Nutrition Publication

NNIW12 - The Economic, Medical / Scientific and Regulatory Aspects of Clinical Nutrition Practice: What Impacts What?

Editor(s): M. Elia, B. Bistrian. vol. 12

Malnutrition is an under-recognized problem in hospitalized, home and community patients. It has been identified as an issue for more than 30 years, but has struggled to be recognized as an important issue by healthcare clinicians, administrators and government officials. Recent data show that at least 30% of hospitalized patients are malnourished, with a large majority of the cases unrecognized and untreated. Although awareness of the situation is increasing, there remains a great deal of work that must be done to educate healthcare professionals on the value of nutrition intervention as an integral part of medical therapy. Along with this is the need to educate administrators and regulators of the cost benefits of nutrition care.

Related Articles

The Magnitude of the Problem of Malnutrition in Europe

Author(s): J. Kondrup, J.M. Sorensen

A review of the publications on hospital malnutrition in Europe over the last 5 years shows that the incidence and prevalence of malnutrition are still very high: 21 and 37%, respectively. The process of structured nutrition support is still far from being generally implemented, as based on the few studies available. As a result, malnutrition diagnosed on admission to hospital is still associated with adverse clinical outcome (increased length of stay and higher rates of complications).

Malnutrition in North America: Where Have We Been? Where Are We Going?

Author(s): G.L. Jensen

Malnutrition was first highlighted as a prevalent concern in hospital care more than 30 years ago. In response the nutrition support field grew precipitously but changes in the healthcare environment have culminated in a period of accountability and consolidation in nutrition support practice over the past decade. Evolving regulatory environment and reimbursement policies have had a profound impact upon nutrition support and these trends are likely to continue. Both undernutrition and overnutrition (obesity) remain prevalent concerns in North America. In particular the growing prevalence of overweight/obesity will have far-reaching implications for nutrition support practitioners and will require the development, testing, and validation of new standards of assessment, intervention, and monitoring. Adoption of common language and definitions by practitioners will facilitate standardized interventions, outcome measures, and high quality research. The future remains bright with tailored nutrition interventions poised to become a part of the individual medical treatment plan for specific patient conditions and genotypes. Future research priorities should include studies of nutritional modulation of inflammatory conditions with specific nutrients and functional foods and the testing of individualized nutritional interventions tailored to gene polymorphisms.

The Economics of Malnutrition

Author(s): M. Elia

Despite extensive information on the adverse physical and psychological consequences of malnutrition, there is little information on its economic consequences. International studies suggest that disease-related malnutrition increases hospital costs by 30–70%. In the United Kingdom the Malnutrition Universal Screening Tool (MUST) was used as the basis for identifying the prevalence of malnutrition in various care settings. Malnutrition increased both the frequency of admissions and length of stay in hospitals, as well as the frequency of visits to a general practitioner and hospital outpatient visits, and residency in care homes. After assigning nationally representative costs to the utilization of these services, the public expenditure on disease-related malnutrition in the UK in 2003 was estimated to be more than GBP 7.3 billion. The large cost of disease-related malnutrition means that small fractional cost savings from intervention can result in substantial absolute cost savings. A summary of nutritional intervention studies with cost analyses (including meta-analyses) and cost-effectiveness analyses are presented, and some of the clinical and ethical implications discussed.

The Need for Consistent Criteria for Identifying Malnutrition

Author(s): L.J. Hoffer

The lack of consistent criteria for diagnosing malnutrition and protein-energy malnutrition (PEM) creates problems in educating medical students and physicians, setting the parameters for observational and controlled clinical trials, and formulating clinical guidelines. There is no validated formal definition of malnutrition (or PEM), and the tools that have been developed to screen for it, or diagnose it, vary in their agreement. I make the following suggestions. First, avoid unqualified use of the term ‘malnutrition’, as it is ambiguous. Second, carefully distinguish between screening and diagnosis, which have different aims and implications. Third, consider the notion that in medicine the diagnosis of PEM is reached by ‘narrative-interpretive’ reasoning, which regards the disease as a pathophysiological entity in a specific clinical context. I recommend that the concept of PEM as a disease (not a score) be imbedded in teaching and the practice of medicine, and in the design of clinical trials and the setting of guidelines. Fourth, disagreements in screening-derived risk scores and uncertainty in diagnosis are difficult to avoid, but only in the grey zone. It would be prudent, at least until the greater medical world considers the nutritional paradigm plausible enough to invest in it, to enroll only patients who have unambiguously diagnosed PEM in prospective trials with hard clinical endpoints.

Enteral Nutrition Reimbursement – The Rationale for the Policy: The US Perspective

Author(s): A.K. Parver, S.E. Mutinsky

Enteral nutrition (EN) is generally defined by third party payers as tube feeding for patients who cannot take food orally. EN is widely accepted in the United States as an effective, often life-sustaining therapy. Coverage and payment policies for EN differ among payers and settings. These differences often may depend on whether EN is reimbursed as a discrete therapy or subsumed into a larger benefit. In the US, the Medicare and Medicaid programs are the major public payers for EN. EN may be susceptible to overuse, especially in the long-term care setting. The trends in coverage and payment for EN suggest tighter reimbursement; competitive bidding between suppliers and data-driven performance measurement and payments may be in the future for EN reimbursement.

Enteral Nutrition Reimbursement – The Rationale for the Policy: The German Perspective

Author(s): N. Pahne

Both the German statutory and private health insurances cover enteral nutrition (EN) products. Approximately 100,000 patients receive reimbursed EN; 70% are tube fed for an average 9 months. 70% of the tube-fed patients are cared for in institutions (i.e. for the elderly) and 30% at home. The prescription and reimbursement of EN is covered by Volume Five of the Social Legislation Code (Social Code Book No. 5). Reimbursement for EN depends on medical prescription and is in principle guaranteed whenever normal food intake is impaired and modification of normal nutrition and other measurements do not improve nutritional status. It is unclear what effect the reform laws will have on EN but they may impact the prices for medical devices and negotiations between health insurance funds and product manufacturers.

Food Modification versus Oral Liquid Nutrition Supplementation

Author(s): H.J. Silver

Oral liquid nutrition supplements (ONS) are widely used in community, residential and healthcare settings. ONS are intended for individuals whose nutrient requirements cannot be achieved by conventional diet or food modification, or for the management of distinctive nutrient needs resulting from specific diseases and/or conditions. ONS appear to be most effective in patients with a body mass index of ≤20. Studies are needed to evaluate the clinical and functional efficacy of food-based versus ONS nutrition interventions.

Cost-Effectiveness Analysis and Health Policy

Author(s): D.J. Torgerson

Economists have devised three main techniques to evaluate healthcare treatments: cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis. Many countries have established regulatory authorities to examine the clinical safety, efficacy, and cost-effectiveness of a product. Currently, economic evaluations play a limited role in decision-making but may increase in importance as healthcare costs continue to rise.

Implementing Nutritional Standards: The Scottish Experience

Author(s): A.W. McKinlay

In the United Kingdom, 5% of the population are underweight or have features of malnutrition. The prevalence of malnutrition rises with age and is more common in the north of England than in the south, but comparable data are not available for Scotland. In 2003, the National Health Service Quality Improvement Scotland (NHS QIS) developed a standard for food, fluid and nutritional care in hospitals (FFNCH). In 2006, a peer review of Scottish health boards was published. The reviewers reported that all Scottish health boards had started to implement the standards, but not across all clinical areas. Every health board had set up a nutritional care group to oversee and advise on the implementation of the standards, but none had produced a financial framework to support the work of the groups. Most health boards had not fully developed a policy or strategic plan to improve nutritional care as required, and there was a shortage of specialist nutrition nurses and clinical and nutrition support teams to supervise the treatment of patients with complex nutritional needs. The Scottish experience emphasizes the size of the task that health services face to bring about change.

Innovative Models for Clinical Nutrition and Financing

Author(s): J. Van Emelen

By translating the principles of ‘disease management’ in an insurance environment, health insurance funds play an important role in the management of chronic diseases of their members. The independent health insurance funds in Belgium have developed an obesity disease management approach based on the integration of collective and individual prevention, early detection and immediate action. Incentive monetary prizes are provided if body mass index (BMI) is reduced by at least 5% following participation in the prescribed treatment plan. The independent health insurance funds plan to launch multimedia projects about the program to educate the target audience of lower income, less educated, obese patients.

ENHA: What is It and What Does It Do? Strategies to Make Malnutrition a Key Priority in EU Health Policy

Author(s): Fr. De Man

In 2005, the European Nutrition for Health Alliance (ENHA, the Alliance) was established to raise awareness of the relevance and urgency of malnutrition and ensure that this important issue is included in policy discussions and appropriate action is taken by policymakers and stakeholders at EU and member state levels. Malnutrition remains under-recognized, under-detected and under-managed across Europe, 4 years after the publication of the Call to Action resolution issued by the Council of Europe in 2003, on food and nutritional care in hospitals. The goal of the ENHA is to implement policy changes in nutrition and health at government and healthcare organizational levels. The value of specific evidence-based medical interventions must be demonstrated.

Brief History of Parenteral and Enteral Nutrition in the Hospital in the USA

Author(s): B.R. Bistrian

The meteoric rise in parenteral and enteral nutrition was largely a consequence of the development of total parenteral nutrition and chemically defined diets in the late 1960s and early 1970s and the recognition of the extensive prevalence of protein calorie malnutrition associated with disease in this same period. The establishment of Nutrition Support Services (NSS) using the novel, multidisciplinary model of physician, clinical nurse specialist, pharmacist, and dietitian, which, at its peak in the 1990s, approached 550 well-established services in about 10% of the US acute care hospitals, also fostered growth. The American Society of Parenteral and Enteral Nutrition, a multidisciplinary society reflecting the interaction of these specialties, was established in 1976 and grew from less than 1,000 members to nearly 8,000 by 1990. Several developments in the 1990s initially slowed and then stopped this growth. A system of payments, called diagnosis-related groups, put extreme cost constraints on hospital finances which often limited financial support for NSS teams, particularly the physician and nurse specialist members. Furthermore, as the concern for the nutritional status of patients spread to other specialties, critical care physicians, trauma surgeons, gastroenterologists, endocrinologists, and nephrologists often took responsibility for nutrition support in their area of expertise with a dwindling of the model of an internist or general surgeon with special skills in nutrition support playing the key MD role across the specialties. Nutrition support of the hospitalized patient has dramatically improved in the US over the past 35 years, but the loss of major benefits possible and unacceptable risks of invasive nutritional support if not delivered when appropriate, delivered without monitoring by nutrition experts, or employed where inappropriate or ineffective will require continued attention by medical authorities, hospitals, funding agencies, and industry in the future.

What Went Right? The Story of US Medicare Medical Nutrition Therapy

Author(s): S. Patrick

When President Lyndon Johnson signed the Medicare and Medicaid bill into law in 1965, it ended the 46-year campaign to enact a healthcare program for senior citizens and started what is now a 42-year effort by the American Dietetic Association (ADA) and its members to expand its coverage to ‘nutrition services’ for all appropriate diseases, disorders and conditions. In December 2000, Congress passed a Medicare Part B Medical Nutrition Therapy (MNT) provision, limited to patients with diabetes and/or renal disease, effective January 2002. In December 2003, the Medicare Modernization Act expanded access to MNT benefit and ADA continues to focus on the role of the registered dietician in MNT. Successful expansion of MNT benefits will require that ADA continues to demonstrate the cost-effectiveness and efficacy of nutrition counseling, as performed by the registered dietitian.