EAL

NSCR: Quick and Easy Nutrition Screening Tools: Adult Patients in Acute and Ambulatory Care Settings (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The purpose of the study was to test whether the Mini Nutrition Assessment-Short Form (MNA-SF) would have predicted the results supplied by the full Mini Nutrition Assessment.

Inclusion Criteria:

Ambulatory patients
Over 60 years of age
Scheduled for elective surgery or exploration under anesthesia
Scheduled for surgery between January and October 1996
Received and were assessed during anethesia consultation
All questionnaire items recorded on full MNA.

Exclusion Criteria:

Patients who did not meet the inclusion criteria
No other specific exclusion criteria listed.

Description of Study Protocol:

Recruitment

Database of MNA files
Database consisted of MNA files from patients from the Centre Hopitalier Universitaire de Nimes, France (university hospital) and the Clinique Beausoleil, Montpellier, France (private surgical hospital)
Every patient who met inclusion criteria between January and October 1996 was included in the study.

Design

Full MNA questionnaire was applied to each patient during a previous study
Patients had American Society of Anesthesiologists (ASA) score recorded to document overall clinical assessment during a previous study
MNA-SF score was determined using six questions from full MNA database from the previous study
- Appetite loss or eating problem
- Recent weight loss
- House-bound
- Acute illness or stress
- Dementia or depression
- BMI <23kg/m²
If MNA-SF score was greater than 12 then patient was not at risk and a full MNA would not have been required
MNA-SF was assessed based on whether or not it would have identified patients at risk of malnutrition or with overt malnutrition as determined by the full MNA
The performance of the MNA-SF was compared to the overall clinical assessment as determined by the ASA score.

Statistical Analysis

Specificity
Sensitivity
Positve and negative predictive values (PPV, NPV)
Likelihood ratio positive and negative (LRP, LRN)
Odds ratio
Chi-squared and non-parametric U-tests were used for comparison; signifcance was P<0.05

Data Collection Summary:

Timing of Measurements

Data collected between January and October 1996
Data collected during pre-surgery anesthesia consultation.

Dependent Variables

Score on MNA-SF.

Independent Variables

Score on full MNA
ASA score.

Description of Actual Data Sample:

Initial N

408 completed MNA files
- 204 men
- 204 women.

Attrition (final N)

408 completed MNA files
- 204 men
- 204 women.

Age

Median age is 72 years
Range is 60-98 years.

Other relevant demographics

62.8% scheduled for general surgery
22.7% scheduled for orthopedic surgery
6.7% scheduled for endoscopies
7.9% scheduled for miscellaneous procedures
291 ASA one to two patients
117 ASA three to four patients.

Anthropometrics [median (range)]

Height=165cm (134-186)
Weight=68.5kg (34-114)
BMI=25.2kg/m² (12.8-40.4).

Location

Centre Hospitalier Universitaire de Nimes, France (228 patients)
Clinique Beausoleil, Montpellier, France (191 patients).

Summary of Results:

	MNA Score Indicated: Overt Malnutrition	MNA Score Indicated: At Risk of Malnutrition	MNA Score Indicated: Normal
MNA-SF Positive	28 patients	85 patients	31 patients	144 (35.3%)
MNA-SF Negative	zero patients	19 patients	245 patients	264 (64.7%)
	28 (6.9%)	104 (25.5%)	276 (67.6%)	408 (100%)

MNA-SF for predicting absence of overt malnutrition (full MNA score less than 17):
- Sensitivity was 100% compared to full MNA
- Specificity was 69.5% compared to full MNA
- NPV was 100% and LRN was zero
- PPV was 19.4% and LRP was 3.28
- OR was infinite.

MNA-SF for predicting absence of risk of undernutirtion (full MNA score less than 23.5):
- Sensitivity was 85.6% compared to full MNA
- Specificity was 88.8% compared to full MNA
- NPV was 92.8% and LRN was 0.16
- PPV was 78.5% and LRP was 7.64
- OR =47.75.

	ASA Score One to Two	ASA Score Three to Four
MNA-SF Positive	86 (29.6%) patients	58 (49.6%) patients	144 (35.3%)
MNA-SF Negative	205 (70.4%) patients	59 (50.4%) patients	264 (64.7%)
	291 (71.3%)	117 (28.7%)	408 (100%)

The MNA-SF scores were not able to predict the ASA scores
The ASA scores were not able to predict the MNA-SF scores.

Other Findings

Based on the MNA-SF results
- 31 patients would have been submitted to the full MNA and have been found without a nutritional problem
- 19 at-risk patients would not have received the full MNA.

Author Conclusion:

The MNA-SF would have correctly excluded 264 of 380 patients without severe malnutrition
The MNA-SF was less efficient for excluding the presence of milder nutirtional risk
Due to its simplicity, the MNA-SF should be used as the first step in the pre-operative nutritional assessment of older surgical patients.

Funding Source:

Industry:

Reviewer Comments:

Ethnicity of the pariticpants was not identified
Descriptive data for the patients was not separated by hospital
Patients from the two hospitals were not analyzed separately
No mention of whether or not informed consent was obtained from the patients
No mention of whether or not the study received approval or review by an institutional review board.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	???
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	???
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	No
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	No
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
	1.	Was the research question clearly stated?	Yes
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
	1.3.	Were the target population and setting specified?	Yes
	2.	Was the selection of study subjects/patients free from bias?	Yes
2.	Was the selection of study subjects/patients free from bias?		Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
	3.	Were study groups comparable?	Yes
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	No
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	No
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	???
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	???
	4.	Was method of handling withdrawals described?	No
4.	Was method of handling withdrawals described?		No
	4.1.	Were follow-up methods described and the same for all groups?	No
	4.1.	Were follow-up methods described and the same for all groups?	No
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	No
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	No
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	Yes
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	Yes
	5.	Was blinding used to prevent introduction of bias?	???
5.	Was blinding used to prevent introduction of bias?		???
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	???
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	???
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	???
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	???
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	???
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	???
	6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?	No
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		No
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	No
	6.6.	Were extra or unplanned treatments described?	No
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	Yes
	7.	Were outcomes clearly defined and the measurements valid and reliable?	Yes
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	No
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	No
	7.7.	Were the measurements conducted consistently across groups?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
	8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	N/A
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	N/A
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	No
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	No
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	8.6.	Was clinical significance as well as statistical significance reported?	No
	8.6.	Was clinical significance as well as statistical significance reported?	No
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
	9.	Are conclusions supported by results with biases and limitations taken into consideration?	Yes
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
	10.	Is bias due to study's funding or sponsorship unlikely?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes