Screening for malnutrition in the community

Transcription

1 Screening for malnutrition in the community Paula McGurk RD PhD Northern Ireland BDA symposium University of Ulster, Jordanstown 30 th November 2016,

2 Presentation format Background information on nutrition screening tools Survey establishing prevalence of malnutrition in General Practice Subsequent work service evaluation in out-patients using an automated system Conclusions

3 Prevalence of malnutrition using MUST?? BAPEN 2009 BAPEN 2014 BAPEN 2015

4 Drivers for undertaking the a survey of malnutrition in GP Varying methods of defining malnutrition, e.g. Mini Nutritional Assessment, BMI of varying cut-offs (18.5 kg/m 2, 20.0 kg/m 2 ), unintentional weight loss Different selection procedures, e.g. consecutive patients, General Practice databases Heterogeneous populations, e.g. different age groups, chronic conditions

5 Survey aims Establish the prevalence of malnutrition in General Practice using MUST To determine if there is a relationship between malnutrition and: use of nutrition support health outcomes healthcare use

6 Methods Developed a questionnaire General characteristics Age, gender, GP Postcode Attended a Practice Manager forum Clinical problems Wounds Infections, Weight loss Nine General Practices agreed to host Healthcare use GP visits Antibiotic use Visited practices on pre-arranged dates

7 Subjects 1130 invited to participate 738 (65%) participated 392 (35%) did not participate 160 were relatives/carers/ friends 578 (24% male) were attending for appointment Variable Mean SD BMI (kg/m 2 ) Weight (kg) 26.2 ± ±17.0 Age (yrs) 43.1 ±18.7

8 Results: Prevalence of Malnutrition Overall prevalence 11.1% (95% CI 8.8%, 13.9%) 8.7% Step 1; BMI contribution to MUST: 50/578 (8.7%) BMI Wt loss 7.8% 0.9% 2.4% Step 2; Weight loss contribution to MUST: 19/578 (3.3%) Step 3; Acute disease score effect: No contribution 3.3%

9 Results: Health outcomes and healthcare use (previous 6 months) 80 P= % % % P= % P= % 28.1% Low risk At risk 0 2.1% Freq of wounds Infection req Abx No. of GP visits

10 Survey findings No individuals had: previously been recognised as being malnourished seen a dietitian received nutritional support Malnutrition was unrecognised and untreated (McGurk et al, 2012)

11 How do we improve detection and treatment of malnutrition in routine clinical practice? Increase awareness about the need for identifying malnutrition Make screening simpler and more user-friendly Speed up the screening process (without affecting reliability and reproducibility) Use new automated equipment to reduce errors Patient involvement (DH 2008; DH 2011, NICE 2012 )

12 Service Evaluation in Outpatients in UHS Purchased a SECA 285 (not designed for selfscreening) Few modifications, e.g. buttons, footprints step by step labels on the instrument A4 laminated page with instructions Sought advice from colleagues about safety and infection control

13 Patient population Gastroenterology clinics Visits occurred in August/Sept years Variety of GI conditions (Crohns Disease, Ulcerative Colitis, IBS, IDA) Malnutrition 21.3% ( MUST 11.9% medium risk; 9.4% high risk)

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15 Step 1 Please remove your footwear then rub your hands with the gel provided

16 Step 2 Stand on footprints, upright with head forward

17 Step 3 Pull down height measure until it touches the top of your head

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21 Total score Risk 1 MEDIUM

22 Patient-Dietitian agreement in MUST categorisation (low risk vs medium + high risk) N Agreement Patient-dietitian 140 Perfect (100%) Precision (CV %) for weight, height and BMI < 1%

23 Ease rating % Very simple 71.9 Simple 24.3 Difficult 3.8 (n= 6; n=5 > 75 y) Very difficult 0.0 Impossible 0.0 TOTAL 100 McGurk, Jackson & Elia (2013)

24 Time to complete self-screening Time to complete self screening (min) Mean min Median 1.14 min Age (years) McGurk, Jackson & Elia (2013)

25 Time taken to screen using MUST Method Healthcare worker Time (min) Self-screening (OPD) Some screening tools 10-15? MUST paper version 5 5* MUST electronic version MUST wifi electronic system MUST modified wifi electronic system *Am J Clin Nutr 2012 ** Clin Nutr abstr 2011 ***Nutrition ? 0.5 3** 1.3***?0.5

26 Conclusions Malnutrition in General Practice was found to affect 11% of individuals (7% medium risk; 4% high risk) using MUST Malnutrition is under-recognised and undertreated Self screening using an in-built electronic system can be undertaken accurately and reliably in about a minute in the hospital outpatient setting

27 Future Work Re-design of equipment so it is selfcontained, eliminates the head piece and is even quicker (prototype available 2015) Trial it in other patient groups in both hospital and community settings