EAL

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

Citation:

Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Ader HJ, Van Bokhorst-de van der Schueren MAE. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr. 2005; 82: 1,082-1,089.

PubMed ID: 16280442

Study Design:

Non-Randomized Controlled Trial

Class:

C - Click here for explanation of classification scheme.

Quality Rating:

POSITIVE: See Quality Criteria Checklist below.

Research Purpose:

To determine the effectiveness and cost-effectiveness of the use of the Short Nutritional Assessment Questionnaire (SNAQ) compared with the usual nutritional care for the early recognition and treatment of malnourished hospital patients with respect to length of hospital stay, weight change, use of nutritional supplements and quality of nutritional care.

Inclusion Criteria:

Patients admitted to a mixed internal ward (general internal medicine, gastroenterology, dermatology, rheumatology and nephrology) and a mixed surgical ward (general surgery and surgical oncology) of the VU Medical Center from February, 2003 to June, 2003, who were able to give informed consent. Also included were patients admitted to the same wards from April, 2002 to October, 2002 who were able to give informed consent.

Exclusion Criteria:

Patients who were unable to give informed consent, could not be weighed or were less than 18 years of age were excluded from the study. Patients who died during their hospital stay were not included in the analysis.

Description of Study Protocol:

Recruitment

Patients admitted to a mixed internal ward (general internal medicine, gastroenterology, dermatology, rheumatology, and nephrology) and a mixed surgical ward (general surgery and surgical oncology) of the VU Medical Center from February, 2003 to June, 2003. Also patients admitted to the same wards from April, 2002 to October, 2002.

Design

Non-randomized controlled trial with a historical control group.

Intervention

Use of the Short Nutritional Assessment Questionnaire (SNAQ) nutritional screening tool to increase early recognition and awareness of malnutrition.

Intervention Group: The nurse completed the SNAQ for every patient admitted to the hospital. Patients were classified as moderately malnourished (SNAQ score greater than two points) and severely malnourished (SNAQ score greater than three points).

Moderately malnourished patients received energy and protein-enriched meals and two in-between meals per day. This accounted for 600kcal and 12g of protein per day.
Severely malnourished patients received treatment by a dietitian, energy and protein enriched meals.

Control Group: Received the usual hospital nutritional care and were not routinely screened for nutritional status. Referral to dietitian occurred only by indication.

Statistical Analysis

Linear regression was used to assess the effectiveness of the screening and of the use of the treatment plan
Analysis of Covariance was used to assess change in weight
Chi-square test and Student's T-test were used to assess the differences in use of supplemental drinks, tube feedings, parenteral nutrition and in-between meals and the number of consultations by a dietitian
Confidence intervals were obtained with bias correction to assess cost-effectiveness.

Data Collection Summary:

Timing of Measurements

Intervention Group: February, 2003 to June, 2003
Control Group: April, 2002 to October, 2002.

Patients were nutritionally screened assessed on admission by a trained researcher.

Dependent Variables

Weight change during hospital stay
Use of supplemental drinks
Use of tube feedings
Use of parenteral nutrition and in-between meals
Number of consultations by a dietitian
Length of hospital stay
Mortality: Died during their hospital stay.

Independent Variables

Use of the Short Nutritional Assessment Questionnaire (SNAQ) nutritional screening tool to increase early recognition and awareness of malnutrition.

Intervention Group: The nurse completed the SNAQ for every patient admitted to the hospital. Patients were classified as moderately malnourished (SNAQ score more than two points) and severely malnourished (SNAQ score more than three).

Moderately malnourished patients received energy and protein enriched meals and two in-between meals per day. This accounted for 600kcal and 12g protein per day.
Severely malnourished patients received treatment by a dietitian, energy and protein enriched meals.

Control Group: Received the usual hospital nutritional care and were not routinely screened for nutritional status. Referral to dietitian occurred only by indication.

Control Variables

Patients admitted to the same wards of the hospital: Mixed internal ward (general internal medicine, gastroenterology, dermatology, rheumatology and nephrology) and a mixed surgical ward (general surgery and surgical oncology).

Description of Actual Data Sample:

Initial N

Intervention Group: 297 (118 males)
Control Group: 291 (117 males).

Attrition (Final N)

N=567

Intervention Group: 284
Control Group: 283

[Noted: Patients who died during their hospital stay were not included in the analysis.]

Age

62 years old (mean age of malnourished group).

Anthropometrics

Intervention group and control group were not significantly different with regard to age, sex, BMI, hand-grip strength and INTERMED score or when classified by nutritional status. Characteristics of the malnourished and well-nourished patients were not significantly different between the intervention and control groups.

Location

Amsterdam, Netherlands.

Summary of Results:

Mean Costs in All Patients and In the Malnourished Patients

Variables	Intervention Group	Control Group
Number of In-Between Meals at 51 Euro Cents (N=588)	887±9.9	0
SNAQ Cart (€, N=588)	2,083	0
Extra Costs of Nutritional Assistant (€, N=588)	4,800	0
Number of Dietitian Consultations (N=588)	1.1±2.0	1.0±2.4
Cost of Dietitian (€, N=588)	60.3±103.4	56±123
Length of Hospital Stay in Days (N=588)	10.4±8.4	12.0±13.5
Number of Dietitian Consultations for Malnourished Patients (N=191)	2.1±2.6	2.0±3.6
Cost of Dietitian for Malnourished Patients (N=191)	120±134	109±184
Length of Hospital Stay in Days for Malnourished Patients (N=191)	11.5±8.0	14.0±13.3

Other Findings

The recognition of malnutrition improved from 50% to 80% with the use of the SNAQ malnutrition screening tool during admission to the hospital
Standardized nutritional care protocol added approximately 600kcal and 12g protein to the daily intake of malnourished patients
In both the intervention group and control group 26%, of patients were severely malnourished and 6% were moderately malnourished
Referral to a dietitian was significantly higher in the intervention group (76% referred compared to 46% in control group)
Supplement use: In the control group, 37% used supplements compared to the intervention group 28% used supplements
Use of tube feeding and parenteral feeding was not significantly different in the intervention and control group
No significant differences were observed in the mean number of consultations from a dietitian between the intervention group (SD: 2.1±2.6) and the control group (SD: 2.0±3.6)
Mean number of days in the hospital before the first consultation with a dietitian was lower in the intervention group (SD: 2.6±2.1 days) than in the control group (SD: 5.8.±6.7 days) (P<0.001)
Early screening and treatment of malnourished patients reduced the length of hospital stay in malnourished patients with low hand-grip strength (i.e., frail patients)
Nutritional intervention had no significant effect on the length of hospital stay (P=0.13)
Weight change during hospital stay was not significantly different between the two groups (P=0.6).

Cost-Effectiveness Analysis

The incremental cost of a one-day reduction in the length of hospital stay in the malnourished group through extra nutritional care and dietetic treatment was €76 (US $91.20)
The incremental costs were comparably low in the whole group and in the subgroup of malnourished patients with low hand-grip strength
The mean (95% CI) length of hospital stay was 1.08 days less in the intervention group than in the control group.

Author Conclusion:

Application of the SNAQ screening and treatment plan improved the recognition of malnourished patients and provided the opportunity to start treatment at an early stage of hospitalization. With a small investment for in-between meals and dietetic care, the nutritional care during the hospital stay was improved and the duration of hospital stay was reduced in a subgroup of frail, malnourished patients.

Funding Source:

Reviewer Comments:

Authors note that other factors beside the SNAQ screening and treatment may have influenced the outcomes.

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.)	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?	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?		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?		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?	N/A
	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?	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?	N/A
	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)?	Yes
	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?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes