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Hospital Diagnosis of Malnutrition:A Call for Action

MARY ANN BOCOCK, PhD, RD, HEATHER H. KELLER, PhD, RD,Department of Family Relations and Applied Human Nutrition, University ofGuelph, Guelph, ON

AbstractThe Canadian Institute for Health Information (CIHI) pro-

vides accurate health information needed to establish soundhealtli care policies. The CIHI mandate is to develop and co-ordinate a uniform approach to health care information inCanada. The instittite uses the International Classification ofDiseases (ICD) system to record the most responsible diagno-sis for each hospital admission. This investigation was con-ducted to de te rmine ifsix ICD protein-calorie malntitrition(PCM) codes could be used for health care utilization analy-ses. Aggregate data (1996 to 2000) from the CIHI dischargeabstract database were used. The data analyzed were the mostresponsible diagnoses data for the six PCM codes and a singlesummaiy statistic for all other "non-malnutrition" diagnosesfor all long-term care facility residents aged 65 or older whowere transferred to an acute care facility. In this population,fewer than five hospital admissions per year were assigned aPCM code. There were too few PCM cases to do trend analysesfor morbidity or mortality. This sttidy suggests a lack of recog-nition and documentation of PCM as a specific health condi-tion in older adults. Lack of tracking of this diagnosis preventsdocumentation that could lead to policy changes to suppor tolder adults' nutrition.(Can J Diet Prac Res 2009;70:37-41 )(DOI: 10.3148/70.1.2009.37)

RsumL'Institut canadien d'infomiation sur lasant (ICIS) fournit

l'information en sant prcise ncessaire potir tablir des poli-tiques srieuses en matire de soins de sant. Le mandat de l'Ins-titut est de concevoir et de coordonner une approche uniformeen matire d'inforniadon sur les soins de sant au Can ada. L'In.s-tiait emploie laClassification internationale des maladies (CIM)pour consigner les diagnostics les plus responsables pour chaqueadmission l'hpital. Laprsente tude a t mene pour dter-miner si six codes CIM de malnutiition protino-calodque(MPC) po uvaient servir analyser l'utilisation des soins de sant.O n a utilis les donn es ag rges (1996 2000) de la b;ise dedonnes abrge de l'ICIS stir les congs des patients. Les don-nes analyses taient les diagnostics les plus responsables potirles six codes M PC et un simple rsum statistique de tous lesautres diagnostics de non-malnutiition pour tous les rsidentsde cen tres hospitaliers de soins de longtie du re de 65 ans etplus qui avaient t transfrs d ans un centj e hosp italier de soinsde courte dure. Dans cette poptilation, moins de cinq admis-sions l'hpital par anne comportiiient un code MPC. Il y araittrop peu de cas de MPC potir m ene r des anal)'ses de tendancequant lamorbidit ou la mortalit. Cette tude suggre unmanque de reconnaissance et de doctimentation de la MPCcomme condition pathologiqtie distincte chez les adultes gs.L'absence de ce diagnostic empch e de documenter des cas quipoun"aient mene r des changements de politiques pourfavoriser lanutrition des adultes gs.(Rev can prat rech ditt 2009;70:37-41 )(DOI: 10.3148/70.1.2009.37)

Malnutrition is prevalent in Canadian long-term careties (LTCFs); estimates of overt malnutiition range from% to 60% (1-3) and up to 70% in the cognitively impaired

(5), malnourished instittitionalized older adults are moreely to be admitted to hospital (6), to have a longer stay (7),

g an actite care admission (8).The etiology of malnutrition in LTCFs is complex. Con-

s from the commtmity (9) and acute care facili-CFs) (10), and the development of malnutrition

s discretionary and thus a consistent

be lacking. Pre\ioi.ts work has identified that malnutrition isfrequently overlooked in acute care admissions (14).T'he first International Classification of Diseiises (ICD)

was developed in tlie early 1900s. Now in its tenth revision,it is the most widely used classification of diseiises (15). TheICD system is used to assign a numeric code for the mostresponsible diagnosis (MRD) provided at the end of thehealth care episode; this MRD is the piimai-y reiison foradmission and tteatment (16,17). This standard approachto disease classification and entimeration hits applicationsbeyond classifying morbidity and mortality data for statisti-cal analyses. These diverse applications include health sys-tems research and policy development, epidemiolog)', andhealth care reimbursement (18). In Canada, and specifi-cally Ontario, the ICD is tised in ACFs to track diseaseprevalence and hospital outcome (18).

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PURPOSELittle research has been done to determine if the ICD

system could be used as a tool to monitor the prevalence ofmalnutrition in hospitalized older adults. In this exploratorystudy, we examined the frequency of malnutrition MRDs inOntario LTCF residents admitted to hospital. As residents ofLTCFs have a high prevalence of malnutrition, limiting theanalysis to this group could be expected to reveal trends indie use of IC D to track malnutrition inacute care. Tf iData sotirce: CIHI ICD-9 discharge abstract database (the ntimber and proportion of Ontario LTCF admissions to hospital that resulted in death)

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Table 2Acute care admissions and deaths for Ontario long-term care facilit)' residents

aged 65 and older with malnutrition as the most responsible diagnoses, by fiscal yearICD-9 nutritional deficienciesclassification codes

Frequency of admissions and deaths byfiscalyear''1996 1997 1998 1999 2000

AD AD AD AD AD260 Kwashiorkor261 Nutritional marasmus262 Other severe malnutrition263 Malnutrition263.0 Malnutrition to a moderate degree263.1 Malnutrition to a mild degree263.8 Other severe protein-calorie malnutrition

0

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identified by a nutrition al assessment to have mo der ateto severe malnutrition, but only 2% of the malnourishedpatients had a reference to nutritional status in the hos-pital record (14). Altho ugh ther e are many p lausibleexplanations for the identified gap, it is clear that withthe current use of ICD, the diagnosis^and thusimpactof malnutr i t ion on hea l th outcomes is notbeing sufficiently tracked in acute care. The first stepstoward treating malnutrition in this setting are definingit, identifying it, and then accurately recording its occur-rence. With subsequent abstraction of malnutrition diag-noses from the medical record and careful tracking, datacan inform needed shifts in policy and practice to pro-vide better intervention for older adults in acute care.

There are limitations to this type of study design. Aggre-gate data are not patient-specific, and we were limited todescriptive analyses. In addition, the nutritional status of theLTCF residents transferred to hospital is unkn own , and thedata are based on the extrapolation that older adults fromLTCFs admitted to hospitals are more undernourished thanhas been shown by the ICD coding. The LTCF data provideonly numb ers of acute care admissions and deaths. We donot know how many of the admissions in a given year wererep eat visits by the sam e LTCF residen ts.Although other research suggests that malnutrition con-tinues to be unrecognized by hospital physicians (14), onlyOntario hospital data were analyzed as we had access to thisprovince's LTCF separation data to p rovide context to theCIHI data. Conclusions cann ot, therefore, be generalized toother provinces or other countries.

RELEVANCE TO PRACTICEToday much research is focused on the identification of"best clinical practices" to prevent o r ameliorate maln utritionin older adults in home care, long-term care, chronic care,and hospital settings. For example, to prevent the develop-me nt of malnu trition, m alnutrition risk screening protocolshave been developed to detect mod ifiable risk factors (12,35-37). Oral nutritional supplem ents (8,38) and community-based meal services (39) have been used successfully toaugment dietary intake in older adults identified as being atmalnutrition risk. Enhance d LTCF men us, individualized tothe needs of residents at high malnutrition risk (2,40), anddietitian time (2) have been demonstrated to improve nutri-ent intake (40) and weight status (2). Malnutrition can beprevented and treated, but it must first be identified.As the complexity of medical care increases and the p op-ulation ages, training medical staff to recognize and docu-me nt malnutrition will have greater impo rtance. Validatedmalnutrition screening tools do exist for older adults admit-ted to hospitals (3,12,13); however, a standard approach toassessing and d ocu men ting malnutrition w ithin tlie healthcare record is required and would assist health care dataabstraction. For example, scoring BMI and weight status atdischarge is an option for facilitating malnutrition diagnosescoding.

Because there is no gold standard to assess nutritional sta-tus, the diagnosis of malnutrition is a challenge. Currentiy,the ICD codes do no t take into consideration the fact that

dietary intake is an im portan t com po nen t of an assessmeto m ake a nu tritional status diagnosis. A necessary first steis convening a panel of experts to review the existing ICDmalnutrition definitions.This research highlights the need to use the ICD sytem as it was originally intended to be used: for the sytematic and accurate classification of human disease.With over 100 years of use and ten revisions, it is timefor dietitians to collaborate with the CIHI to focus onusing the ICD system effectively for evidence-basedclient care, nutritional epidemiology, health care polidevelopment, and cost analyses.AcknowtedgementsThis research was supported by the Canadian-Instittitefor Health Information Graduate Stud ent Data Access Prgram (GSDAP). Parts of this material were based on dataand information provided by the Canadian Institute forHealth Information. However, the analyses, concltisions,opinions, and statements expressed herein are those of tauthors, an d not necessarily those of the Canadian Institufor Health Information.References1. Freidman R, Kalant N. Comparison oilong-tem i care in an acute

institution a nd in a long-tem i care institution. GMA|. 1998; 159:111113.

2. Keller HH , Gibbs A), Botidreau LD, Coy R, Patullo MS, Brown H.Prevention of weight loss in d eme ntia widi compreh ensive nutritiotreatment. J Am Geriatr Soc. 2003;51:945-952.

3. I^aporte M, Villalon L, Payette H. Sim ple ntitrition s cree ning toolshealth care facilities: deve lopm ent an d validity assessment. CanJ DPrac R es. 2001 ;62:26-35,

4. Guigoz Y. Th e mini-nutritional assessment (MNA) review of theliteraturewhat does it tell us? J Nutr Health Aging. 2006; 10:4664

5. Milne AC, Potter J, Avenell A. Protein and energy supp lemen tatioelderly people at risk from malnu trition. Gochran e Database ofSystematic Reviews; 2005 [cited 2007 9 Sep] Issue 1. Ail. No.:CD003288. DOI: 10.1002/14651858.GD003288.pub2. Available frohttp://ivww.cochrane.org/reviews/cn/abOOS288.html

6. Mowe M, Bh mer T, Kindt E. Reduced nutritional status in an eldpopulation (>70 y) is probab le before disease and possibly con tribto the developm ent of disease. Am J Clin Nutr. 1994;59:317-324.

7. Milne AC, Avenell A, Po tter J. Meta-analysis: protein and energysupplementat ion in older people. Ann In tern Med. 2006; 144:37-48. Van Ness MC, He rnn an n FR, Gold G, Michel JP , Rizzoli R. Does t

mini n utritional assessment predict hospitalisation otitcomes in olpeople? Age Ageing. 2001;30:211-226.

9. Payette H, Co ulom be C, Boutier V, Gray-Donald K Nutrition riskfactors for insdtutionalization in a free-liwng functionally de pe nd eelderly pop ulau on .J Clin Epidemiol. 2000;53:579-587.

10. Nelson KJ, Gotilston AM, Sucher KP, Tseng RY. Prevalence ofmalnutrition in the elderly admitted to long-term-care facilities. ) Diet Assoc. 1993;93:459-461.

11. Wendland BE, Greenwood CE, Weinberg 1, Young KWH. Malnutrin institutionalized seniors: the iatrogenic component . J Am CeriaSoc. 2003;51:85-93.12. Guigoz Y Vellas B, Garr)' PJ. Th e m ini ntitritional assessment; apractical assessment tool for grading the nutritional state of elderl

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5/6

PERSPECTIVES IN PRACTICEPERSPECTIVES POUR LA PRATIQUE

person s. In: Vellas B, Guigoz Y, Garr)' PJ, Albar ede JL , editor s. Facts,research and intervention in geriatrics. 3rd ed. Paris, France: SerdiPtiblishing C o; 1997. p. 15.60.

. Sacks GS, Dea rma n K, Replogle WH, Cora VL, Meeks M, Ganada T. .Use of subjective global assessment to identify nutrition associatedcomp lications an d de ath in geriatric long-term care facility residents. JAm Coll Nutr. 2000;19:57a.577.Singh H, Watt K, Veitch R, Gantor M, Duerkesen DR. Malnutrition isprevalent in hospitalized medical patients: are house staff identifyingthe mal nour ished patient? J N utr. 2006;22:3.50-354.O'Malley KJ, Gook KF, Price MD, Raiford Wildes K, HurdleJF, AstonCM. Measuring diagnoses: ICD code accuracy. HSR Health ServicesRes. 2005;40:1620-1639.World Health Organization. International classification of diseases andrelated health problems. 10th rev. Geneva: World HealtliOrganization; 1992.World Health Organization. International classification of diseases andrelated health problems. 10th rev, vol 2. Instruction mantial. vol 2.Geneva: World Health Organization; 1993.

. Canadian Institute for Health Infomiation. A bout CIHI. CIHI profile;2007 [cited 2007 7 Mar]. Available from: http://Www.CIHI.ca/cihiweb/dispPagejsp?cvv_page=profile_eOn tari o LTCFs 1996 levels of care classification. P rovincial s umm arydata. Ontario, Canada. Ministry of Health; 1997.

. On tari o LTCFs 1997 levels of care classification. Provincial sum mai ydata. Ontario, Canada. Ministry of Healtli; 1998.

. On tari o LTCFs 1998 levels of care classification. Provincial su mm arydata. Ontario, Canada. Ministry of Health; 1999.

. On tari o LTCFs 1999 levels of care classification. Provincial su nima r)'data. Ontario , Canada. Ministry of Health; 2000.

. Ontario LTCFs 2000 levels of care classification. Pro\incial summarydata. Ontario , Canada. M inistry of Health; 2001.College of Dietitians of Ontario. The provision of nutrition sen ices inOntario long-term care facilities. Toronto: College of Dietitians ofOntario ; 1997.

. Gary M, Gillespie SG. Position of the A merican Dietetic Association:cost-effectiveness of medical nutrit ion therapy. J Am Diet Assoc.1995;9.5(1):88-91.

. Ghima GS, Barco K, Dewitt MLA, Maeda M, Teran JG, Mullen KD.Relationship of nutritional status to length of stay, hospital costs, anddischarge status of patients hospitalized in the m edicin e service. J AmDiet Assoc. 1997;97:975-978.

. Gazzotti G, Arnaud-Battandier F, Parello M, Farine S, Albert A,PetermansJ. Prevention of malnutrition in older people during and

after hospitalisation: results from a randomised controlled clinicaltrial. Age A geing. 2003;32:321-325.

28 . Bistrain BR, Blackbuni GL, Gochran D, NaylorJ. Prevalence ofmalnutrition in general medical patients. JAMA. 1976;2.%: 1567-1570.

29 . Kyle UG, Unge r P, Mensi N, Genton L, Pichard C. Nutrition su\ttis inpatients younger and older than 60 y at hospital admission: acontrolled population study in 995 subjects.J Ntitr. 2002; 18:463-409.

30 . Jensen GL. Inflammation as the key interface of the medical andnutrition universes: a provocative examination of the ftittire of clinicalnutrition and medicine. JPEN. 2006:30:45.3-463.

31 . Hofier JL . Glinical ntitridon 1: Piotein -energ )' maln titrition in theinpatient. GMAJ. 2001; 165:1345-1349.

32. Swails WS, Samour PQ, Babineau TJ, Bistrain BR. A proposed rewsionof the ctirr ent 1GD-9-GM m alntitrition code defin itions. J Am DietAssoc. 1996 96:370-373.

33 . Ganadian Instittite of Health Infomiation, (GIHI). Internationalstatistical classification of diseases and related health proble ms, 10threv vol 1. Tabular list lCD-10-CA, 2006 [cited 2007 9 Sep].Available from: http://secure.cihi.ca/ciliiweb/en/dovvnloads/ICD-10

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