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

Citation:

Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C, Elia M. Malnutrition in hospital outpatients and inpatients: Prevalence, concurrent validity and ease of use of the 'malnutrition universal screening tool' ('MUST') for adults. Br J Nutr. 2004 Nov; 92 (5) : 799-808.

PubMed ID: 15533269
 
Study Design:
Cross-sectional study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

The aims of the study were:

  • To compare the prevalence of malnutrition risk assessed by the Malnutrition Universal Screening Tool (MUST) and a variety of other published tools in both hospital outpatients and inpatients;
  • To investigate the concurrent validity of MUST with other published tools and to assess whether the same patients are identified as malnourished;
  • To compare the ease of use of MUST with other published tools.

 

Inclusion Criteria:

Patients able to give informed consent.

Exclusion Criteria:

Patients unable to give informed consent including those with dementia, confusion and unconsciousness.

Description of Study Protocol:

Recruitment

 Hospital inpatients or outpatients who were able to give informed consent.

  • Study 1: Consecutive patients attending a gastroenterology outpatient clinic
  • Study 2: Consecutively admitted elective and emergency medical patients
  • Study 3: Consecutively admitted elderly medical and surgical patients
  • Study 4: Consecutively admitted medical patients less than 65 years of age
  • Study 5: Consecutively admitted elective and emergency general surgical patients.

Design

  •  Five studies were conducted during which MUST was:
    • Used to categorize hospital outpatients and inpatients into three malnutrition risk categories (low-, medium- or high-risk) and two risk categories (low-risk and combined medium-risk + high-risk of malnutrition);
    • Compared to published tools to determine concurrent validity;
    • Compared to published tools based on ease of use on a four-point Likert scale.
  • Prevalence of malnutrition as determined by MUST were compared to seven other published nutritional tools in specific populations
    • Study 1: MEREC Bulletin tool, Hickson and Hill tool
    • Study 2: Nutrition Risk Score (NRS),  Malnutrition Screening Tool (MST)
    • Study 3: Short-form Mini-Nutritional Assessment Screening Tool (MNA-tool) 
    • Study 4: Subjective Global Assessment (SGA)
    • Study 5: Undernutrition Risk Score (URS).

Blinding used (if applicable)

 None.

Intervention

 Assessment using MUST and one or more of the other specified tools.

Statistical Analysis

  •  To test concurrent validity
    • Agreement and chance-corrected agreement (K) between pairs of tools applied to the same patients
  • To assess systematic under- or over-categorization of malnutrition risk between two tools
    • Binomial test; for tools with two categories, this corresponds to the McNemar test
  • To determine differences in the prevalence of malnutrition between two tools used in the same patients
    • Test of paired proportions.
Data Collection Summary:

Timing of Measurements

  • Study 1: During outpatient visit
  • Study 2: Within 72 hours of admission
  • Study 3: Within 72 hours of admission
  • Study 4: Timing of measurements not provided
  • Study 5: Timing of measurements not provided

Dependent Variables

  • MUST tool utilizes three criteria:
    • BMI
    • Percentage of unintentional weight loss in three to six months
    • No intake for greater than five days (past or future).

Independent Variables 

  • MEREC Bulletin tool utilizes three criteria:
    • BMI
    • Unintentional weight loss
    • Intake of food or fluid
  • Hickson and Hill tool utilizes five criteria:
    • Unintentional weight loss in three months
    • BMI
    • Appetite
    • Ability to eat or retain food
    • Clinical or medical stress factor
  • Nutrition Risk Score (NRS) utilizes five criteria:
    • Unintentional weight loss in three months
    • BMI
    • Appetite
    • Ability to eat or retain food
    • Clinical or medical stress factor
  • Malnutrition Screening Tool (MST) utilizes three criteria:
    • Weight loss
    • Quantity of weight loss
    • Poor intake or appetite
  • Short-form Mini-Nutritional Assessment Screening Tool (MNA-tool) utilizes six criteria:
    • Declining food intake over three months
    • Mobility
    • Psychological stress 
    • Acute disease
    • Neuropsychological problems
    • BMI
  • Subjective Global Assessment (SGA) utilizes nine criteria:
    • Clinical history
    • Weight change
    • Change in dietary intake
    • Gastrointestinal symptoms
    • Functional capacity
    • Disease and its relation to nutrition requirements
    • Loss of subcutaneous fat
    • Muscle wasting
    • Ankle or sacral edema or ascites
  • Undernutrition Risk Score (URS) utilizes seven criteria:
    • Acceptable weight (appearance)
    • Unintentional weight loss in three months
    • Appetite
    • Age
    • Ability to eat
    • Gut function
    • Medical condition

Control Variables

 None.

Description of Actual Data Sample:

 Initial N

  • Study 1: 50 patients; 31 female, 19 male
  • Study 2: 75 patients; 30 female, 45 male
  • Study 3: 86 medical patients; 85 surgical patients
  • Study 4: 50 patients
  • Study 5: 52 patients; 29 female, 23 male

Attrition (final N)

  • Study 1: 50 patients; 31 female, 19 male
  • Study 2: 75 patients; 30 female, 45 male
  • Study 3: 86 medical patients; 85 surgical patients
  • Study 4: 50 patients
  • Study 5: 52 patients; 29 female, 23 male

Age

  • Study 1: 56±16 years (mean ± SD)
  • Study 2: 44±14 years
  • Study 3: Medical patients 78±7.37 years; surgical patients: 61±20.2 years
  • Study 4: 45±13.9 years
  • Study 5: 62±16 years

Ethnicity

Not provided

Other relevant demographics

  • Study 1: Diagnoses
    • Esophageal stricture
    • Colitis
    • Diverticular disease
    • Gluten-sensitive enteropathy
  • Study 2: Reasons for admission
    • Respiratory infection
    • Crohn's disease
    • Cancer
    • Accidental falls
    • Gastrointestinal complaints
    • Respiratory complaints
  • Study 3: Reasons for admission
    • Medical patients:
      • Chronic obstructive pulmonary disease
      • Cerebrovascular accident
      • Pneumonia
      • Angina
      • Heart failure
      • Renal failure
      • Gastrointestinal complaints
    • Surgical patients:
      • Gastrointestinal complaints
      • Bowel obstruction
      • Pancreatitis
      • Appendicitis
      • Cholecystitis
  • Study 4: Reasons for admission
    • Chest pain
    • Shortness of breath
    • Gastrointestinal problems (e.g., severe vomiting, gasteroenteritis)
    • Chronic renal failure
    • Pneumonia
  • Study 5: Reasons for admission
    • Hernia repair
    • Varicose vein removal
    • Cholecystectomy
    • Urological surgery

Anthropometrics

  • BMI=28.4±10.1kg/m2 (mean ± SD)
  • Study 2: BMI=27.0±5.48kg/m2
  • Study 3:
    • Medical patients: BMI=25.5±5.22kg/m2
    • Surgical patients: BMI=26.7±4.70kg/m2
  • Study 4: BMI=27.3±6.30kg/m2
  • Study 5: BMI=27.7±6.08kg/m2  

Location

Southampton General Hospital, Southampton, United Kingdom

Summary of Results:

 

Tool Comparison Nutrition Risk Categories (N) Patients N Agreement (Percentage)¥ Agreement (K)§ SE
Community Setting            
MUST vs. MEREC 3 Outpatients 50 92 0.893 0.077
MUST vs. HH 3 Outpatients 50 84 0.711 0.105
Hospital Setting            
MUST vs. NRS 3 Medical less than 65 years old 75 89 0.775 0.072
MUST vs. NRS 2 Medical less than 65 years old 75 92 0.813 0.073
MUST vs. MST 2 Medical less than 65 years old 75 88 0.707 0.091
MUST vs. MNA-tool 2 Medical greater than 65 years old 86 77 0.551 0.081
MUST vs. MNA-tool 2 Surgical 85 80 0.605 0.083
MUST vs. SGA 3 Medical 50 72
MUST vs. SGA 2 Medical 50 92 0.783 0.102
MUST vs. URS 3 Surgical 52 67 0.255 0.101
MUST vs. URS 2 Surgical 52 77 0.431 0.130

 ¥Percentage of patients placed in the same malnutrition risk category by the two tools. Disagreements in categorization between tools were not systematically biased, except between MUST and MNA-tool in medical and surgical patients (two categories, P=0.0005) and MUST and URS (two categories, P=0.039).

§K 0.400-0.750 fair to good; K>0.750 excellent agreement beyond chance

€ As the observer did not categorize any patients as high risk with SGAK was not calculated for the three category comparison.

    MUST Low Risk MUST Medium and High Risk Total
Medical less than 65-year-old patients (N=75)   n n n
MST No Risk 49 4 53
  Risk 5 17 22
Total   54 21 75

 

    MUST Low Risk  MUST Medium and High Risk  Total
     n  n  n
 Surgical Patients (N=85)        
MNA-tool   No Risk  31  14 45 
  Risk  3  37  40
Total     34  51  85
 Elderly medical patients (N=86)        
 MNA-tool No Risk  29  1  30
  Risk  19  37  56
 Total    48  38  88

Other Findings

  • Prevalence of malnutrition risk (medium and high) using MUST ranged from 19-60% across patient groups
    • Lowest prevalence of malnutrition risk was in general surgical patients
    • Highest prevalence of malnutrition risk was in gastrointestinal surgical patients
  • Prevalence of malnutrition risk using the seven comparison tools ranged from 19-65% across patient groups
    • Lowest prevalence of malnutrition risk was in general surgical patients (using SGA)
    • Highest prevalence of malnutrition risk was in elderly medical patients (using MNA-tool)
  • Compared to MUST
    • A significantly higher proportion of patients were identified as being at risk by the URS
      • General surgical patients
      • 35 vs. 19%, P=0.001
    • A significantly higher proportion of patients were identified as being at risk by the MNA-tool
      • Elderly medical patients
      • 65 vs. 44%, P=0.0005
    • A significantly lower proportion of patients were identified as being at risk by the MNA-tool
      • Gastrointestinal surgical patients
      • 47 vs. 60%, P=0.0005.

 

Author Conclusion:
  • Overall proportion of patients identified with malnutrition can vary significantly when different procedures are used in the same patient group
  • Even when different tools identify a similar prevalence of malnutrition, the individuals identified at risk may differ
  • MUST has 'fair-good' to 'excellent' concurrent validity with a range of previously published tools with the exception of the URS tool for surgical patients
  • Screening with MUST was quick and 'very easy' or 'easy' to use
  • There is a high prevalence of malnutrition in hospital outpatients and inpatients using MUST.
Funding Source:
Reviewer Comments:

Since there is no universally accepted definition of malnutrition, it may be difficult to assess the validity of any malnutrition screening tool.

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.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? No
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? Yes
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? 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.) N/A
  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? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) 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
  6.8. 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? 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)? 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
  8.7. 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? Yes
  10.2. Was the study free from apparent conflict of interest? Yes