Treatment of Malnutrition and Heart Failure - Bryan Health · Treatment of Malnutrition and Heart Failure ... New York, NY: McGraw-Hill;2002. ... Treatment of Malnutrition and Heart

8/31/2016

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Steven Krueger MD

Bryan Heart

2016 Bryan Heart Fall Cardiology Conference

Treatment of Malnutrition and Heart Failure

Currently on the speaker bureau’s for the following companies related to this talk:

Ensure Enlive – Abbott

All Honoria to Big Heart Initiative charitable fund

…One Final Disclosure..

Disclosure

A. Introduction

B. Preliminary Data

C. NOURISH Trial

D. Readmissions

E. Conclusions


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OBJECTIVES

• Review the clinical impact of malnutrition and loss of lean body mass (LBM)

• Discuss the clinical and economic benefits of oral nutrition supplements (ONS)

• Present new scientific evidence of specialized ONS in the management of malnourished hospitalized patients

1. Tappenden KA et al. JPEN J Parenter Enteral Nutr. 2013;37(4):482-497. 2. Naber TH et al. Am J Clin Nutr. 1997;66(5):1232-1239.3. Somanchi M et al. JPEN J Parenter Enteral Nutr. 2011;35(2):209-216. 4. Braunschweig C et al. J Am Diet Assoc. 2000;100(11):1316-1322.

HOSPITAL ADMISSION

33% of severely

malnourished patients and

38% of well-

nourished patients experience

nutritionaldecline4

Many patients continue to lose

weight after discharge5

Patients with weight loss are at increased risk for

readmission1

HOSPITAL STAY

30% to 55%of hospital

patients are malnourished

upon admission1-4

HOSPITAL DISCHARGE

HOSPITAL READMISSION

5. Beattie AH et al. Gut.2000;46(6):813-818.

DISEASE ASSOCIATED MALNUTRITION ISASSOCIATED WITH ILLNESS, INJURY, ANDHOSPITALIZATION

Risk of dying increases when food intake is limited by illness or injury4

Loss of lean body mass delays recovery and impedes rehabilitation3

Hospitalization itself often worsens nutritionalstatus2

Anyone who is sick or injured is at risk for malnutrition, especially older people1

1. Imoberdorf R, et al. Clin Nutr. 2010;29:38-41. 2. Krumholz HM. N Engl J Med. 2013;368:100-102. 3. Li HJ, et al. J Adv Nurs.2013;69:1691-1703. 4. Hiesmayr M, et al. Clin Nutr. 2009;28:484-491.

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MALNUTRITION NEGATIVELY AFFECTS PATIENT OUTCOMES

Wound Healing

Infections

Complications

Convalescence

Malnutrition

Hospital Readmissions

Adapted from Norman K et al. Clin Nutr. 2008; 27: 5-15. Allaudeen N, et al. J Hosp Med. 2011;6(2):54-60.

Mortality

Treatment

Length of Stay

(LOS) in Hospital

CostQuality of Life

MALNUTRITION SARCOPENIA SYNDROME

• Protein calorie

malnutrition

• Undernutrition

• Hospital acquired malnutrition

• Disease related malnutrition

Morbidity MortalityEconomic Impact

• Sarcopenia

• Frailty

• Deconditioning

• Sarcopenic Obesity

• Cardiac Cachexia

• Cancer Cachexia

• ESRD/CKD

• COPD

• ICU Acquired Weakness

• HIV Cachexia

Sarcopenia Loss of LBM

Vandewoude M et al., J Aging Res. 2012.

Malnutrition

WHAT IS LEAN BODY MASS (LBM)?

Muscles

Organs

Bone

• LBM accounts for 75% of normal body weight

• Muscle is the largest component of LBM

Functions of LBM include:

• Mobility

• Balance

• Generation of heat (energy)

• Protein / amino acid pool for skin, immune & digestive systems

• Survival during periods of stress

Everything except for fat (fat free mass)

Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; 2002.

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PROGRESSIVE LOSS OF LBM / MUSCLE MASS OCCURS NATURALLY WITH AGE

Age-related loss of muscle mass, strength

and/or functionality is called Sarcopenia

1. Baier S, et al. JPEN J Parenter Enteral Nutr. 2009;33(1):71-82. 2. Flakoll P, et al. Nutrition. 2004;20(5):445-451. 3. Grimby G, et al. Acta Physiol Scand. 1982;115(1):125-134. 4. Janssen I, et al. J Appl Physiol. 2000;89(1):81-88. 5. Vandewoude MFJ, et al. Malnutrition-Sarcopenia

100%ofMuscleMass

Age 25 yrs 40 yrs 70 yrs 80 yrs

8%loss

Per decade

from 40-70

Per decadeafter age70

15%loss

100%

40%

50%

60%

70%

80%

90%

<70%: Zone

where risk of

death is high

Syndrome: is this the future of nutrition screening and assessment for older adults. J Aging Res. 2012;2012:651570. Epub 2013 Sep 13.

BED REST, AGE AND HOSPITALIZATION INCREASE LOSS OF LBM

HealthyElders

10 Days Inactivity2

HealthyYoung

28 Days Inactivity1

Elderly Inpatients

3 Days Hospitalization3

1. Paddon-Jones D et al. J Clin Endocrinol Metab. 2004;89:4351-4358. 2. Kortebein P et al. JAMA. 2007;297:1772-1774. 3. Paddon-Jones D.

.04 lb/day

0.2 lb/day

Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, Ohio.

0

-0.1

-0.2

-0.3

-0.4

-0.5

-0.6

-0.70.7 lb/day

-0.8

Po

un

ds

Lo

stP

erD

ay

1 lb (28) 2.2 lb (10) 2.2 lb (3)Approximate

total lossof LBM

(time indays)

INTERVENTIONS TO MITIGATE LBM LOSS

• Exercise/activity

• Dietary intervention

– Dietary Proteins

– ONS

– Targeted nutrients

• amino acids

• beta-hydroxy-beta-

methylbutyrate (HMB)

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A. Introduction

B. Preliminary Data

C. NOURISH Trial

D. Readmissions

E. Conclusions


NUTRITION INTERVENTIONS LEAD TO IMPROVED OUTCOMES

Nutrition intervention can produce positive resultsto improve patient care quality and reduce overall costs.

28% reduction in avoidable readmissions1

2-day reduction in average length of stay2-4

25% reduction in pressure ulcer incidence5

14% reduction in overall complications6

(e.g., infections, anemia, etc.)

ONS use is associated with reduction in mortality in select patients

(e.g., elderly malnourished6)

1. Gariballa S, et al. Am J Med 2006;119(8):693-9 2. Brugler L et al. J Qual Improv 1999; 25: 191-206 3. Somanchi M et al. JPEN 2011; 35: 209-216 4. Smith PE, et al. Healthcare Financial Management 1997;51:66-69. 5. Stratton RJ, Ek AC, Engfer M, et al. Ageing Res Rev.

2005;4:422-450. 6. Milne AC, et al. Cochrane Database Syst. Rev. 2009 APR 16(2):CD003288. DOI:10.1002/14651858.

ORAL NUTRITION SUPPLEMENTS PROVIDED DURING HOSPITALIZATION WAS ASSOCIATED WITH:

21% decreasein length of stay

(2.3 days)

21.6% decrease†

in episode costs ($4734)

6.7% decrease*in probability of

30-day readmissions

†Monetary figures are based on 2010 US dollars and inflation adjusted.*Readmission defined as return to study hospital for any diagnosis. Data measured delayed readmission and does not include patients not

readmitted due to recovery ordeath.In a retrospective health economic study, Philipson T et al. Am J Manag Care. 2013;19(2):121-128.

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Bioactive metabolite of leucine:

• Occurs naturally in human muscle cells

• Found in small amounts in many foods (e.g., avocado, grapefruit, catfish)

Exerts its effects through protective, anticatabolic mechanisms and

has been shown to:

• Decrease protein degradation via NFkB downregulation

• Preserve muscle mass in older adults during extended bed rest

• Stabilize muscle cell membrane

4. Deutz et al., Clinical Nutrition 2013.

1. Nissen SL, Abumrad NN. J Nutr Biochem. 1997;8:300-112. Wilson. Nutr Metab. 2008;5:1

3. Eley HL et al. Am j Physiol Endocrinol Metab. 2008;295:E1409-26.

TARGETED NUTRIENT:ß-HYDROXY ß-METHYLBUTYRATE (HMB)

EFFECT OF HMB ON LEAN BODY MASS DURING 10 DAYS OF BED REST IN OLDER ADULTS

• Supplements: 2 sachets/day with 4 g maltodextrine, 200 mg Ca and flavoring agents

– HMB group: 1.5 g Ca-HMB

– Controls: no addition

• Diet stabilization to 0.8 g protein/kg BW/day and (calculated) energy requirements

• Bed rest for 10 days with only wheelchair for toileting or showering

– Prophylacticmeasures

• D-Dimer test, TED hose and daily checking

• Constant monitoring by nursing staff and daily physical by physician

• Rehabilitation for 8 weeks with resistance exercise training - 3 days/week

10 d Bed Rest (In patient)

8 Wk Recovery/Resistance Exercise

5 d

Supplement HMB or Control

DEXA DEXADEXA

Isocaloric Diet (All)

Deutz et al, Clinical Nutrition2013.

HMB PRESERVES LBM

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

Bed rest Bed rest+ Rehabilitation

Ch

an

ge

inle

gs

lea

n(k

g)

Change in Total Leg Lean Mass

Control

HMB

-4

-3

-2

-1

0

1

Bed rest Bed rest+ Rehabilitation

Ch

an

ge

into

tal

lea

n(k

g)

Change in Total Lean Mass

Control

HMB+

Deutz et al, Clinical Nutrition2013.

+

*

*

8/31/2016

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10

5

0

-5

15

HMB Placebo

Leg

Ex

ten

sor

Str

eng

th,

60°* s-1

Non-exercising Groups

EFFECT OF HMB ON MUSCLE STRENGTH IN HEALTHY MEN AND WOMEN

p=0.04

Stout JR, et al. Exp Gerontol.2013

HMB — SAFE AND WELL TOLERATED

Review article and meta-analysis of HMB clinical studies published in 2013

n=39 articles

Conclusions:

• 3 g/day (CaHMB) efficacious dose

• Effective in preventing exercise-related muscle damage

• Effective in preventing muscle loss during chronic diseases

• No safety concerns

Molfino et al., Amino Acids. 2013 Dec;45(6):1273-92

A. Introduction

B. Preliminary Data

C. NOURISH Trial

D. Readmissions

E. Conclusions


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Readmission and Mortality in Malnourished, Older, Hospitalized Adults Treated With a Specialized Oral Nutritional Supplement: A randomized clinical trial

Deutz NE, et al., Clin Nutr; 2016, 35 (1):18-26.

NOURISH STUDY OBJECTIVE

Deutz NE, et al., Clin Nutr; 2016, 35 (1) :18-26.

NOURISH: Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients

Evaluation of a high-protein oral nutritional supplement containing

beta-hydroxy-beta-methylbutyrate (HP-HMB) on post discharge outcomes of non-elective readmission and mortality in malnourished, hospitalized older adults.

NOURISH: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTICENTER (N=652) STUDY

Statistical Analysis: Intention-to-treat; p<0.05 statistical significance

Screen

PLACEBO(BID)

+ standard

nutr/medcare

HP-HMB(BID)

+ standard

nutr/medcare

652 patients with mild �

severemalnutrition

Patients ≥65y, hospitalized with CHF, AMI, COPDor pneumonia

D0

PrimaryComposite Outcome:• Readmission andmortality through90 days post-discharge.

D30 D60 D90

SecondaryOutcomes:• Nutritional• Functional


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SUBJECTIVE GLOBAL ANALYSIS

• Evaluated nutritional and medical history and changes

• Validated in healthy and disease populations

• The gold standard for diagnosing malnutrition

Detsky AS, et al. JPEN J Parenter Enteral Nutr. 1987 ;11(1):8-13.

Study Results

BASELINE DEMOGRAPHIC AND CLINICAL CHARACTERISTICS SHOWED NO STATISTICAL DIFFERENCE BETWEEN GROUPS

Placebo HP-HMB

Age (yr, Mean ±SEM) 78.14 ± 0.49 77.72 ± 0.47

Charlson Comorbidity Score (Mean ± SEM) 2.05 ±0.08 2.12 ± 0.08

Government sponsored insurance, n(%) 278(89%) 276 (89%)

Income < $25,000/yr, n(%) 130 (42%) 154 (49%)

11.7

48.2 47.6 51.8 52.4

88.3 85.3

14.7

0

20

40

60

80

100

Male Female Non-white

Per

cen

t

Gender and Race

Control

White

HP-HMBPlacebo


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BASELINE DEMOGRAPHIC AND CLINICAL CHARACTERISTICS SHOWED NO STATISTICAL DIFFERENCE BETWEEN GROUPS

8.1

25.3 25.2

9.6

32.5 30.4 34.1 34.8

100

80

60

40

20

0

CHF AMI PNA COPD

Per

cen

t

Primary admission Dx

ControlPlacebo HP-HMB

86.7 87.910080604020

0

B, Mildly-Moderately Malnourished

13.3 12.1

C, Severely Malnourished

Per

cen

t

SGA

Control HP-HMBPlacebo


PRIMARY PATIENT ADMITTING DIAGNOSIS AND COMORBIDITIES


Comorbidities per Charlson Index

N (%)

Myocardial infarctio

n

Congestive heart

failure

(CHF)

Chronic pulmonary disease

Pri

ma

rya

dm

issi

on

dia

gn

osi

s

AMI (n=5

5)

55(100%)

13(23.6%)

10(18.2%)

CHF (n=157)

35(22.3%)

157(100%)

56(35.7)

COPD (n=21

4)

24(11.2)

48(22.4%)

214(100%)

Pneumonia (n=195)

19(9.7)

47(24.1%)

106(54.4%)

PRIMARY COMPOSITE ENDPOINT

Pro

po

rtio

n

Kaplan-Meier Survival CurveComposite Endpoint of 90-Day Readmission and Mortality

1.00

0.95

0.90

0.85

0.80

0.75

0.70

0.65

Placebo

HP-HMB

p = 0.214

0

309

313

10

269

282

20

254

264

30

243

252

40

230

249

50

223

235

60

216

230

70

208

224

80

206

219

90

159

183

100

Placebo, n

HP-HMB, n

Days post-dischargeDeutz NE, et al., Clin Nutr; 2016, 35 (1) :18-26.

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Placebo

HP-HMB

p = 0.749

0

309

313

10

269

282

20

254

264

30

243

252

40

230

248

50

223

235

60

216

230

70

208

224

80

205

219

90

159

183

100

Placebo, n

HP-HMB, n

Days post-dischargeDeutz NE, et al., Clin Nutr; 2016, 35 (1) :18-26.

Pro

po

rtio

n

Kaplan-Meier Survival Curve Readmission

1.00

0.95

0.90

0.85

0.80

0.75

0.70

0.65


Placebo

HP-HMB

p = 0.013

0

309

313

10

290

302

20

280

292

30

272

283

40

264

280

50

257

273

60

253

268

70

248

262

80

246

259

90

190

211

100

Placebo, n

HP-HMB, n

Days post-discharge


Pro

po

rtio

n

Kaplan-Meier Survival Curve: Mortality

1.00

0.95

0.90

0.85

0.80

0.75

0.70

0.65

HP-HMB WAS ASSOCIATED WITH 50% REDUCTION IN MORTALITY

Post hoc estimation of the number needed to treat (NNT)

p=0.049

p=0.018

p=0.020

6.2

8.79.7

2.9

4.24.8

14

12

10

8

6

4

2

0

Day 30 Day 60 Day 90

Per

cen

t

Mortality

Control HP-HMBPlacebo

to prevent 1 death was 20.3 (95% CI, 10.9 to 121.4).


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HP-HMB IMPROVED NUTRITIONAL STATUS

By day 90, HP-HMB had higher odds of better nutritional status as assessed by SGA (OR = 2.04,P=0.009)

13.3 12.17.0 5.1 3.1 3.6 3.8 2.4

86.7 87.9

82.981.6

73.970.4

66.3

52.1

10.2 13.3 23.0 26.0 30.0 45.5

0%

10%

40%

30%

20%

50%

60%

70%

80%

90%

100%

Controln=309

HP-HMB n=313

Controln=187

HP-HMB n=196

Controln=161

HP-HMB n=169

Controln=160

HP-HMB n=167

Per

cen

to

fp

ati

ents

Placebo Placebo Placebo Placebo


Baseline Day30

SGA-A SGA-B

Day60

SGA-C

Day90

HP-HMB IMPROVED WEIGHT GAIN


HP-HMB INCREASED SERUM VITAMIN D LEVEL


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“NUMBERS WHICH COUNT”

Laviano A; Clin Nutr. 2016 Feb;35(1):5-6.

“Deutz et al. showed that 20 patients should be treated to save 1 death [6]. Their decision to provide

this information is interesting since it associates nutritional support to pharmacological therapies,

and it is relevant since the NNT for this specific ONS is quite encouraging. Indeed, Schork has recently reviewed the NNT for some blockbuster drugs, and

it is surprising to note that the NNT for esomeprazole is 24 [8].”

HMB

• 350 Cal per 8-fl-oz serving

• 1.5 grams of CaHMB

• 20 grams of high-quality protein

• 120% Daily Value of vitamin D

• 26 vitamins and minerals

• Omega-3s (plant-based ALA)

• Antioxidants (vitamins C and E and selenium)

• 3 grams of fiber

SUMMARY

• Among hospitalized patients, disease associated malnutrition and the loss of lean body mass is prevalent and costly

• Nutritional interventions including oral nutritional supplements help improve patient outcomes

• The use of a high-protein oral nutritional supplement

containing beta-hydroxy-beta-methylbutyrate is associated with improved clinical and nutritional outcomes in malnourished hospitalized patients with

cardio-pulmonary disease

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WHAT CAN YOU DO FOR YOUR MALNOURISHED PATIENTS?

Standardize Nutrition Intervention for Improved Patient Care

INTERVENE

Early

SCREEN

All Patients

Identify risk of• Malnutrition• LBM loss

• Recommend two ONS per day

• Nutrition therapy

Correia et al., J Am Med Dir Assoc. 2014; 15; pp. 544-50. Tappenden et al., JPEN J Parenter Enteral Nutr. 2013; 37: 482-497. Deutz NE, et al., Clin Nutr; 2016, 35 (1) pp 18-26.

Sriram K et al., JPEN J Parenter Enteral Nutr 2016; 40, pp 24-25.

FOLLOW-UP

Compliance

Reassess to improve patient outcomes

A. Introduction

B. Preliminary Data

C. NOURISH Trial

D. Readmissions

E. Conclusions


Optimizing the Nutrition Care Process to Reduce 30-day Readmissions

© 2016 USANENS160179/FEB 2016

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CMS REDUCES PAYMENTS FOR PREVENTABLE READMISSIONS

• 2,592 hospitals were penalized by the Centers for Medicare and Medicaid Services (CMS) in fiscal year (FY) 20151

• Fines estimated by CMS in FY 2015 — $420 million1

• Penalties increased in FY 2015 to 3%: A hospital with $100 million in Medicare payments could be penalized $3 million1

• 75% of hospitals subject to theHospital Readmission Reduction Program

are being penalized1

• Hardest hit hospitals are in New Jersey;

New York; Washington, DC; Arkansas; Kentucky; Mississippi; Massachusetts;

and Illinois2

1.Rau J. Medicare fines 2,610 hospitals in third round of readmission penalties. Kaiser Health News. http://khn.org/news/medicare-readmissions-penalties-2015/. Accessed January 28, 2016.2. Health Industry Distributors Association (HIDA). 2013 Acute Care Market Report. http://www.marketresearch.com/Health-Industry-Distributors-Association-HIDA-v2745/Acute-Care-7731227/. Accessed January 28, 2016.

EVIDENCE THAT NUTRITION INTERVENTION DECREASES READMISSIONS

3. Gariballa S et al. Am J Med. 2006;119:693-699.

Hospital patients who received dietary counseling plus oral nutritional supplements (ONS) experienced significantly fewer readmissions (P=0.041)1

30-Day readmission rates decreased from 16.5% to 7.1% after institution of comprehensive nutrition pathway from inpatient to post discharge2

Patients who received ONS (≤995 kcal/day) in addition to food for 6 weeks had fewer readmissions: 29% who consumed ONS vs 40% who ate foodonly3

Counselingonly

Before

Foodonly

48%

16.5%

40%

ONS

After

ONS

26%

7.1%

29%

1. Norman K et al. Clin Nutr. 2008;27:48-56. 2. Brugler L et al. Jt Comm J Qual Improv. 1999;25:191-206.

REAL WORLD EVIDENCE FOR VALUE OF NUTRITION IN THE NEW HEALTH CARE ENVIRONMENT

A Rapid, Comprehensive OralNutritional Supplement Quality

Improvement Program (QIP) Reduced 30-day Readmission in

Malnourished Hospitalized Patients


This trial was registered with U.S. National Institutes of Health and U.S. National Library of Medicine on www.ClincalTrials.gov: NCT02262429.w.ClinicalTrials.gov

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STUDY SETTING: ADVOCATE HEALTH CARE SYSTEM

• The largest health care provider in Illinois

• One of the largest accountable care organizations (ACO) in the

US

• 250 sites of care and 12 hospitals

• Over 2 million patients seen annually

• Five Level I trauma centers, three Level II trauma centers

• Not-for-profit, mission-based health system

• A leader in population health management and coordinatedcare

RESEARCH QUESTION AND PRIMARY ENDPOINT

• Study Hypothesis: Administration of a rapid, automatic ONS intervention from screening to discharge will decrease 30-day readmission rate by 20% or more and yield superior cost-effectiveness compared with existing ONS protocol in patients at risk for malnutrition

• Primary Endpoint: Incidence of nonelective readmission 30-days post discharge

• Patient Population: 18+, any primary diagnosis, risk for malnutrition (Malnutrition Screening Tool [MST] score ≥2)


MALNUTRITION SCREENING TOOL (MST)

Ferguson, M et al. Nutrition 1999 15:458-464

• MST is a validated screening tool and evaluates weight loss and appetite as two criteriamost indicative of malnutrition risk

• The set of questions helps to quantify patients malnutrition risk level

No 0

Unsure 2

If yes, how much weight have you lost?

2-13 lb 1

14-23 lb 2

24-33 lb 3

34 lb or more 4

Unsure 2

Weight loss

score:

Have you recently

lost weight without

trying?

Yes

Appetite

score:

Have you been

eating poorly

because of adecreasedappetite?No 0

1

STEP 1: Screen with the MST

Add weight loss and appetite scores

MST SCORE:

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Differences of QIP+ and QIPPrograms QIP+ QIP

MST is a part of EMR √ √

RN completesMST √ √

ONS selection via automatic drop down menu √

ONS ordered by MD, RN, orRD √ √

RD consultation √ √

Time to RD consultation: <24 hours √

Time to ONS Delivery (onaverage) 1 – 24 h 24 – 48 h

Discharge planning instructions √ √

Discharge materials including coupons and literature √

Standard post-discharge phone calls (24-72hours) √ √

Nutrition-focused post-discharge questions on phone calls √

DIFFERENCES BETWEEN QIP+ AND QIP

MD, Physician; RN, Registered Nurse; √ = Yes.

Sriram K et al., JPEN J Parenter Enteral Nutr 2016; 40.

RESULTS FOR QIP SITES (N=769)

Pre-QIPQIP

Readmission Rate:

20% Readmission Rate:

16.4%

Screening

Intervention

Post discharge

Education

Validated screening tool (MST)

integrated into EMR

Targeted ONS intervention

in 24-48 hours

No formalized nutrition

discharge education

No post-discharge reminders

about nutrition

Nonvalidated

screening tool

No early intervention


discharge education


about nutrition

18% Reduction vs Baseline

p<0.01


Screening

Intervention

Post discharge

Education

RESULTS FOR QIP+ SITES (N=500)

Readmission Rate:

20% Readmission Rate:

15.6%


integrated into EMR

Automatic ONS intervention

in 24 hours

Formalized nutrition discharge

education with coupons

Follow-up calls encouraging

ONS adherence

QIP+

Nonvalidated screening tool



discharge education


about nutrition

Pre-QIP

22% Reduction vs Baseline

p<0.01


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RESULTS FOR ALL QIP AND QIP+ SITES

Screening

Intervention

Post discharge

Education

ReadmissionRate:

16.4%

ReadmissionRate:

20%

Pre-QIP

ReadmissionRate:

15.6%

QIP+QIP


integrated into EMR

Automatic ONS intervention

in 24 hours


integrated into EMR


Targeted ONS intervention

in 24-48 hours


discharge education

No post-discharge

reminders about nutrition

Nonvalidated

screening tool



discharge education


about nutrition

Formalized nutrition discharge

education with coupons

Follow-up calls encouraging ONS adherence

22%Reduction vsBaselinep<0.01

18%Reduction vs Baseline

p<0.01

ECONOMIC MODEL OF STUDY RESULTS

QIP+ SITES (500 patients enrolled)

• 100 expected – 78 observed = 22 prevented readmissions x $18,500 average readmission cost1 = $407,000

QIP SITES (769 patients enrolled)

• 154 expected – 126 observed = 28 prevented readmissions x $18,500

average readmission cost1 = $518,000

*During the period of this study involving 4 hospitals only.†Based ONLY on application of current, limited QIP protocol.

Total 6-Month Savings = $925,000*Projected Annual Savings = $1,850,000†

1. Philipson TJ et al. Am J Manag Care. 2013;19(2):121-128.

• A comprehensive ONS QIP reduced 30-day unplanned hospital readmissions among hospitalized patients at risk of malnutrition

• Keys to success:

��Multidisciplinary team collaboration and follow-up

��Implementation of a validated nutrition screening tool in EMR

��Immediate provision of ONS

��Ongoing patient and care giver education in hospital and at discharge

��Post-discharge questions related to ONS

��Ongoing provider education

��Sustained provider and administrative program support

CONCLUSIONS

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A. Introduction

B. Preliminary Data

C. NOURISH Trial

D. Readmissions

E. Conclusions


A. Malnutrition is a big problem in patients with Heart Failure

B. Therapy can decrease mortality and readmissions

C. We should screen for malnutrition and treat Heart Failure patients that qualify

Treatment of Malnutrition and Heart Failure Conclusions

Documents

Treatment of Malnutrition and Heart Failure - Bryan Health · Treatment of Malnutrition and Heart Failure ... New York, NY: McGraw-Hill;2002. ... Treatment of Malnutrition and Heart