EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To test the applicability and compare the results of the Mini Nutritional Assessment (MNA), the Subjective Global Assessment (SGA), and the Nutrition Risk Screening-2002 (NRS-2002) in geriatric hospital patients.

Inclusion Criteria:

All patients less than 65 years of age
Admitted consecutively to two acute geriatric wards
Admitted between October 1 and December 15, 2004
Provided informed consent (either themselves or a family member).

Exclusion Criteria:

Not specified

Description of Study Protocol:

Recruitment

Not specified.

Design

Prospective cohort–patients admitted consecutively to two geriatric wards in an acute hospital were invited to participate.

Blinding

Physicians administering the SGA and NRS-2002 were blinded to the results of the MNA screening.

Intervention

The screening tools were administered within the first four days of admission to the hospital. The MNA was completed as part of a routine geriatric assessment. The SGA and NRS-2002 were administered separately by trained physicians blinded to the results of the MNA screening. Fasting blood samples for serum albumin were obtained in the morning while the patient was still in bed.

Statistical Analysis

SPSS for Windows 12.0G
Level of significance P<0.05
Kruskal-Wallis test used to detect differences between groups.
Cross-tables and Chi-square used to test accordance of NRS-2002 with MNA and SGA.

Data Collection Summary:

Timing of Measurements

Screening and assessment was done during the first four days of admission. The timing of height, weight and serum albumin measurement was not specified.

Dependent Variables

Variable 1: Degree of nutrition risk as measured by MNA
Variable 2: Degree of nutrition risk as measured by SGA
Variable 3: Degree of nutrition risk as measure by NRS-2002
Variable 4: Agreement between NRS with MNA and SGA (measured by cross-tables and Chi-square)
Variable 5: Difference between results of screening tests and BMI (measured by non-parametric Kruskal-Wallis test)
Variable 6: Difference between results of screening tests and serum albumin (measured by non-parametric Kruskal-Wallis test)
Variable 7: Association between length of stay and screening tools
Variable 8: Association between mortality and screening tools.

Independent Variables

Nutritional risk as defined by MNA, SGA, NRS-2002.

Control Variables

Age, sex and state of dependency (independent at home, assisted living facility, old people’s home or nursing home).

Description of Actual Data Sample:

Initial N

219 patients admitted to study wards.

Attrition (final N)

121 patients completed study (67.8% female and 32.2% male)
98 patients could not be included (reason not given).

Age

80.2±7.7 years

Ethnicity

Not specified

Other relevant demographics

State of Dependency Before Admission
Independent at home	46 (38.0%)
Assisted living facility	37 (30.6%)
Old people's home	6 (5.0%)
Nursing home	22 (18.2%)
Diagnoses
Acute infections (bronchitis, pneumonia, UTI)	22.0%
Gastrointestinal diseases	22.0%
Neurologic/psychiatric	21.2%
Acute and chronic cardiovascular disease	18.6%
Other internal diseases	24.6%

Anthropometrics

BMI men: 24.6±4.3; BMI women: 24.8±6.1

Location

Medizinische Klinic 2– Klinikum Nurnberg Lehrstuhl fur Innere Medizin V der Universitat Erlangen-Nurnberg.

Summary of Results:

Variable 1: Degree of nutrition risk as measured by MNA

Number of Patients Completing MNA	80
Good nutrition	24 (30%)
At risk for malnutrition	30 (37.5%)
Malnourished	26 (32.5%)

Variable 2: Degree of nutrition risk as measured by SGA

Number of Patients Completing SGA	120
A (well-nourished)	66 (55%)
B (mild/moderately malnourished)	49 (40.8%)
C (severely malnourished)	5 (4.2%)

Variable 3: Degree of nutrition risk as measured by NRS-2002

Number of Patients Completing NRS	119
No nutrition risk	43 (36.1%)
<3	28 (23.5%)
≥3	48 (40.3%)

Variable 4: Agreement between NRS-2002 with MNA and SGA

NRS-2002 and MNA At Risk or Malnourished	84.6% Agreement	P<0.05
NRS-2002 and MNA normal	37.0% agreement	P<0.05
NRS-2002 and SGA at risk or malnourished	79.2% agreement	P<0.001
NRS-2002 and SGA normal	77.5% agreement	P<0.001

Variable 5: Difference between results of screening tests and BMI; significant association between BMI and all three screening tests existed (P<0.01).

Variable 6: Difference between results of screening tests and serum albumin (measured by non-parametric Kruskal-Wallis test); relationship between MNA and serum albumin was statistically significant (P<0.05).

Variable 7: Association between length of stay and screening tools; significant association between MNA and length of stay.

Variable 8: Association between mortality and screening tools; no significant association observed due to low mortality among study participants.

Author Conclusion:

MNA is the first choice in geriatric patients (due to other research done in establishing malnutrition in geriatric population)
MNA is valid for outpatients, nursing home and hospital patients as long as the required information can be obtained
If the information required for the MNA cannot be obtained, the author suggests using the NRS-2002
It is best to choose the screening and assessment tool based on the individual patient's capability to provide necessary information
More studies should be done to focus on the applicability and effects of nutritional intervention programs.

Funding Source:

Other:

funding source unclear, unless you assume funded by Universitat Erlangen-Nurnberg

Reviewer Comments:

I question whether or not the study methods and statistical analyses were strong enough to support the author's conclusion.

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)	???
	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?		???
	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?	No
	2.2.	Were criteria applied equally to all study groups?	N/A
	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?	???
3.	Were study groups comparable?		N/A
	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.)	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
	3.6.	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?	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%.)	No
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	No
	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?		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
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	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
	6.6.	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?	N/A
	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?	N/A
	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?	N/A
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)?	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?	No
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?		???
	10.1.	Were sources of funding and investigators' affiliations described?	No
	10.2.	Was the study free from apparent conflict of interest?	Yes