ONC: Nutrition Status and Outcomes in Adult Oncology Patients (2013)
Citation:
Amaral TF, Antunes A, Cabral S, Alves P, Kent-Smith L. An evaluation of three nutritional screening tools in a Portuguese oncology centre. J Hum Nutr Diet. 2008; 21: 575-583.
Study Design:
Diagnostic, Validity or Reliability Study
Class:
C - Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
- To evaluate the ability of the Malnutrition Screening Tool (MST) and the Malnutrition Universal Screening Tool (MUST) to identify nutritionally at-risk cancer patients, compared to a reference screening tool (Nutritional Risk Screening 2002)
- To compare the ability of each screening tool to predict long length-of-stay in nutritionally at-risk oncology patients.
Inclusion Criteria:
- Male or non-pregnant female
- Aged at least 18 years
- Anticipated length of stay over 24 hours
- Provide informed consent.
Exclusion Criteria:
- Patients admitted to the following departments:
- Pediatric units
- Intensive and intermediate care units
- Bone marrow transplant units
- Brachytherapy.
Description of Study Protocol:
Recruitment
- March through June 2005
- The first of every two admissions (every other admission) who met study criteria were included until half the department's available inpatient beds were filled.
Design
- Nutrition screening was completed by the same investigator for each tool in the order below:
- Malnutrition Screening Tool (MST)
- Score calculated based on appetite and unintentional weight loss
- Classified as normal or at-risk.
- Malnutrition Universal Screening Tool (MUST)
- Score calculated based on BMI, unintentional weight loss and acute disease effect with potential for no nutrition intake of more than five days
- Classified as low, medium or high risk.
- Nutritional Risk Screening (NRS-2002)
- Score calculated based on BMI, percentage of recent weight loss, recent change in food intake and disease severity
- Classified as normal, mild, moderate or severe risk.
- Malnutrition Screening Tool (MST)
- Demographic and anthropometric data were collected.
Blinding Used
Data collected by interviewer not involved with patients' care.
Statistical Analysis
- Chi-square test was calculated to compare proportions
- Student's T-test or Mann-Whitney U-test used to compare means
- Using NRS-2002 as the reference, sensitivity, specificity, positive and negative predictive values were calculated for MST and MUST. Fleiss' kappa coefficient assessed agreement.
- Multivariate analyses and odds ratios were calculated to assess the association between nutrition risk and length of stay. Adjusted for age and gender.
- Patients with ascites or edema were excluded from BMI determination (N=4)
- For the MUST tool, medium and high risk were combined into high risk category, due to small numbers in each nutrition risk category
- Significance: P<0.05.
Data Collection Summary:
Timing of Measurements
- Data was collected from the medical record or interview on Day One of admission for surgical patients or Day Two for non-surgical patients
- Anthropometrics
- Height or recumbent height
- Weight
- Tricep skinfold and arm circumference.
- Education
- Clinical diagnosis.
- Anthropometrics
Dependent Variables
- Nutrition risk identification
- MST
- MUST.
- Long length of stay (median length of stay for the study sample): At least seven days
Independent Variables
Nutrition risk screening tools.
Control Variables
- Age
- Gender.
Description of Actual Data Sample:
- Initial N: 130 (73 males and 57 females)
- Attrition (final N): 130
- Age (mean±SD): 57.1±13.5 years (range, 22 to 97 years)
- Ethnicity: Not described
- Location: Comprehensive cancer center in Portugal.
Summary of Results:
Key Findings
Nutrition Risk Screening
- Nutrition risk identification by tool
- NRS-2002: N=37 (28.5%)
- MST: N=23 (17.7%)
- MUST: N=57 (43.8%).
- Stratified by tumor location
- All three tools identified head and neck cancer patients as those presenting with the highest risk and showed good agreement identifying patients with peritoneal and gastrointestinal and lympha ganglia tumors
- No patients with hematopoietic or endothelial reticulum tumors were identified at nutrition risk with any tool
- Compared with NRS-2002, MST failed to identify patients at nutrition risk in seven tumor location categories
- MUST failed to identify one patient at nutritional risk, compared to NRS-2002.
- Agreement of screening tools, compared to NRS-2002
- Restricting the analysis to the tumor location groups with the highest nutritional risk (head and neck and peritoneal and gastrointestinal, N=52), MST showed good agreement with NRS-2002. MUST maintained a high sensitivity but the other parameters declined with moderate agreement with NRS-2002.
Sensitivity | Specificity | Positive Predictive Value | Negative Predictive Value | Agreement | Kappa | Interpretion | |
MST | 48.7% |
94.6% |
78.3% |
82.2% |
81.5% |
0.49 |
Moderate |
MUST | 97.3% |
77.4% |
63.2% |
98.6% |
83.1% |
0.64 |
Good |
Risk of Long Length of Stay [(OR (95% CI) adjusted for age and gender)]
- NRS-2002: 2.47 (1.05 to 5.80), P=0.003
- MST: 2.31 (0.84 to 6.36), not significant
- MUST: 3.24 (1.50 to 7.00), P=0.038.
Author Conclusion:
MUST agreed with NSR-2002 better than MST in hospitalized cancer patients and also predicted oncology patients at greater risk for longer length of stay.
Funding Source:
University/Hospital: | Nutrition & Food Science, University of Porto, Portugal; Instituto Portugues de Oncologia do Porto Francisco Gentil, Porto, Portugal |
Reviewer Comments:
- NRS-2002 may not represent the gold standard to evaluate the nutritional status of oncology patients
- Length of stay was affected by many non-nutrition-related factors and may not have been a good outcome variable.
Quality Criteria Checklist: Primary Research
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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? | 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? | 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) | 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")? | Yes | |
4. | Was method of handling withdrawals described? | Yes | |
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? | Yes | |
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? | 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? | Yes | |
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? | 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? | 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? | 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? | N/A | |
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)? | 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 | |