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

Citation:

Visvanathan R, Penhall R, Chapman I. Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes. Age Ageing. 2004 May; 33 (3): 260-265. Erratum in: Age Ageing. 2004 Jul; 33 (4): 427.

PubMed ID: 15082431
 
Study Design:
Prospective cohort study
Class:
B - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • The goal of this study was to determine the prevalence and consequences of under-nutrition among older people in a sub-acute facility using four screening methods:
    • "Rapid screen"
    • Single-tiered Mini-Nutritional Assessment (MNA)
    • Two-tiered MNA
    • Standard Nutritional Assessment (SNA
  • The study also compared the results of the first three methods to the results of the SNA.
Inclusion Criteria:
  • Patients admitted to the sub-acute health care facility between 10/22/2002 and 1/17/2003
  • Patients 65 years or older
  • Willingness to sign an informed consent.
Exclusion Criteria:
  • Unable to speak English
  • Unable to provide informed consent
  • Moderate to severe dysphagia
  • On nasogastric feeds
  • Amputees.
Description of Study Protocol:

Recruitment

All eligible participants were asked to enter the study within 48 hours of admission.

Design

Prospective cohort study

  • All participants were assessed using the four screening methods
  • Participants were labeled as having under-nutrition or not based on each of the results
  • Participants were followed until they left the sub-acute care facility for home, hospital or other accommodations
  • Patients were categorized as having a poor discharge outcome or not.

Blinding

  • Patients and investigators were blinded of assessment results until all were completed 
  • A referral to the dietitian was made based on SNA results of mild or moderate under-nourished.

Statistical Analysis

  • Sensitivity and specificity of the Rapid Screen and single and two-tiered MNA compared to SNA were calculated using the following definitions:
    • Sensitivity: Proportion of patients found to be under-nourished by the various screen tools compared to the proportion of patients classified as under-nourished by the SNA
    • Specificity: Proportion of patients considered nourished according to the screening tool compared to the proportion of patients identified as nourished by the SNA
  • Rates for poor outcome occurrence among groups with different nutritional status were compared using individual Chi-square analysis
  • P<0.05 were statistically significant.
Data Collection Summary:

Timing of Measurements

All screening assessments were completed within 48 hours of admission to the facility.

Dependent Variables

Poor Discharge Outcome: Defined as a transfer to an acute hospital directly or to a place with greater supports than they lived in before admission to the acute hospital (e.g., nursing home).

Independent Variables

Nutritional Assessments (each measurement was completed by two investigators at separate times in random order)

  • Rapid Screen consisted of BMI less than 22kg per m2 or reported weight loss greater than 7.5% over previous three months
  • MNA:  Four components
    • Anthropometric (weight, height, weight loss)
    • Global Assessment (six questions of lifestyle, medication and mobility)
    • Dietary Assessment (eight questions related to number of meals, food and fluid intake and autonomy of feeding)
    • Subjective Assessment (self-perceived health and nutrition)
  • Single-tiered MNA: Score less than 24/30 classified a patient as malnourished
  • Two-tiered MNA score: Patients were classified as malnourished with a score less than 17
  • SNA: Assessed six criteria
    • BMI
    • Percent unintentional weight loss over three months
    • Number of GI issues (e.g., nausea, vomiting, constipation and diarrhea), difficulty chewing or swallowing
    • Total cholesterol
    • Serum albumin level
    • Total lymphocyte count
    • Indicators: Normal (N), borderline (B), or under-nourished (U)
      • Mild under-nourished = 1U plus 2B or 2U plus1B; Moderate to Severe = 3U or more.
Description of Actual Data Sample:
  • Initial N: 65 patients (21 males) in three units (Medical, Orthopedic and Geriatric)
  • Attrition (final N): All patients were followed until discharge
  • Mean age ± std:
    • Medical: 76.5±5.3 years 
    • Orthopedic: 79.5±5.6 years
    • Geriatric: 79.8±7.7 years
  • Ethnicity: Not reported
  • Mean BMI ± std:
    • Medical: 26.3±4.8kg per m2 
    • Orthopedic: 25.9±5.7kg per m2 
    • Geriatric: 24.9±5.8kg per m2  
  • Location: Hampstead Rehabilitation Center, Adelaide, South Australia.
Summary of Results:

 

Variables

Undernourished

 

Not Undernourished

 

Compared to SNA

Sensitivity/Specificity % and 95% CI

Rapid Screen

35.4%; N=23

64.6%; N=42

78.6% (N/A)

97.3% (N/A)

Single-tier MNA

 75.4%; N=49

 24.6%; N=16

92.5% (77.4-98.0)

37.8% (24.1-53.9)

Two-tier MNA

43.1%; N=28

56.9%; N=37

89.5% (68.6-97.1)

87.5% (64.0-96.5)

SNA

43.1%; N=28

56.9%; N=37  

 Other Findings

 Under-nourished patients were more likely to experience a poor discharge outcome than nourished patients.

  • SNA: Under-nourished 50.0% vs. nourished 21.6%, P=0.017
  • Two-tiered MNA: Under-nourished 50.0% vs. Nourished 21.6%, P=0.017
  • Single-tiered MNA: Under-nourished 66.7% vs. nourished 10.5%, (Chi square not performed because event rate was too low among nourished)
  • Rapid Screen: Under-nourished 56.5% vs. nourished 21.4%, P=0.004.
Author Conclusion:
  • A systematic screening process for under-nutrition in sub-acute care facilities is needed because prevalence is high
  • The prevalence of under-nutrition in patients of a sub-acute facility in South Australia varied from 35.4 to 75.4% by the screening tool used to assess nutritional risk
  • The Rapid Screen had higher specificity, but lower sensitivity than the two-tiered MNA when compared to the SNA
  • Under-nourished patients were more likely than well-nourished patients to transfer to an acute hospital directly from the center or require discharge to accommodations with increased support.
Funding Source:
Other: Not Disclosed
Reviewer Comments:

Strengths:

  • Relevance of testing the various screening tools to diagnose under-nutrition
  • Association to a poor discharge outcome

Limitations:

  • Generalizability is limited because the study sample was small and from one sub-acute facility in one particular area
  • Generalizability is also limited because of one outcome measure (authors only considered Poor Discharge Outcome)
  • Patient enrollment was based on nonrandom selection
  • Confounding factors were not addressed
  • Study does not identify one screening tool as the screening tool of choice.
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? No
  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? No
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? No
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) 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
  3.4. 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? No
  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? N/A
  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%.) N/A
  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? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  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? 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? N/A
  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? No
  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? No
  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)? N/A
  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? 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? No
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