EAL

ONC: Malnutrition Screening and Nutrition Assessment of Adult Oncology Patients (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The purpose of this study was to develop a simple, reliable and valid malnutrition screening tool that could be used to identify acutely ill adult patients at risk of malnutrition upon admission to the hospital.

Inclusion Criteria:

All patients admitted to the Wesley Hospital in Brisbane, Queensland, Australia during a three-month study period were eligible for inclusion.

Exclusion Criteria:

Patients were excluded if they were:

Less than 18 years old
In psychiatric care
Pregnant or under maternity care
Unable to communicate.

Description of Study Protocol:

All study participants were assessed for malnutrition risk within two days of hospital admission using:

Subjective Global Assessment (SGA)
20 nutrition screening questions.

The results of these scoring systems were then statistically analyzed to create the Malnutrition Screening Tool (MST) at the highest combination of sensitivity and specificity compared to the SGA as "gold standard".

Validity of MST was assessed by comparing the MST to anthropometric and biochemical parameters.

Reliability of MST was assessed by comparing results to 32 additional subjects.

Weight and height were self-reported by the subjects.

Age, gender, ward and length of stay were obtained retrospectively from the medical records.

Data Collection Summary:

Timing of Measurements

All subjects were screened within two days of admission. Additional information was obtained retrospectively from the medical record.

Subjective Global Assessment

Performed on all subjects and considered the standard for comparison in this study.

Nutrition Screening Questions Used in the Study Were Selected from the Literature Based on the Following Criteria

Applicable for use in heterogeneous adult population
Use routinely available data
Convenient to use
Non-invasive and inexpensive
Valid and reproducible.

Nutrition Screening Questions

Have you lost weight recently without trying? If yes, how much weight have you lost (kilograms) and over what time period have you lost the weight (weeks)?
Is your current appetite: Poor, fair, good, unsure?
What is your appetite/food intake like usually? Poor, fair, good, unsure?
Has your appetite/food intake been less than usual lately?
Have you been eating poorly because of a decreased appetite?
Do you have an illness or condition that has made you change the kind and/or amount of food you eat?
Do you have tooth, mouth or swallowing problems that make it hard for you to eat?
Have you had nausea, vomiting, or diarrhea for the past three days or longer?
Do you regularly skip meals?
Do you eat alone most of the time?
Are you always physically able to shop, cook and feed yourself?
Do you wear dentures?
Do you have any allergies or intolerance for food?
Are you on any special diets?
How many medications prescribed by your doctor or bought over the counter are you taking?
Have you been in a hospital overnight or longer in the past 12 months? If yes, how many different times did you stay in a hospital overnight or longer in the past 12 months?
Have you had surgery in the past six months?
Have you had an illness that kept you in bed during the past month?
In general, would you say your health is: Poor, fair, good, very good, excellent, unsure?
Compared to one year ago, how would you rate your health in general now? Much worse, somewhat worse, about the same, somewhat better, much better, unsure?

Anthropometric Parameters Utilized for Validity Comparison

Body mass index (based on reported height and weight)
Mid-arm circumference
Mid-arm muscle area
Hand grip strength.

Biochemical Parameters Utilized for Validity Comparison

Total protein
Albumin
Prealbumin
Hemoglobin
Hematocrit
Total lymphocyte count
White cell count
C-reactive protein.

Description of Actual Data Sample:

Initial N

N=408 subjects selected in the convenience sample represents 10.3% of the eligible patients during the study period.

201 Male (49.3%)
207 Female (50.7%).

Age

Average, 57.7±16.5 (19 to 94) years.

Other Relevant Demographics

Length of stay average, 6.0±9.3 (0 to 77) days
20.6% Plastic surgery
15.9% Cardiac
14% Gynecology
13.2% General surgery/urology
12.5% Gastrointestinal
9.6% Oncology
9.3% General medical/respiratory
4.9% Orthopedic.

Location

The Wesley Hospital in Brisbane, Queensland, Australia.

Summary of Results:

Malnutrition Screening Tool (MST)

Developed from the statistical analysis of the impact of each of the 20 questions on sensitivity and specificity to the similar result of the SGA:

Have you lost weight recently without trying? No (0) Unsure (2)
If yes, how much weight (kilograms) have you lost? One to five (one), six to 10 (to), 11 to 15 (three), more than 15 (four), unsure (two)
Have you been eating poorly because of a decreased appetite? No (zero), Yes (one)
A score of two or more indicates a patient at risk of malnutrition.

Variables	True Prediction	False Prediction	Predictive Value
Positive malnourished	64	24	98.4%
Negative malnourished	315	5	72.7%
Classification rate	93%	7.1%

Other Findings

The validity of the MST is evidenced in subjects at risk of malnutrition and had significantly lower mean values for objective nutrition parameters when compared to well-nourished subjects, except for total lymphocyte count and white cell count
Sensitivity and specificity of the MST were both 93%
The length of stay of subjects who were at risk of malnutrition was significantly longer than subjects who were not at risk of malnutrition
Inter-observer reliability was strong, with 93% to 97% agreement (P<0.01).

Author Conclusion:

The Malnutrition Screening Tool (MST) is a simple, quick, valid and reliable tool that can be used by medical, nursing, dietetic or administrative staff as well as family, friends or the patient themselves, to identify patients at risk of malnutrition. The authors recommend screening within 24 hours of admission. Patients who are not at risk should be rescreened weekly until discharge. Patients who are at risk should have a detailed nutrition assessment and interventions as needed.

Funding Source:

Reviewer Comments:

It is interesting that so much can be discovered with self-reported information.

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.)	Yes
	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")?	Yes
4.	Was method of handling withdrawals described?		N/A
	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?		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?	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?	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?	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?	Yes
	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?	Yes
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?	N/A
	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)?	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?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		No
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes