EAL

UWL: Screening and Assessment Methods (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To determine the reliability and validity of the Ayrshire Nutrition Screening Tool in determining risk of poor nutritional status in elderly patients attending community day hospitals.

Inclusion Criteria:

65 years or older
Attending one of three day hospitals in Scotland.

Exclusion Criteria:

Severe cognitive impairment
Failure to provide consent to anthropometric nutritional assessment.

Description of Study Protocol:

Recruitment

All patients who attended the three day hospitals were asked to consent to the study.

Design

Cross-sectional; each patient was screened using a screening tool and then assessed using a full set of anthropometric measurements.

Intervention

The nutrition screen was conducted by a dietitian and a nurse; it consisted of:

Weight
Appetite
Dietary intake
Fluid intake
Ability to eat
Clinical condition.

An overall score of seven or higher (maximum, 18) were referred to a dietitian for further assessment.

The assessment was completed by the same dietitian and included:

Knee height
Weight
BMI
Corrected arm muscle circumference (cAMA)
Mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST).

Statistical Analysis

Cohen's Kappa was used to assess inter-rater reliability
Spearman's Rank correlation coefficient was used to assess validity of the screening tool compared to the anthropometric assessment.

Data Collection Summary:

Timing of Measurements

The screening occurred upon admission by the nurse and the dietitian; the full assessment followed if the score was above seven for the screen but the timing is not clear.

Dependent Variables

Nutritional Screening score; if above seven, the patient is considered at nutritional risk.

Independent Variables

Full anthropometric assessment; only completed on patients who were identified by the screen as at nutritional risk.

Description of Actual Data Sample:

Initial N: 70 (20 male, 50 female)
Attrition (final N): 70
Age: Mean, 78 years
Anthropometrics: Distribution of BMI was 1.4%, 8.6%, 11.4%, 41.4%, 25.7% and 11.4% for BMI less than 16, 16.1 to 18, 18.1 to 20, 20.1 to 25, 25.1 to 30, and more than 30, respectively. Mean BMI was 24.4. Mean cAMA was 32.88. Mean MAMC was 22.74.
Location: Scotland.

Summary of Results:

Variables	Cohen's Kappa	Outliers: Those Classified Differently by the Nurse and Dietitian
Body weight	0.94	3
Appetite	0.92	3
Dietary intake	0.77	3
Fluid intake	0.77	10
Ability to eat	0.90	3
Clinical condition	0.94	2

Other Findings

The measure of agreement for overall score was 0.73
Reliability: The dietitian classified 11 of 70 patients at nutritional risk; the nurse classified 13 of 70 at nutritional risk
When comparing the screening scores assigned by the nurse and dietitian with the objective anthropometric assessments, a significant correlation was found for all categories
- BMI: R±0.42, P=0.01
- TST: R±0.36, P=0.01 (triceps skinfold)
- MAC: R±0.39, P<0.01
- MAMC: R±0.37, P<0.01
- cAMA: R±0.34, P<0.01.

Author Conclusion:

The Ayrshire nutrition screening tool is a reliable and valid tool that can be used by qualified nurses to assist in screening elderly patients at high risk of poor nutritional status.

Funding Source:

University/Hospital:

Hospital Trust - Research and Development Committee

Reviewer Comments:

This study did not assess sensitivity and specificity. The full assessment (to which the screening tool results were compared) was only completed on those who were identified as at nutritional risk using the screening tool instead of all patients. So only one part of validity was examined in this study.
The results of the study are difficult to generalize beyond the small population of elderly attending day hospitals in Scotland
This screening tool is not quick and easy
The screening tool is not compared against a gold standard method; only anthropometric measurements.

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)	No

Validity Questions
1.	Was the research question clearly stated?		No
	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?	No
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?	No
	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)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	No
	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.)	No
	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?		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?	N/A
	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?	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?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		No
	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?	No
	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?	No
	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?	No
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	No
7.	Were outcomes clearly defined and the measurements valid and reliable?		No
	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?	No
	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?	No
	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?	No
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?	No
	8.2.	Were correct statistical tests used and assumptions of test not violated?	No
	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?	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?		No
	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?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes