MNT: Cost Effectiveness, Cost-benefit, or Economic Savings of MNT (2009)


Ockenga J, Freudenreich M, Zakonsky R, Norman K, Pirlich M, Lochs H. Nutritional assessment and management in hospitalised patients: implication for DRG-based reimbursement and health care quality. Clinical Nutrition. 2005; 24: 913-919.


PubMed ID: 16046034
Study Design:
Cohort study.
B - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To evaluate the economic effect of a nutritional screening procedure on the identification and coding of malnutrition in medical patients in the German Diagnosis-related Groups (G-DRG) system.



Inclusion Criteria:

Patients were eligible for entry if they were:

  • Age of 18
  • Assumed to stay longer than two days in the 30-bed gastroenterological ward
  • Willing and able to give written informed consent.


Exclusion Criteria:

Patients admitted to day care units and patients who were unable to give informed consent were excluded.

Description of Study Protocol:


Patients admitted to the 30-bed gastroenterological ward between January, 2004 and December, 2004.


Cohort study. Nutrition assessment by trained dietitians within 48 hours of admission. Dietitians used the subjective global assessment, which classified patients as well nourished (SGA A), moderately or suspected of being malnourished (SGA B) or severely malnourished (SGA C). Patients with malnutrition were scheduled for further nutritional therapy. The medical records of all patients were then coded according to the diagnosis and procedures. After considering length of stay, the effective cost weight was calculated.  


To analyze the direct cost associated with nutritional support, a randomized subgroup of 50 patients received nutritional intervention in detail. 

Statistical Analysis

X2 or the Fisher's exact test were used for discrete variables. Student's T-test or Mann-Whitney's rank sum test were used for unpaired data as indicated. P-values below 0.05 were considered statistically significant.

Data Collection Summary:

Timing of Measurements

Subjects recruited between January, 2004 to December, 2004; patients given nutrition assessment within 48 hours of admission.

Dependent Variables

  • Patients with malnutrition (SGA B or C)  
  • Patients without malnutrition (SGA B or C) 
  • Cost weight and reimbursement of malnourished patients.

Independent Variables

Patients given nutrition assessment within 48 hours of admission. Patient medical records then coded according to diagnosis and procedures to determine cost and reimbursement. 


Description of Actual Data Sample:
  • Initial N: 541 consecutive patients (301 male) 
  • Attrition (final N): 541 patients.


  • Without malnutrition: 59±18 years
  • With malnutrition 56±17 years.


  • BMI without malnutrition: 27±6.7
  • BMI with malnutrition: 22±4.7.


Berlin, Germany.

Summary of Results:

Other Findings

  • 92 patients (19% of the eligible population) were classified malnourished, of which 14 (3%) were severely malnourished
  • Recognition of malnutrition increased from 4% to 19%
  • Malnourished patients exhibited a significantly increased length of hospital stay (7.7±7 days to 11±9 days, P<0.0001)
  • In 27% of the malnourished patients the inclusion code resulted in a change of the G-DRG and hence a favorable reimbursement difference. In the remaining 73% of the malnourished patients, the comorbidity malnutrition made no difference because these patients already had other complex comorbidities.
  • In the 27% of malnourished patients, the introduction of comorbidity malnutrition increased the case mix index of the malnourished group to 1.65±2.9 and the reimbursement to 4,956±8,703. This means an additional reimbursement of 360€ per malnourished patient. 
  • Nutritional support in the subgroup of 50 randomly selected patients resulted in additional costs of 10,268€
  • Forty-four of these patients (86%) were classified malnourished
  • The reimbursement covered only approximately 75% of the expenses, but did not include the potential financial benefits resulting from clinical interventions. 
Author Conclusion:

Malnourished patients can be detected with a structured assessment and documentation of nutritional status and this is partly reflected in the G-DRG system. In addition to increasing direct healthcare reimbursement, nutritional screening and intervention have the potential to improve healthcare quality. 

Funding Source:
University/Hospital: Universitatsmedizin Berlin
Reviewer Comments:
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.) 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? 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.) N/A
  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? Yes
  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? Yes
  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? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  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.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  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? N/A
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? Yes
  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
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  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? 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
  7.4. 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)? N/A
  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? N/A
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? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes