The High Price of Undiagnosed Malnutrition Kathy J Irwin, MS, RD, LDN, CNSC Clinical Nutrition Manager, Morrison Healthcare Methodist Medical Center A member of Covenant Health Oak Ridge, Tennessee
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Methodist Medical Center 301 bed acute care hospital; not-for-profit community hospital Fourth largest employer in Oak Ridge Approximately 1000 employees and 275 physicians Average Daily census: 140 ED Visits: 45,000+ annually
Malnutrition Patient Care The Skeleton in the Hospital Closet by Charles Butterworth, MD, 1974 The LeRoy Catastrophe by Michael M Meguid, MD, 2015 Definition of malnutrition Any nutritional imbalance Undernutrition typically with inadequate intake and/or increased requirements, impaired absorption, altered transport, and altered nutrient utilization Undernutrition historically, is poorly described Difficult to see in patients Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White, Jane V. et al. Journal of the Academy of Nutrition and Dietetics, Volume 112, Issue 5, 730-738
Malnourished patients have 5x the likelihood of death Increased comorbidities 4x more likely to develop a pressure injury Depression of immune system Near 3x increase in length of hospital stay Near 3x increase in cost of hospital stay Corkins MR, Malnutrition diagnoses in hospitalized patients: United States, 2010, JPEN J Parenter Enteral Nutr. 2014 Feb;38(2):186-95. doi: 10.1177/0148607113512154. Epub 2013 Nov 18. Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013: Statistical Brief #210. 2016 Sep. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Available from: https://www.ncbi.nlm.nih.gov/books/nbk396064/
Admission and Discharge Characteristics of Discharged Patients With and Without a Diagnosis of Malnutrition, United States. Malnutrition Effects 30 Not malnourished Malnourished 26.9 25 20 15 12.6 10 9.5 5 4.4 0 Length of stay (in days) Total Costs (mean $) x1,000 Mark R. Corkins et al. JPEN J Parenter Enteral Nutr 2013;38:186-195
Malnutrition Prevalence Malnutrition is under recognized in the hospital setting in the United States 33-54% estimated to be malnourished in the hospital Yet, only 3.2% of patients are diagnosed in the hospital Therefore, opportunities exist for patient care and financial reimbursement In 2015, physicians at Methodist Medical Center were diagnosing 3-4% of hospital patients with malnutrition Corkins MR, Malnutrition diagnoses in hospitalized patients: United States, 2010, JPEN J Parenter Enteral Nutr. 2014 Feb;38(2):186-95. doi: 10.1177/0148607113512154. Epub 2013 Nov 18.
Malnutrition is costly The annual burden of disease-associated malnutrition across the 8 diseases was $156.7 billion in 2014 ($508 per U.S. resident) Why are hospital cost nearly tripled among malnourished patients? Infections, wounds, staff time/attention, MD time/attention, specialists, increased ICU days, increased vent days, PT/OT/ST needs, length of stay, medications, readmissions Corkins MR, Malnutrition diagnoses in hospitalized patients: United States, 2010, JPEN J Parenter Enteral Nutr. 2014 Feb;38(2):186-95. doi: 10.1177/0148607113512154. Epub 2013 Nov 18. Economic burden of community-based disease-associated malnutrition in the United States. Snider JT, JPEN J Parenter Enteral Nutr. 2014 Nov;38(2 Suppl):77S-85S.
Benefits of recognizing and diagnosing Malnutrition Improved patient care Nutritional interventions (earlier) Patient specific nutrition plan of care Follow-up and support by dietitians Adjusted hospital measures Geometric mean length of stay (GMLOS) Risk of mortality (ROM) Severity of Illness (SOI) Significant Improved reimbursement
Example of a Diagnosis Impact Lung ca w/ lobectomy Lung ca w/ lobectomy Lung ca w/ lobectomy $9000 $12300 ($3300 increase) DRG DRG with CC (Moderate PCM/Malnutrition) $16300 ($7300) DRG with MCC (Severe PCM/Malnutrition) GMLOS 3.0 SOI 1 ROM 1 GMLOS 5.1 SOI 2 ROM 2 GMLOS 10.4 SOI 3 ROM 2 DRG Diagnostic Related Groups, CC Complication or Comorbidity, MCC Major Complication or Comorbidity Each DRG also has an assigned expected length of stay (GMLOS) [O/E ratio], severity of illness (SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Diagnosing Malnutrition can be Challenging Old markers are not reliable BMI malnutrition can be present in all BMIs PAB, Albumin influenced by inflammation and hydration Malnutrition criteria Re-defined in 2012 2 of these 6 must be present for a diagnosis Weight loss Inadequate Energy Intake Loss of Muscle Mass Loss of Subcutaneous Fat Loss of Fluid Accumulation Diminished Functional Capacity 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White, Jane V. et al. Journal of the Academy of Nutrition and Dietetics, Volume 112, Issue 5, 730-738
Registered Dietitians The Hospital s Nutrition Experts Trained to feed, support and recognize nutrition problems Nutrition undergraduate science degree, many have graduate degrees 1200-hour internship with 42 competencies Licensed by the state Many RDs have advanced certifications Nutrition Experts, but are they Malnutrition experts? (They can be )
Methodist Medical Center Malnutrition Initiative Dietitians developed an Expertise on Malnutrition Nutrition-focused physical Exam (NFPE) essential to comprehensive assess for Malnutrition Dietitian buy-in can be challenging (We weren t trained to touch patients) NFPE training available from the Academy of Nutrition and Dietetics NFPE is new dietetic internship competency 2017
Methodist Medical Center Malnutrition Initiative Only a physician can give a medical diagnosis Tool was developed to communicated the dietitian s findings to the physician; physician makes an independent decision on diagnosis Out-side the box screening (initiated Oct 2017) RD-led comprehensive nutrition screening trial Required an additional FTE Team approach nurses, therapists, case managers, physicians, administrators Awareness effort
Methodist Medical Center Malnutrition Initiative Results percentage of patients Methodist Medical Center Percentage of In-patients Diagnosed with Malnutrition 19.00% Benchmark 19% 15.00% 11.00% 7.00% 3.00%
Methodist Medical Center Malnutrition Initiative Results Increase due to Malnutrition Diagnoses $1,200,000 Methodist Medical Center Malnutrition Impact on Medicare Reimbursements* $1,074,144.00 $1,000,000 $800,000 $658,439.00 $600,000 $400,000 $275,896.00 $200,000 $0 2015 2016 2017 *Above includes only Medicare (excludes all per diem, commercial payers, managed care, TennCare and self pay); only includes severe malnutrition (excludes nonsevere, mild); only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs). 2015 data: yearly total extrapolated from Oct-Dec 2015 since ICD10 codes Oct; 2016 data: Actual data; 2017 data: yearly total estimated from Jan-Aug 2017 data
Conclusions Missing Malnutrition is significant to hospitals Patient Care Financial Dietitians need to be trained The NFPE is essential for a comprehensive malnutrition assessment Dietitian duties and staffing is evolving A Paradigm Shift is occurring focus changing from Joint Commission requirements toward improved patient care Undertrained and Understaffed units will limit patient care and will lead to missed reimbursement opportunities
Questions? Kathy J Irwin, MS, RD, LDN, CNSC Clinical Nutrition Manager Contracted by Morrison Healthcare Phone: 865-835-4118 email: kathyirwin@iammorrison.com