terms of the fat mass index (FMI; kg/m², ≥8.3 (M), ≥11.8 (F)). Malnutrition was identified according to FFMI in 12 (19%) patients, according to GLIM criteria in 5 (8%) patients, and on the basis of BMI (<18.5 kg/m²) in 1 (1%) patient. None were identified by NRS2002 to be at nutritional risk. Our study revealed high prevalence of abdominal obesity and low FFMI. Waist circumference was a good indicator of FMI. BMI, NRS2002, and HGS did not capture patients with malnutrition identified by DXA.     

Evaluation of malnutrition status and related risk factors in geriatric outpatient clinic

BACKGROUND/OBJECTIVESMalnutrition risk and malnutrition among the elderly is a public health concern. In combating this health-related problem, it is critically important to evaluate the risk factors in a multidimensional way and to apply appropriate nutrition intervention based on the results.SUBJECTS/METHODSA cross-sectional study was conducted on 215 elderly patients (32.6% male, 67.4% female) in a geriatric outpatient clinic of a hospital in Turkey. Nutritional questionnaires that incorporated the 24-h recall method were applied to determine general characteristics of patients, their health status, nutritional habits, and daily energy and nutrient intakes. Mini Nutritional Assessment was used to determine nutritional status. Relevant anthropometric measurements were obtained.RESULTSThe subjects'' mean age was 76.1 ± 7.0 years, and the prevalence of malnutrition (n = 7) and risk of malnutrition (n = 53) among the 215 subjects was 3.2% and 24.7%, respectively. Patients with malnutrition or risk of malnutrition were found to be single, have a depression diagnosis, in an older age group, have less appetite, more tooth loss, have more frequent swallowing/chewing difficulty, and have more frequent meal skipping. In addition, mean daily energy, carbohydrate, fat, fiber, vitamin E, vitamin B1, vitamin B2, vitamin B6, vitamin C, folates, potassium, magnesium, phosphorus, iron intake, and water consumption were found to be statistically significantly low in subjects with malnutrition or risk of malnutrition. After performing regression analysis to determine confounding factors, malnutrition risk was significantly associated with marital status, loss of teeth, appetite status, and depression.CONCLUSIONSRoutine nutritional screening and assessment of the elderly should be performed. If nutritional deficiencies cannot be diagnosed early and treated, self-sufficiency in the elderly may deteriorate, resulting in increased institutionalization.     

Malnutrition in Hospitalized Old Patients: Screening and Diagnosis,Clinical Outcomes,and Management

Malnutrition in hospitalized patients heavily affects several clinical outcomes. The prevalence of malnutrition increases with age, comorbidities, and intensity of care in up to 90% of old populations. However, malnutrition frequently remains underdiagnosed and undertreated in the hospital. Thus, an accurate screening to identify patients at risk of malnutrition or malnourishment is determinant to elaborate a personal nutritional intervention. Several definitions of malnutrition were proposed in the last years, affecting the real frequency of nutritional disorders and the timing of intervention. Diagnosis of malnutrition needs a complete nutritional assessment, which is often challenging to perform during a hospital stay. For this purpose, various screening tools were proposed, allowing patients to be stratified according to the risk of malnutrition. The present review aims to summarize the actual evidence in terms of diagnosis, association with clinical outcomes, and management of malnutrition in a hospital setting.     

Phase Angle as a Comprehensive Tool for Nutritional Monitoring and Management in Patients with Crohn’s Disease

Background and Aims: Crohn’s disease (CD) is usually accompanied by malnutrition. CD-related malnutrition can increase morbidity, disability, mortality, and hospitalization costs. The purpose of this study was to find a reliable indicator for evaluating CD patients’ nutritional status. Methods: All data were retrospectively collected from Xiangya Hospital, Central South University between May 2021 and February 2022. All patients were evaluated for nutritional status using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Body composition, resistance, and reactance were recorded by a body analyser, and the phase angle (PhA) was calculated simultaneously. The Mann–Whitney U test, chi-square test, Fisher’s exact test, and univariate and multivariate logistic regression analyses were used. A receiver operating characteristic (ROC) curve was built to evaluate the predictive value of differential variables for diagnosing malnutrition based on the GLIM criteria. Results: A total of 169 CD patients were enrolled, of which 74 (58.3%) males and 32 (76.2%) females were diagnosed with malnutrition; 34 (45.9%) males and 22 (68.8%) females were severely malnourished. Univariate analysis identified that as nutritional status deteriorated, body mass index, PhA, and levels of haemoglobin and albumin decreased, while platelet count, erythrocyte sedimentation rate, and levels of C-reactive protein and fibrinogen increased (p < 0.05). Logistic regression analysis revealed that the PhA was significantly independently associated with malnutrition (p < 0.05). The ROC curve analysis indicated that the optimal PhA cut-off levels of 6.11° and 5.55° could be used to predict malnutrition according to the GLIM criteria in males and females, respectively, with a PhA < 5.53° and < 5.12° indicating severe malnutrition in males and females, respectively. Conclusion: The PhA is a sensitive, noninvasive, portable, inexpensive tool that can be used to monitor and manage the nutritional status of CD patients.     

Comparing Assessment Tools as Candidates for Personalized Nutritional Evaluation of Senior Citizens in a Nursing Home

Nutrition is an important health issue for seniors. In nursing homes, simple, inexpensive, fast, and validated tools to assess nutritional risk/status are indispensable. A multisurvey cross-sectional study with a convenient sample was created, comparing five nutritional screening/assessment tools and the time required for each, in order to identify the most useful instrument for a nursing home setting. Nutrition risk/status was evaluated using the following tools: Subjective Global Assessment (SGA), Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening 2002 (NRS 2002), and calf girth (CG). The time spent completing each tool was recorded. Eighty-three subjects were included. MNA-SF and CG were the screening tools that ranked highest with regards to malnutrition identification. CG failed to identify nutritional risk/malnutrition in seniors with lower limb edema. CG was the fastest tool while SGA was the slowest. This was the first study comparing non-invasive nutritional tools with time expended as a consideration in the implementation. CG is responsive, fast, and reliable in elders without edema. MNA-SF was more efficient at detecting malnutrition cases in the elderly population. Both MNA-SF and CG are considered the most suitable for the nursing home setting.     

Nutritional Management in Adult Patients With Dysphagia: Position Paper From Japanese Working Group on Integrated Nutrition for Dysphagic People

This position paper prepared by the Japanese Working Group on Integrated Nutrition for Dysphagic People (JWIND) aims to summarize the need for nutritional management in adult patients with dysphagia, the issues that nutrition professionals should address, and the promising approaches as well as to propose a vision for the future of nutritional care for adult patients with dysphagia. JWIND is a joint certification system recognized by the Japan Dietetic Association and the Japanese Society of Dysphagia Rehabilitation; its members are mostly experts known as “Certified Specialist of Registered Dietitian for Dysphagia Rehabilitation.” Malnutrition and dysphagia are associated with each other. Therefore, malnutrition detection and intervention are essential for patients with dysphagia. However, evidence on the usefulness nutritional assessment and intervention to ensure appropriate nutritional care remains insufficient. Here, we present current knowledge of the relationship between primary diseases causing dysphagia and malnutrition, the indicators used for nutritional assessment, and nutritional interventions such as texture-modified diet (TMD) quality improvement, oral nutritional supplementation, and comprehensive intervention. We also discuss the current status and issues in nutritional care for adult patients with dysphagia. Furthermore, we have proposed measures that nutrition professionals should consider based on 3 perspectives: nutritional assessment, TMD, and nutritional intervention. Individualized and specialized nutritional management by registered dietitians (RDs) through appropriate assessment of the nutritional status of adult patients with dysphagia is needed. To maintain and improve swallowing function and nutritional status, RDs should intervene from the state of risk or early dysphagia onset, providing individualized care per their expertise as part of a multidisciplinary team. However, systematic clinical practice and research regarding the association of nutrition with dysphagia are currently insufficient. Therefore, further clinical practice and evidence building, including the verification of the efficacy on nutritional support through intervention research, are needed.     

Comparison of a malnutrition screening tool with subjective global assessment in hospitalised patients with cancer--sensitivity and specificity

Malnutrition is common in hospitals and it is important to implement an appropriate nutrition screening tool to identify patients at risk. The aim of the study was to assess the sensitivity and specificity of the malnutrition screening tool developed by the Malnutrition Advisory Group of the British Association of Parenteral and Enteral Nutrition against subjective global assessment in hospitalised patients with cancer. A cross-sectional study assessing the risk of malnutrition and nutritional status of sixty-five hospitalised patients with cancer, aged 56 +/- 15 years. According to subjective global assessment, 25 % of patients were well nourished and 75% were malnourished (63% were moderately or suspected of being malnourished and 12% severely malnourished). The malnutrition screening tool had a low sensitivity of 59% and a specificity of 75%. The positive predictive value was 88% and the negative predictive value 38%. There were significant linear trends between subjective global assessment classification and percentage weight loss in the previous six months (P < 0.001) and body mass index (P = 0.007). The malnutrition screening tool developed by the Malnutrition Advisory Group of the British Association of Parenteral and Enteral Nutrition is not a suitable screening tool for detecting risk of malnutrition in hospitalised patients with cancer.     

Impact of Nutritional Assessment on the Clinical Outcomes of Patients with Non-albicans Candidemia: A Multicenter Study

Several studies have demonstrated that malnutrition is a negative prognostic factor for clinical outcomes. However, there is limited evidence for the effect of malnutrition on clinical outcomes in patients with candidemia. We investigated the relationship between malnutrition and all-cause 28-day mortality among patients with non-albicans candidemia. Between July 2011 and June 2014, all adult patients with non-albicans candidemia, including C. tropicalis, C. glabrata, C. parapsilosis and so on, were enrolled. The Malnutrition Universal Screening Tool (MUST) scores were used to determine the patients’ nutritional status before the onset of candidemia. A total of 378 patients were enrolled; 43.4% developed septic shock and 57.1% had a high risk of malnutrition (MUST ≥ 2). The all-cause 28-day mortality rate was 40.7%. The Cox proportional hazards model revealed that C. tropicalis (HR, 2.01; 95% CI, 1.24–3.26; p = 0.005), Charlson comorbidity index (HR, 1.10; 95% CI, 1.03–1.18; p = 0.007), Foley catheter use (HR, 1.68; 95% CI, 1.21–1.35; p = 0.002), concomitant bacterial infections (HR, 1.55; 95% CI, 1.11–2.17; p = 0.010), low platelet count (HR, 3.81; 95% CI, 2.45–5.91; p < 0.001), not receiving antifungals initially (HR, 4.73; 95% CI, 3.07–7.29; p < 0.001), and MUST ≥ 2 (HR, 1.54; 95% CI, 1.09–2.17; p = 0.014) were independently associated with all-cause 28-day mortality. A simple screening tool for nutritional assessment should be used for patients with non-albicans candidemia to detect early clinical deterioration, and a tailored nutritional care plan should be established for malnourished individuals, to improve their clinical outcomes.     

Risk of Malnutrition upon Admission and after Discharge in Acutely Admitted Older Medical Patients: A Prospective Observational Study

There is a lack of knowledge about malnutrition and risk of malnutrition upon admission and after discharge in older medical patients. This study aimed to describe prevalence, risk factors, and screening tools for malnutrition in older medical patients. In a prospective observational study, malnutrition was evaluated in 128 older medical patients (≥65 years) using the Nutritional Risk Screening 2002 (NRS-2002), the Mini Nutritional Assessment-Short Form (MNA-SF) and the Eating Validation Scheme (EVS). The European Society of Clinical Nutrition (ESPEN) diagnostic criteria from 2015 were applied for diagnosis. Agreement between the screening tools was evaluated by kappa statistics. Risk factors for malnutrition included polypharmacy, dysphagia, depression, low functional capacity, eating-related problems and lowered cognitive function. Malnutrition or risk of malnutrition were prevalent at baseline (59–98%) and follow-up (30–88%). The baseline, follow-up and transitional agreements ranged from slight to moderate. NRS-2002 and MNA-SF yielded the highest agreement (kappa: 0.31 (95% Confidence Interval (CI) 0.18–0.44) to 0.57 (95%CI 0.42–0.72)). Prevalence of risk factors ranged from 17–68%. Applying ESPEN 2015 diagnostic criteria, 15% had malnutrition at baseline and 13% at follow-up. In conclusion, malnutrition, risk of malnutrition and risk factors hereof are prevalent in older medical patients. MNA-SF and NRS-2002 showed the highest agreement at baseline, follow-up, and transitionally.     

三种营养不良诊断标准在头颈部恶性肿瘤放疗病人中的应用研究

目的:采用不同营养不良评定标准,描述并比较头颈部恶性肿瘤病人在放疗期间营养不良的变化情况。方法:在北京大学肿瘤医院放疗科选取拟接受放疗的头颈部恶性肿瘤病人,分别在放疗前、放疗中期和放疗结束时随访。采用营养不良评定标准全球领导人共识(GLIM)标准、欧洲肠外肠内营养学会2015年营养不良专家共识(ESPEN 2015)和病人参与主观全面评定(PG-SGA)进行营养评定,其中,营养筛查采用营养风险筛查2002,肌肉量评价采用生物电阻抗分析法测得的四肢骨骼肌指数和去脂体质指数。结果:共纳入502名头颈部恶性肿瘤病人。随着放疗进行,营养风险的比例显著增加;三种标准诊断的营养不良比例均显著增加;且三种标准得到的结果一致性均较差(0.303≤Kappa≤0.681)。结论:头颈部恶性肿瘤病人在放疗期间的营养风险和营养不良比例均显著增加,不同营养不良诊断标准得出的结果差异明显。建议结合临床结局指标进行评价研究,使其更具临床意义。     

Nutritional assessment and management in hospitalised patients: implication for DRG-based reimbursement and health care quality

INTRODUCTION: Malnutrition is associated with a higher morbidity resulting in an increased need for medical resources and economic expenses. In order to ensure sufficient nutritional care it is mandatory to identify the effect of malnutrition and nutritional care on direct cost and reimbursement. The primary aim of this study was to evaluate the economic effect of a nutritional screening procedure on the identification and coding of malnutrition in the G-DRG system. METHODS: All G-DRG relevant parameters of 541 consecutive patients at a gastroenterology ward were documented. Moreover, all patients were screened for malnutrition by a dietician according to the subjective global assessment (SGA). Patients were then grouped into the appropriate G-DRG and the effective cost weight (CW) was calculated. RESULTS: Ninety-two of 541 patients (19%) were classified malnourished (SGA B or C). Recognition of malnutrition increase from 4% to 19%. Malnourished patients exhibited a significantly increased length of hospital stay (7.7+/-7 to 11+/-9, P<0.0001). In 26/98 (27%) patients, the coding of malnutrition was considered relevant by grouping and resulted in a rise of DRG benefit. Mean case mix value and patients' complexity and comorbidity level (PCCL) increased after including malnutrition in the codification (CV 1.53+/-2.9 to 1.65+/-2.9, P=0.001 and PCCL 2.69+/-1.4 to 3.47+/-0.82, P<0.0001). The reimbursement increase by 360/malnourished patient or an additional reimbursement of 35280 (8.3% of the total reimbursement for all patients of 423186). Nutritional support in a subgroup of 50 randomly selected patients resulted in additional costs of 10268 . Forty-four of these patients (86%) were classified malnourished (32 SGA B and 12 SGA C). However, the subsequent reimbursement covered only approximately 75% of the expenses (7869), but did not include the potential financial benefits resulting from clinical interventions. CONCLUSION: Malnourished patients can be detected with a structured assessment and documentation of nutritional status and this is partly reflected in the G-DRG/ICD 10 system. In addition to increasing direct health care reimbursement, nutritional screening and intervention has the potential to improve health care quality.     

Évaluation de l’état nutritionnel au cours de la cirrhose : méthodes,limites et implications

Liver plays a key-role in the metabolism of nutrients. Therefore, liver failure is often associated with malnutrition. It is well established that malnutrition stands as a pejorative factor for prognosis in cirrhotic patients with liver failure. But nutritional assessment is difficult in cirrhotic patients since standard anthropometric and biological indexes are linked with liver dysfunction. We detail here the various causes and mechanisms leading to malnutrition in cirrhosis. We also describe the reliable methods used to assess nutritional state of cirrhotic patients. Finally, we put emphasis on the involvement of nutritional care in cirrhosis and liver dysfunction, describing its specific characteristics and indications.