EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To use proven nutritional assessment methods to determine the prevalence of malnutrition in patients recently admitted to a hospital and to test the validity of five screening tests.

Inclusion Criteria:

Every fifth adult admitted to the hospital between March 2001 and February 2002 was entered into the study. The researchers had assessed, through power analysis, that the sample size would need to be 1,911. Written informed consent was obtained from 2,211 patients.

Exclusion Criteria:

Patients were excluded if:

Pregnant
Psychiatric condition or diagnosis
Admitted to intensive care unit.

Description of Study Protocol:

Recruitment:

2,211 patients admitted to Adana Teaching and Research Center, Baskent University, Adana, Turkey.

Design

Every fifth patient admitted to the hospital was entered into the study. All participants were to be assessed for all parameters. However, some patients refused to allow laboratory data and not all data could be collected for all patients. All patients were assessed with 48 hours of admission.

Blinding Used

Patients were randomly selected; however, all were included in the prospective study and researchers were aware of inclusion when doing assessment.

Statistical Analysis

Power analysis utilized for sample size determination
K-value was used for inter-observer agreement assessment
Chi-square analysis for categorical values
Student's T-test for continuous variables
Contingency tables for sensitivity, specificity, accuracy and positive or negative predictive values
Logistic regression analysis used for independent factors affecting SGA.

Data Collection Summary:

Timing of Measurements

All measurements were taken within 48 hours of admission.

Nutritional Assessment Methods

Subjective Global Assessment (SGA): Combines interview data, anthropometrics and laboratory results related to weight loss, food consumption, gastrointestinal symptoms, functional status and physical examination information
Combination Criteria Method (CC): Includes anthropometric and laboratory results with a positive score if two or more of six criteria are met (more than 10% weight loss in past six months, body mass index (BMI) less than 20kg/m², TSF less than or equal to fifth percentile, midarm muscle circumference less than or equal to fifth percentile, albumin less than 3.0g per dL, pre-albumin less than 0.2g per dL)
Malnutrition Screening Tool (MST): This is a two-question screening related to recent unplanned weight loss and decreased appetite
Mini-nutrition Assessment (MNA): Two self-assessment questions related to comparing health status to other individuals of the same age and to concerns about nutritional status were used
Simple two-part tool (UWL + LSF): Developed by researchers as part of this study includes unintentional weight loss (UWL) and loss of subcutaneous fat (LSF)

Independent Variables

Anthropometric assessments included:
- Height, weight, body mass index
- Triceps skinfold, midarm circumference, midarm muscle circumference
Laboratory assessments included:
- Hemoglobin, hematocrit
- White blood cell, lymphocyte count
- Albumin, pre-albumin, total protein
- Total cholesterol.

Description of Actual Data Sample:

Initial N: 2,211 patients (48.8% male, 51.2% female)
Attrition (final N): Same
Age: Mean age was 54.3+14.8 years.

Other Relevant Demographics

91.9% urban areas
85.4% low income household
27.3% emergency admissions
15.7% one systemic disease
2.9% two systemic diseases
4.7% involved malignancy
45.8% admitted to surgery department
44.7% had at least one surgery during this admission.

Anthropometrics

All patients were studied in the same manner. All data is reported for the study population as a whole.

Location

Adana, Turkey.

Summary of Results:

Nutrition Assessment Tool	Patients Malnourished	Accuracy (%) Compared to SGA and CC	Sensitivity (%) Compared to SGA and CC	Specificity (%) Compared to SGA and CC	P Value Compared to SGA and CC
Malnutrition Screening Tool (MST)	646 (29.2%)	76.0 and 68.2	74.4 and 42	76.2 and 73.1	<0.001 and <0.001
Mini Nutrition Assessment (MNA)	A: 1,039 (46.9%) B: 983 (44.5%) UWL: 776 (35.1%) LSF: 323 (14.7%)	A: 54.4 and 50.8 B: 58.3 and 55.3 UWL: 71.1 and 63.5 LSF: 91.9 and 80.5	A: 63.3 and 47.6 B: 70.6 and 54.5 UWL: 78.9 and 45.8 LSF: 80.2 and 34.9	A: 53.4 and 51.4 B: 56.8 and 55.5 UWL: 70.2 and 66.8 LSF: 93.4 and 89.1	A: <0.001 and 0.734 B: <0.001 and 0.001 UWL: <0.001 and <0.001 LSF: <0.001 and <0.001
Simple Two-part Tool	218 (9.9%)	93.0 and 82.9	63.2 and 27.0	96.7 and 93.2	<0.001 and <0.001

Author Conclusion:

The authors concluded that all of the nutritional assessment tools studied, except MNA question A, would be good indicators of malnutrition status in adult inpatients. However, through studying the weighted effects of various components of these accepted methods, the most simple yet still effective assessment tool is the two-part tool they developed that combines unexpected weight loss and loss of subcutaneous fat as a predictor of malnutrition. The authors suggest tagging a patient's chart upon admission if they state that they experienced unexpected weight loss. Then, a trained practitioner could follow up with assessment of subcutaneous fat loss.

Funding Source:

Reviewer Comments:

The authors conducted an extensive and diligent study of the research tools noted.

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)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	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

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	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
	2.2.	Were criteria applied equally to all study groups?	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
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
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	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?	Yes
	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.)	???
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		No
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	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%.)	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
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	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.)	No
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	No
	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?	No
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	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?	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
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	No
	6.6.	Were extra or unplanned treatments described?	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?	N/A
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?	N/A
	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
	7.4.	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
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	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
	8.1.	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
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	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)?	Yes
	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?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	Yes
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		No
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes